To some extent, this line is getting silly.
As a humble country GP, my primary interest is in the data. Most of the
clinical data I want externally are numeric rather than Boolean, although I
also have use for data that might be more suited to my primitive idea of a
neural network: The rash "conforms fairly strongly with my impression of" an
urticarial rash...
The opinions offered by other practitioners come into that category, as are the
opinions which I expressed at previous encounters with this patient or clinical
problem. However, all of this is fundamentally different from rocket science.
Rocket science gives me the impression of being close to absolute. Maybe
variations in weather will affect solutions close to the Earth, but the long
stretches between planets, or between stars should be much more predictable
than balls on a billiard table.
In contrast, there are very few absolute parameters in the "science" of
Medicine. While not nearly as chaotic as weather patterns that might be
affected by the beat of a butterfly's wings, I want to be free to make my own
assessment of the data I receive from other practitioners. Each datum I receive
in that manner should be subjected to a degree of critical review. Looking at
scaling on that "degree of crticial review" I expect IT analysts to want to
differentiate as many states as possible, but I do not believe that we will
reach a quantal level of granularity. I am prepared to give a high degree of
credibility to the serum rhubarb. That is not to say that I would not expect
some variation in the values reported by different laboratories on samples
taken from the same patient and the same time, but I do expect the variations
to be within the limits of error of the several different techniques that might
be used to perform the assay. However, I do expect to see some difference in
the "normal range" ascribed by each laboratory, and I also expect a greater
degree of variation ( for "abnormal" results) in the "comment" line reported by
each lab, and even each of the reviewing specialists within a given lab.
That's with the relatively "hard" data provided by the lab. With radiology, I
accept that the "report" is likely to be less black and white than the films,
and that the report from the radiologist will vary from day to day, even if the
same films are under review. So I can go down the list of specialist opinions
right down to... well, there's no need to be rude about those specialities.
However, in each case, I need to be able to overlay my judgment array which
will include:
the reproducibility of the observation: a. generally b. in the hands of
the reporter
the usefulness of the observation
the quality of this reporter for this type of observation
...
Yes, it would be lovely, eventually, to mimic this process using software.
However, my impression over the last three decades is that attempts to do this
have merit at an academic level, both as an excercise in their own right and as
a means of helping to train the next generation of practitioners in ths process.
The other aspect of "opinion"s is that they are evanescent. The patient's
"admission diagnosis" may have a strong positive correlation with the
"discharge diagnosis", but if we could claim identity between the two lists,
there would be no need for tests after admission, no need for changes in
management and certainly no need to record "opinions". On the contrary, the
initial (working) diagnosis is likely to be of limited precision, and to be
accompanied by a list of other options. The tests ordered at that stage are
ordered in the hope of being able to either strengthen or weaken the relative
rankings of the differential diagnosis. Similarly, the effect of various
treatment options can help to effect changes in those rankings, as will the
opinons, prejudices and expertise of the various practitioners invited to
participate in the process. The point to be made at this stage is that the
addition of just one more datum at this point may be enough to change content
as well as ranking within the "patient status report". If this occurs, then we
may find that the opinion expressed by the most prestigious and competent
practitioner can be totally reversed within the span of the few seconds it
takes for that datum to be perceived. This bears some similarity to the Humean
dichotomy between deeds and moral issues.
So, much as I appreciate and indeed give a fair amount of weight to the
opinions offered to me by others, those opinions are no more than information
that I need to weigh in my own deliberations. Having played extensively with
coding systems, it seems fairly clear that the best way of giving that opinion
is verbally, with the language of the phone call, letter or email giving clues
as to the matters in question, the observations used in moving toward the
conclusion(s) reached and the advice sought or offered. Yes, I'm happy to
compose the bulk of my letter from elements formally represented in my medical
record and to parse the reply for similar elements, but the opinions expressed
are likely to have their value reduced if they are removed from that context
and the implicit timeframe.
By all means let us look at ways of extracting useful elements from either
letter, but let's not lose sight of the value of the letter which is
undoubtedly greater than the sum of its parts.
Jan Ravet
----- Original Message -----
From: Gerard Freriks
To: openehr-clinical at openehr.org
Sent: Friday, September 16, 2005 4:35 AM
Subject: Re: 'Actionability' of orders
Whay are the arguments for your preference for service models and generic
distrinuted technology?
Gerard
-- <private> --
Gerard Freriks, arts
Huigsloterdijk 378
2158 LR Buitenkaag
The Netherlands
T: +31 252 544896
M: +31 654 792800
On 9-sep-2005, at 11:51, Thomas Beale wrote:
I missed this post this morning, but it hits the nail right on the head.
The problem to be solved is protocols. They can be defined in the form of:
- protocol definitions, as in the telecom industry, to which Bernie refers
above
- in terms of service interfaces, which can be designed to implement
intended protocols of communication
They can be implemented in terms of:
- in message definitions, where different parts of the message, and
different message types explicitly implement a protocol definition.
- in generic distributed object technology, e.g. RPC, Corba etc, where the
messages are defined and created by magical tools which read the input service
interface definitions to determine what the packets must be
- in generic messaging technology.
Personally, I believe we should be using service models and generic
distributed technology.
- thomas beale
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