Re: [Gnumed-devel] automatic episode namin

[Richard Terry]

On Wed, 7 Sep 2005 05:55 am, Karsten Hilbert wrote:
> Richard, all,
>
> assume you entered a progress note. You did not select
> beforehand which episode it belongs to.

I have a feeling my reply will be confusing because of my confusion about 
episodes vs problems vs consutations, however:

Just a question here, maybe I'm finally 'getting it', is your 'episode' the 
equivalent of what I'd call a consultation? ie the period of time the patient 
is sitting in front of me in my room? (or on the phone, or at home etc). This 
seems to be the case from looking at your EMR Journal dump, but maybe not. I 
have a horrible feeling your concept of episode is something that spans 
several consultations ie captain kirks lacerated wound, starts an episode, 
and all subsequent parts of consulations related to that wound are episodes? 
is that closer? I guess in AU we would simply call that a diagnosis or 
problem.
>
> Upon saving the system will try to determine a suitable name
> for the episode. First it will enforce that the progress
> note contains at least RFE and Plan. It then uses either
> Assessment or RFE (in that order) to chose a name for the
> episode.

Mmmmm, problematic. Malcolm ireland (remember GP/Acadenmic/IT degree/presenter 
at many many international medical record conferences over the years)  and I 
debated this many moons ago and some of this is reflected below.

I disagree about the enforcement stuff, and I don't beleive every time the 
patient sits before me one needs to 'name' the encounter. To me linking the 
encounter to a problem (eg Hypertension) is a different issue from needing 
some sort of summary tag for the consultation eg 'Flu' or "Investigation of 
chest pain'. I do beleive the option should be there for the doctor to add a 
summary tag (I do this all the time in my notes - in the right most column to 
allow me a visual vertical flow chart for when I have to go back through the 
notes) - as per the png file enclosed of my 'mock up' wx2.6 medical records.

 Think about this as two extremes

Why in the first place have we chosen to have a multi-lined progress note?
This has more to do with organisation of information than anything else. For 
example context sensitive pop up phrase wheels can be implemented according 
to whilch line the user is on.

Remember my postings some time ago when I tried various combinations of 
headings, when I entered progress notes using a widgit during real 
consulations and posted the png's to the list - ie headings such as SOAP, or 
Patient history, Dr History, clinical Findings, Assessment, plan, or Patient 
Request, etc etc, and I commented that I found NONE (sorry Sebastian for 
shouting) of them worked terribly well to encompass all types of 
consultations, not in the png I've used symptoms, examination, assessment, 
treatment/plan (which sits probably best with me of all the  wordings - ie 
the old SOAP in another guise!). 

Now at the other extreme consider that many medical records programs have as 
their data input area -  a single large textbox, where the user combines all 
the information as they so desire.

Now think about what you put down on a page (this is how I do anyway),

20/10/2004  Complaining of headaches, myalgia                                   
        
                    No skin rash, no fever bla bla                              
                   O/E T=38 BP=134/70, no meningism, red throat 
                          chest clear, no rashes                                
    
                   Dx   viral influenze                                         
        
                   Rx    symptomatic script panadeine forte,             
                           advised review if deteriorates                       
    
              
                pm visit:
                           Sudden deterioration, haemorrhagic rash      
                           obtunded, BP 60/40                                   
     
                           Dx   Meningococcal Septicaemia                    
                         Rx    ivi penicillin, urgent transfer to hospital    
                         

Now niether of these visits are 'tagged' but it is self evident what has 
happened (and what will happen - ie I will be sued bit time for 
misdiagnosis!)

Now consider this constation - patient comes in requests  a script for 
paracetamol, the notes just say:

20/10/2004     script paracetamol.

ie nothing else is needed. Not linked to anything, the RFE is implied is the 
patient has said "can I have a script for paracetamol", you should not have 
to write that in the notes. The action is on the plan line only "ie script 
paracetamol).  

I guess what I'm saying is that whearas you should obviously not save a blank 
consultation, the information for the consultation may be written  on one or 
more of the input lines and is really the responsibility of the user.
>
> Now the question:
>
> Should then the user be *prompted* for editing/ changing/
> selecting the episode (name) the progress note actually
> really belongs to ?

Definately not - one wants the least interuptions to consultation flow 
possible. Our major medical program uses such prompting. Users spend all day 
having to type into stupid boxes or click on ok/cancel buttons to get 
anything done - adds thousands of extra clicks/mouse movements a day.
>
> The alternative would be:
>
> Assume that an "as-yet unassociated progress note" is just
> that - a *new* problem - or else the problem would have been
> pre-selected from the problem list. 

Yes and no. You are making an assumption (which I think is not correct), that 
everything the doctor types into the clinical notes is a problem or 
associated with a problem, whearas in fact it might be a few lines of 
clinical information as described with paracetamol above,  not related to 
anything at all and may or may not ever be, ie it is a clinical note which 
needs no tag at all.

> Hence guess a "good" 
> episode name and store the progress note under that name as
> a new episode. The user can always come in later and
> associate the note with another episode (which, of course,
> won't happen in a busy practice).

Yes, the user should be able to associate that particular progress note with a 
problem, and I expect it would happen quite commonly. This is what I've 
previously discussed as 'linking' a SOAP encounter to a particular problem.
No, don't guess a name at all.

===============================================
IE after such verbosity, my opinion is don't enforce a progress note episode 
name, but if you have to have a name stored in the back-end make it 
anonymouse eg 'episode-drblogs-10/10/2004-1:54pm' and don't print it in the 
EMRJournal when it is non-clinical.
===============================================

Now as a final comment, just to make you think I'm disagreeing with myself 
completely, I do believe the as the patients case-notes are being saved, a 
modal (yes modal) dialog box should pop up and ask the doctor for a one line 
(or suggested by intelligent interpretation by the program) summary, to be 
later displayed as per the png file below. This of course could be blank.

Regards

Richard



>
> Karsten

progressnotes_wxdemo.png
Description: PNG image