David Rowen brought up an issue with the modeling of Diagnosis as being a
specialized Problem. I concur and the comments in CKM are shown below.
The question is how do these issues get resolved - or will they not get
resolved - once modeled can an archetype never change due to architecture
e.g. the AQL requires the diagnosis to be in a specific place in a specific
archetype so there will be resistance to change?
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david.rowed [Show user profile]
(07-Jul-2009 08:46) [david.rowed]
Issue/Problem vs Diagnosis
I don't accept Diagnosis is a specialisation of Problem in the "is a" sense
of specialisation.
The two are quite appropriately used in the same way by clinicians under
many circumstances but their intrinsic meanings are diferent. When used like
this, 'Problem' is the intended concept and Diagnosis has a relationship
(which needs to thought out ) to the problem. A pathologist would not
consider Diagnosis as a specialisation of Problem.
I made some of the following comments on the Issue archetype:
Problem is a specialisation or property of Issue. We need to sort out
Issue, Problem, and Diagnosis. They mean different things according to
strict definition, but their use overlaps. Problem is a type of issue.
Diagnosis can be an aspect (attribute or relationship) of a problem. This
causes untold debate in clinical IT groups and could be put to rest if we
could just come up with clear definitions of the concepts and info models
which capture these usages and separate out the different components of
each concept.
A Diagosis may clearly exist but not be a problem (depending on owner,
context, circumstance, values and perception). It may "be a" problem for a
while then, although itself persisting, cease to "be a" problem.
Specialisation, then is not the right relationship to express this, but what
is? Is it that a diagosis takes on the role of a problem and that this role
is allowed to commence, terminate, qualify etc?
Problems and Issues exist because of perceptions and values while diagnoses
exist becuse of matches against criteria, terminology and definitions. Like
the recognition/Creation of Issue and Problem, this matching that declares
a Diagosis is evaluative and so Dx, like Problem correctly belongs in the
Evaluation group of archetypes ---as we currently have it.
gregory.caulton [Show user profile]
(01-Jun-2009 18:55) [gregory.caulton]
Re: Issue/Problem vs Diagnosis
I agree, well spotted. Two different concepts which may have a relationship
but should be modelled separately. Nursing problems and nursing diagnoses
are distinct too.
heather.leslie [Show user profile]
(12-Jun-2009 05:06) [heather.leslie]
Re: Issue/Problem vs Diagnosis
Good discussion - brings out some good points.
I think that there is enormous value in having a 'softer' problem and a more
'rigorous' differentiation to create diagnosis. I wonder if the discussion
point here might be more about the naming of 'problem' and 'diagnosis' and
'issue' and their semantic loading.
In practice (and therefore paralleled in modelling) I think that there is a
very close relationship between 'problem' and 'diagnosis' - largely the same
data elements are required by both, with additional elements required to
support the more rigorous nature of a formal diagnosis. This is why they
have been modelled here as a parent and child specialisation.
To me, 'issues' are softer again - highlighting things that are of
significance to the patient but not formalised in clinical terms, and as
author of the CLUSTER.issue archetype, the intent was to allow for
expression of a soft concern of the patient as part of a history taking
process, not an evaluative process. In my parlance, identification of an
evaluative 'problem' is likely to be the assessment of a clinician that
follows the patient's expression of a perceived issue within a clinical
consultation.
In my mind a Current Condition or Current problem list (again, whatever your
favorite phrase) will then comprise a combination of 'softer' problems' and
more rigorously defined diagnoses.
sundaresan.jaganathan [Show user profile]
(07-Jul-2009 08:07) [sundaresan.jaganathan]
Re: Re: Issue/Problem vs Diagnosis
Suggested definition/description for diagnosis.
Diagnosis is the name or label assigned to the conclusion/clinical judgement
reached through the process of clinical reasoning which is obtained from the
presentation, assessment &findings and investigations & results, on which
further management is based.
Is codeable and may appear in ICD10, ICF, NANDA, SNOMED-CT Read, ICNP etc
Problems, issues, concerns etc are the Factors which may instigate the
purpose of an encounter with a health professional.
These would be the Reason for Encounter (different from Purpose of
Encounter) which may include symptoms and signs, a known diagnosis,
impairment, health needs, social problems etc.
Purpose of encounter would be : for consultation, treatment (eg chemotherapy
sessions), investigation, admission, check up, advice, education, antenatal
classes etc
david.rowed [Show user profile]
(07-Jul-2009 08:46) [david.rowed]
Re: Re: Re: Issue/Problem vs Diagnosis
Yes, but as a definition it needs the qualification that the name or label
must be drawn from a predetermined set of agreed pathological states, ie it
must appear in one of : {some authoratitive clinical work, ICD10,
SNOMED-CT, ......, etc.}. I can't arbitrarily assign/invent a new name
or label on the fly for the clinical abnormalities in the case of Diagnosis
but I can for a Problem.
As an aside, we commonly see things like "Abdominal Pain" under the heading
of Diagnosis on hospital discharge summaries. This is an abuse; really there
is often no Diagnosis, just a Problem which probably = the Reason For
Encounter.
david.rowed [Show user profile]
(07-Jul-2009 08:57) [david.rowed]
Re: Re: Re: Re: Issue/Problem vs Diagnosis
Problems, Issues and Concerns are references to situations which have the
possibility of evolving into, or indicating the existence of, something
impacting on well-being.
A Problem specialises / constrains an Issue to one where the impact would
be unfavourable. A Concern is probably the same as an Issue ie more
general.
I don't have a good word for an Issue that where the impact would be
favourable --ie the opposite of a Problem ----perhaps something like an
Advantage?
sundaresan.jaganathan [Show user profile]
(07-Jul-2009 09:20) [sundaresan.jaganathan]
Re: Re: Re: Re: Re: Issue/Problem vs Diagnosis
If I am not mistaken, there is a recommendation that where there is no
formal diagnosis made, the presenting problem, signs, symptoms are to be
recorded as the diagnosis as they appear in the authoratative pieces of
work.
Yes, I agree it is strictly an abuse. It should be probably be recorded as
diagnosis: None
Medicine is constantly evolving, new dignoses do appear. For a start, the
authoratative pieces of work like ICD10, SNOMED-CT do fulfil a majority of
the requirements and I would assume they undergo reviews and change control.
We have to accept that almost nothing is 100 % achievable
Can you give me an example where you have to invent or create a new
diagnosis?
Problems, issues, concerns and needs are used for want of a better term.
Regards
Jag
--
Gregory Caulton
Principal at PatientOS Inc.
personal email: caultonpos at gmail.com
http://www.patientos.com
corporate: (888)-NBR-1EMR || fax 857.241.3022
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