Le 14/03/2018 à 12:41, Thomas Beale a écrit : > Translated in technological concepts, my own take is that is means > switching: >> >> - from a record oriented vision to a project management vision (a >> record is the place where you optimize your own decision support >> ability through keeping the signal/noise ratio as high as possible ; >> a project manager is the place where people build/feed/contribute to >> a set of shared processes). >> > > I don't quite agree here: because the 'record' (properly conceived) is > the only thing that exists to chart the long-term situation of the > patient, as doctors retire, nurses go on holidays, patients themselves > move to new cities or countries. What can you trust to tell the story > from your childhood asthma to your 2 pregnancies and births, to your > hypertension and type 2 diabetes? Or even just your 10 year battle > with one of the lesser cancers (very common) or lifelong management of > a single disease. There is only the longitudinal health record. > > I agree though with the project management notion of course. Our > recent work on Task Planning > <https://www.openehr.org/releases/PROC/latest/docs/task_planning/task_planning.html>is > trying to get up to this next level and join 'model' care pathways > with real patient care plans and team-based care processes. It's going > to take some years to get it really sorted out, but I think we are on > the right path. I have seen the latest increment of the Activity-Based > Design work at Intermountain Healthcare last week - we are converging. > > So when I say the 'EHR' I also include informational artefacts from > long-running Planning and work processes, not just what we have today, > which is observations, decisions, orders, and a record of actions done.
Tom, this question is pivotal and deserves a dedicated conference ;-) When you ask "What can you trust to tell the story from your childhood asthma to your 2 pregnancies and births, to your hypertension and type 2 diabetes?" what can of "record" are you thinking about? Namely, in the practitioner reference frame, a record is the place where you mention the smallest quantity of information that are "food for thoughts". What I summed up as "optimizing the signal/noise ratio". Hence a GP record doesn't look like a cardiologist record and is much different from a nurse record. In many countries (France included), governments made the assumption that a "record of records" can be a "continuity of care record". I have always claimed that it is a terrible idea since a record of records is a place where the signal/noise ratio plummets. In France, the DMP (initially Personal Health Record, now Shared Health Record since the "P" switched from Personnel to Partagé) already failed several times since its announcement in 2004. A new attempt will start in October. From 10 years of interaction with practitioner about this "record of records", I noticed that what they expect from it (for those who expect something!) is always in the form "other will provide their information sorted as I expect it"... no need to say that it is not what the word "sharing" means ;-) Pretty everywhere, the answer relies on magical thinking, à la "automatic specialized views"... but the core issue is not addressed (and even not really understood). So far, we ends up with - many siloed specialized records that only consist in instant "viewpoint oriented" pictures (in the words of Koray "As a result the patient information is all over the place in various formats"), - the conclusion that pilling them up in the same "meta-record" will deliver a mess of heterogeneous pictures and not the movie that could tells your story. The real issue is twofold: - how to select information that "historically matter"? (you may remember the words of Ed Hammond in Berlin (Eurorec 2002) saying that "hospitals produce lots of information, a small part of it being of historical matter, while family doctors produce little information that are nearly 100% of historical matter"), - how to have them "tell your (health) story"? As an engineer, the proper attitude when a problem cannot be (smartly) solved in a given reference frame is to try to find a different reference frame where "things become simple(r)". My take is that what is very hardly achievable in the organizations' reference frame (typically Cartesian, with access rights as matrix, for example - what I call "the boxes") becomes much more "natural" when addressed in the person's reference frame (typically Polar with the team "around" and access rights as Roses - what I call "the bubble"). Since I have been exploring this "reference frame shift" for nearly twenty years (and will only launch the Ligne de vie this year), I can say that what is at stake in the bubble is actually not a record, but plainly a project manager (means the dual concept project + team) and that "your history" is by far more accurately told this way than it would be in any record. As a conclusion, I have to confess that such concepts are pretty new (and that the concept of shifting from a Cartesian to a Polar reference frame often leads to quickly loose the audience). When it comes to "project management vs record", even people that attended to numerous demonstrations of the Ligne de vie often use a "time line" in order to built a "time oriented view" of their record and claim they have a Ligne de vie. A project management system is way more than a diachronic view plugged on a document manager (or an information manager) but, as nailed by Ed Catmull at Pixar "Unfortunately people like to copy the wrong things"... and you probably know it firsthand since so many people keep thinking that Archetypes are GUI forms instead of flexible information schemas ;-) Philippe
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