Nice post Anoop. I'd be happy to get involved via FCI. @Ian McNicoll <[email protected]> thanks for the papers, very useful.
-- Dr Paul Miller MBCHB MRCGP FFCI DRCOG DMI Glenburn Medical Practice Fairway Avenue Paisley PA2 8DX Tel: 0141 884 7788 http://www.glenburnsurgery.scot.nhs.uk/ Clinical Lead NES Digital Service https://nds.nes.digital/ Mobile: +44 7711 346 928 Twitter: @docpaulmiller On Fri, 28 Jun 2019 at 18:06, Shah, Anoop <[email protected]> wrote: > Lots of interesting thoughts and perspectives here! > > In the NHS there is the added complexity that primary care and secondary > care are different organisations, each maintaining their own patient > records (with responsibility for maintaining accuracy), and even if it were > possible for them to share the same problem list, it would be unclear who > would be responsible for curating it. > > I have been working on a project to try to scope out this area and produce > guidance for improving problem and diagnosis recording. The project is led > by the Professional Record Standards Body and the Royal College of > Physicians Health Informatics Unit, and our report should be published in a > couple of months (I can send the draft to anyone who is interested). > > Personally I think that terminology ('problem' or 'diagnosis') can be > confusing. In my understanding there is a concept of an evaluation which > represents the clinical understanding of a fact about a patient > ('condition', 'diagnosis', 'sign', 'symptom', 'problem'). This is generally > similar among all clinicians (although some may be interested in more > detail than others), but can change over time either because the patient's > condition changes or the clinical understanding of the condition changes. > This is distinct from the 'problem attribute' of an entry in a problem > list, which is a statement of its importance to healthcare task planning > (e.g. whether the problem is active or inactive, major or minor, high or > low priority), and can legitimately vary between clinical specialties > according to their particular focus. > > The task for the EHR is to present the list of patient's problems in a way > that facilitates clinical decision making. This may be through the coded > problem titles (e.g. diabetes is always important for every clinician to > know about, a common cold is unimportant after X months), concurrent > prescriptions (e.g. gastro-oesophageal reflux is considered active as long > as the patient is prescribed antacid medication), explicit manually created > problem links (e.g. shortness of breath is due to heart failure, > amitryptiline was started because of pain), and explicit manual problem > attributes (e.g. the GP has marked osteoarthritis as a major active > problem). > > Without any problem attributes the system should ideally be able to > present a useful list by using problem attributes inherited from the code. > However, creating the 'problem profiles' associated with diagnosis codes > requires thought and broad consensus among clinicians, and is a major piece > of work. But I think it is necessary in order to be able to reap the > benefits of coding for clinical usability of systems. In parallel a change > is needed in the way clinicians use problem lists, with a focus on trying > to refine and improve the problem list with each consultation so that it > becomes more precise and accurate over time. > > Going forward we want to develop more thinking in this area through the > Faculty of Clinical Informatics in the UK, and it would be good to hear > from anyone who would like to get involved. > > Thank you, > > Anoop > > --- > > Dr Anoop D. Shah > Clinical Lecturer, UCL Institute of Health Informatics > THIS Institute Postdoctoral Fellow > Honorary Consultant in Clinical Pharmacology and General Medicine, > University College London Hospitals NHS Trust > > Room 403, Institute of Health Informatics, University College London, 222 > Euston Road > London, NW1 2DA > > Email: [email protected] / [email protected] > Mobile: +44 (0)78 7676 7478 > Website: https://www.ucl.ac.uk/health-informatics > <https://www.hdruk.ac.uk/> > > > ________________________________________ > From: openEHR-clinical <[email protected]> on > behalf of [email protected] < > [email protected]> > Sent: 28 June 2019 12:09 > To: [email protected] > Subject: openEHR-clinical Digest, Vol 81, Issue 19 > > Send openEHR-clinical mailing list submissions to > [email protected] > > To subscribe or unsubscribe via the World Wide Web, visit > > https://eur01.safelinks.protection.outlook.com/?url=http%3A%2F%2Flists.openehr.org%2Fmailman%2Flistinfo%2Fopenehr-clinical_lists.openehr.org&data=02%7C01%7C%7Cd74c790266144f0784d708d6fbb90c4b%7C1faf88fea9984c5b93c9210a11d9a5c2%7C0%7C1%7C636973169532391300&sdata=I9TJDdQyXPHONVtOlc4nljaeYN3Jlc5KvzlmMNrdT%2FM%3D&reserved=0 > > or, via email, send a message with subject or body 'help' to > [email protected] > > You can reach the person managing the list at > [email protected] > > When replying, please edit your Subject line so it is more specific > than "Re: Contents of openEHR-clinical digest..." > > > Today's Topics: > > 1. Re: Problem orientation in OpenEHR (Paul Miller) > 2. Re: Problem orientation in OpenEHR (Ian McNicoll) > > > ---------------------------------------------------------------------- > > Message: 1 > Date: Fri, 28 Jun 2019 10:48:06 +0100 > From: Paul Miller <[email protected]> > To: For openEHR clinical discussions > <[email protected]> > Subject: Re: Problem orientation in OpenEHR > Message-ID: > < > ca+owoyqjmh_d72et3bhs6p53tkyo6_rzwhzxz-qnrtqry-c...@mail.gmail.com> > Content-Type: text/plain; charset="utf-8" > > Enjoying this thread but also finding it a challenge! > > In my experience the load required to maintain a POMR is significant, as > Heather points out, and thus it is often not done at all or done well and > maybe Marcus's suggestion of 'tagging' is simply a UI method for making it > easier to do, but it does not really solve much more. > > One of the problems here is that the medical profession has never agreed > what it means by POMR in respect of EHRs and implementations vary > significantly in different EHR systems, perhaps analogous the the diversity > of clinical information models in silo-ed systems than the openEHR approach > sorts. > > Tagging could be helpful metaphor but I think the magic would lie in > defining / agreeing what the LINK types were - 'caused by', 'to > investigate', 'prescribed for'??? Dunno - would need some work, but that > would then allow people to view the data in more logical and useful ways. > > Getting people to maintain all that is probably impossible, even with super > UI, so probably we would need to find clever ways to automate it - but > inevitably it will need some level of manual curation. > > I maybe don't quite understand yet the approach Thomas suggests for SOAP > persistence. In my head SOAP is a way of structuring an encounter (not > modelling a 'problem'), and various other such encounter headings are > present in other EHRs. Thus I think any encounter recorded in a SOAP > structure may relate to a 'problem', but not actually be the definition of > the problem itself. Although if an initial encounter record using SOAP or > whatever was persisted and curated I can see how that may build a > meaningful set of links, although still not sure we have the 'Problem' > defined there? > > Paul > > > -- > > Dr Paul Miller > > MBCHB MRCGP FFCI DRCOG DMI > Glenburn Medical Practice > Fairway Avenue > Paisley > PA2 8DX > Tel: 0141 884 7788 > > > https://eur01.safelinks.protection.outlook.com/?url=http%3A%2F%2Fwww.glenburnsurgery.scot.nhs.uk%2F&data=02%7C01%7C%7Cd74c790266144f0784d708d6fbb90c4b%7C1faf88fea9984c5b93c9210a11d9a5c2%7C0%7C1%7C636973169532391300&sdata=umFiKWXdKedVekiaLYDUTzujOayBSvD1H0nj5AfVWwE%3D&reserved=0 > > > > Clinical Lead > > NES Digital Service > > > https://eur01.safelinks.protection.outlook.com/?url=https%3A%2F%2Fnds.nes.digital%2F&data=02%7C01%7C%7Cd74c790266144f0784d708d6fbb90c4b%7C1faf88fea9984c5b93c9210a11d9a5c2%7C0%7C1%7C636973169532401308&sdata=qUBOY%2FrnhqLXWw4K28Qr0H2SZHOx02tVI%2BQFjsCdppI%3D&reserved=0 > > > > Mobile: +44 7711 346 928 > > Twitter: @docpaulmiller > > > On Fri, 28 Jun 2019 at 02:58, Heather Leslie < > [email protected]> wrote: > > > Great discussion. > > > > > > > > I think there are semantic issues at play here as well ? the POMR use of > > ?problem? vs the ?Problem??Diagnosis continuum? that is used as part of > > the conclusion to a consult etc. Problems are problematic! Add in Contsys > > and then we start to get into tricky territory. > > > > > > > > In my discussions over the years, I think Ian?s view is closest to mine. > > And in a world where the reality of getting up-to-date Medication Lists > or > > Problem lists of raw/real problems, diagnoses and procedures is not easy, > > the notion of the synthesised, coordinated, connected POMR Problems seems > > like a distant pipe dream. > > > > > > > > The openEHR LINKs nicely allow for Marcus? and Richard?s dreams of > > connecting items in the health record. > > > > > > > > But imagine curating this for each of our patients with chronic disease ? > > time and lack of funding will crush it in most clinical environments as > > they stand at the moment. > > > > > > > > But let?s keep dreaming and planning. If we can put the building blocks > in > > place, and there are many that are ready to go within openEHR now, with > > CDS, smart UI, AI etc maybe much of this could be automated, or at least > > collated presented to a clinician for verification. > > > > > > > > Regards > > > > > > > > Heather > > > > > > > > *From:* openEHR-clinical <[email protected]> > *On > > Behalf Of *[email protected] > > *Sent:* Friday, 28 June 2019 10:04 AM > > *To:* For openEHR clinical discussions < > [email protected] > > > > > *Subject:* Re: Problem orientation in OpenEHR > > > > > > > > Thanks for all the responses > > > > I guess I see "problem" as a high level construct, decided by an expert > > clinician as a way of "coding" the client's various ongoing, significant > > issues in a way that is relevant to management. It could be a formal > > diagnosis like Diabetes or a less structured problem like "smoker". I am > > not sure how this could be coded in a consistent way - the definition of > a > > problem can be quite subjective and in general it is the task of a > > sophisticated clinician. Short term issues like "Upper respiratory tract > > infection" or even "abscess" would not normally be defined as problems in > > my practice. > > > > I agree with Marcus on the understanding - I have struggled with the > whole > > concept of OpenEHR for a long time as a sophisticated clinician and > perhaps > > somewhat less sophisticated IT enthusiast. I see it as a data modelling > > system accessible to clinicians to allow computable models - which in > turn > > will allow decision support. > > > > But I think the "problem" concept ids an important one > > > > Perhaps we should relax a bit - allow the clinician to create problems at > > their discretion which are not necessarily connected to other elements of > > the record. This is effectively how it works now. > > > > R > > > > > > ----- Original Message ----- > > > > *From:* > > > > "For openEHR clinical discussions" <[email protected]> > > > > > > > > *To:* > > > > <[email protected]> > > > > *Cc:* > > > > > > > > *Sent:* > > > > Thu, 27 Jun 2019 17:05:35 -0300 > > > > *Subject:* > > > > Re: Problem orientation in OpenEHR > > > > In a slightly roundabout way, Links from Problem-SOAP Compositiions to > > Entries committed at other times is essentially the equivalent of > tagging, > > and indeed the UI could easily be built to make it look exactly like > > tagging, by presenting a list of existing SOAP note problem names, and > the > > 'tag this under problem X' action would create the relevant Link. > > > > Literal tagging causes some issues in versioned, medico-legal EHRs, > > because you are updating the link target, not the logical link source, > when > > there is nothing changing in the target. > > > > it seems to me we should think a bit more about (?semi-)persistent SOAP > > Compositions, and maybe a related micro-service to make it easy to do > > logical tagging that actually does the correct linking... > > > > - thomas > > > > On 27/06/2019 16:33, Marcus Baw wrote: > > > > If I wanted to solve POMR in a simple way without repetition, I'd use > > Tagging > > > > You'd tag anything relevant to the Problem with that problem's Tag, you > > index by Tags too, in a background job > > > > Then when searching by Problem you get all entries Tagged as relevant. > > > > M > > > > > > > > On Thu, 27 Jun 2019 at 19:32, Gunnar Klein <[email protected]> > wrote: > > > > I do agree pomr has an important role in primary care and I like the > > proposal of Thomas to manage it in openEHR. I am not sure why pomr never > > took on in hospitals. Larry Weeds idea was not restricted to primary > care. > > > > > > > > Gunnar Klein, GP an professor of health informatics > > > > > > > > _______________________________________________ > > openEHR-clinical mailing list > > [email protected] > > > > > https://eur01.safelinks.protection.outlook.com/?url=http%3A%2F%2Flists.openehr.org%2Fmailman%2Flistinfo%2Fopenehr-clinical_lists.openehr.org&data=02%7C01%7C%7Cd74c790266144f0784d708d6fbb90c4b%7C1faf88fea9984c5b93c9210a11d9a5c2%7C0%7C1%7C636973169532401308&sdata=mSG5dCHbdDAKk5tMBCyt7lmLHMJqe4bCF8jam78vAJw%3D&reserved=0 > > > -------------- next part -------------- > An HTML attachment was scrubbed... > URL: < > https://eur01.safelinks.protection.outlook.com/?url=http%3A%2F%2Flists.openehr.org%2Fpipermail%2Fopenehr-clinical_lists.openehr.org%2Fattachments%2F20190628%2Ff934c6d4%2Fattachment-0001.html&data=02%7C01%7C%7Cd74c790266144f0784d708d6fbb90c4b%7C1faf88fea9984c5b93c9210a11d9a5c2%7C0%7C1%7C636973169532401308&sdata=NY%2FxXA59nbjzx9LI%2FLRzXQ6kMZzo9E3J7CJGR0rzio0%3D&reserved=0 > > > > ------------------------------ > > Message: 2 > Date: Fri, 28 Jun 2019 12:07:48 +0100 > From: Ian McNicoll <[email protected]> > To: For openEHR clinical discussions > <[email protected]> > Subject: Re: Problem orientation in OpenEHR > Message-ID: > < > cag-n1kwpzsmik83p9aaec8ykcrw8rgblbtsgqugcxoyntzh...@mail.gmail.com> > Content-Type: text/plain; charset="utf-8" > > Hi Paul, > > Indeed confusing but that just reflects real-world complexity. > > It is important not to mix up SOAP and POMR Problem lists , though both > were Larry Weed's invention. I used both in clinical practice. > > SOAP is a way of organising information during a single consultation > Subjective, Objective, Assessment, Plan. > > POMR Problem Lists is a way of organising problems/diagnoses across > multiple consultations or other patient contacts. > > As part of SOAP style data-entry the Assessment part might well contain a > Diagnosis/Problem entry which may (but may not) appear on the POMR Problem > list. Ideally linked back to the original consultation. Problem Lists may > be flat and have simple attributes like inactive/active major/minor but may > have much more complex nesting to reflect condition grouping, process > groupings, temporal groupings. > > Some systems in the UK and Netherlands are entirely Problem driven i.e. for > every new consultation the clinician must allocate it to an existing > problem header or create a new one. > > And in non-primary care settings it is common to see Contextual Problem > lists - Care plans, Outpatient consults, Speciality Problem lists e.g Renal > medicine. > > https://eur01.safelinks.protection.outlook.com/?url=https%3A%2F%2Fwww.archetextur.es%2Fdiagnosing-the-contextual-problem-list%2F%3Fno-cache%3D1&data=02%7C01%7C%7Cd74c790266144f0784d708d6fbb90c4b%7C1faf88fea9984c5b93c9210a11d9a5c2%7C0%7C1%7C636973169532401308&sdata=iaPu73tW8ahakeErhvFgx0Gu8dz8WF5KkXR3fYFy6nY%3D&reserved=0 > > Some stuff I wrote here > > https://eur01.safelinks.protection.outlook.com/?url=https%3A%2F%2Fopenehr.atlassian.net%2Fwiki%2Fspaces%2Fhealthmod%2Fpages%2F2949176%2FProblem%2BIssue%2BDiagnosis%2Band%2BConcern%3FfocusedCommentId%3D2949237&data=02%7C01%7C%7Cd74c790266144f0784d708d6fbb90c4b%7C1faf88fea9984c5b93c9210a11d9a5c2%7C0%7C1%7C636973169532401308&sdata=i%2FPt8blPd4OZyW%2FMBMZIf1PsZ11B8%2BfXFFfoHiRycWk%3D&reserved=0 > > and one of the best papers is > > https://eur01.safelinks.protection.outlook.com/?url=http%3A%2F%2Fwww.differance-engine.net%2Fchirad%2Fhealthrecords2007%2FThe%2520Problem%2520Oriented%2520Medical%2520Record.doc&data=02%7C01%7C%7Cd74c790266144f0784d708d6fbb90c4b%7C1faf88fea9984c5b93c9210a11d9a5c2%7C0%7C1%7C636973169532401308&sdata=z6IHn8fw6%2BxcTho%2Fh9EQddMKEocJZ9HiZ5cZepa3kwc%3D&reserved=0 > > Ian > > Dr Ian McNicoll > mobile +44 (0)775 209 7859 > office +44 (0)1536 414994 > skype: ianmcnicoll > email: [email protected] > twitter: @ianmcnicoll > > > > Director, freshEHR Clinical Informatics Ltd. > CCIO inidus Ltd. [email protected] > Co-Chair, openEHR Foundation [email protected] > Hon. Senior Research Associate, CHIME, UCL > > > On Fri, 28 Jun 2019 at 10:48, Paul Miller <[email protected]> wrote: > > > Enjoying this thread but also finding it a challenge! > > > > In my experience the load required to maintain a POMR is significant, as > > Heather points out, and thus it is often not done at all or done well and > > maybe Marcus's suggestion of 'tagging' is simply a UI method for making > it > > easier to do, but it does not really solve much more. > > > > One of the problems here is that the medical profession has never agreed > > what it means by POMR in respect of EHRs and implementations vary > > significantly in different EHR systems, perhaps analogous the the > diversity > > of clinical information models in silo-ed systems than the openEHR > approach > > sorts. > > > > Tagging could be helpful metaphor but I think the magic would lie in > > defining / agreeing what the LINK types were - 'caused by', 'to > > investigate', 'prescribed for'??? Dunno - would need some work, but that > > would then allow people to view the data in more logical and useful ways. > > > > Getting people to maintain all that is probably impossible, even with > > super UI, so probably we would need to find clever ways to automate it - > > but inevitably it will need some level of manual curation. > > > > I maybe don't quite understand yet the approach Thomas suggests for SOAP > > persistence. In my head SOAP is a way of structuring an encounter (not > > modelling a 'problem'), and various other such encounter headings are > > present in other EHRs. Thus I think any encounter recorded in a SOAP > > structure may relate to a 'problem', but not actually be the definition > of > > the problem itself. Although if an initial encounter record using SOAP or > > whatever was persisted and curated I can see how that may build a > > meaningful set of links, although still not sure we have the 'Problem' > > defined there? > > > > Paul > > > > > > -- > > > > Dr Paul Miller > > > > MBCHB MRCGP FFCI DRCOG DMI > > Glenburn Medical Practice > > Fairway Avenue > > Paisley > > PA2 8DX > > Tel: 0141 884 7788 > > > > > https://eur01.safelinks.protection.outlook.com/?url=http%3A%2F%2Fwww.glenburnsurgery.scot.nhs.uk%2F&data=02%7C01%7C%7Cd74c790266144f0784d708d6fbb90c4b%7C1faf88fea9984c5b93c9210a11d9a5c2%7C0%7C1%7C636973169532401308&sdata=TrNGtlCs3FpjLf4pL3H1xVHJzx3dg22%2FtqC2FX6Emys%3D&reserved=0 > > > > > > > > Clinical Lead > > > > NES Digital Service > > > > > https://eur01.safelinks.protection.outlook.com/?url=https%3A%2F%2Fnds.nes.digital%2F&data=02%7C01%7C%7Cd74c790266144f0784d708d6fbb90c4b%7C1faf88fea9984c5b93c9210a11d9a5c2%7C0%7C1%7C636973169532401308&sdata=qUBOY%2FrnhqLXWw4K28Qr0H2SZHOx02tVI%2BQFjsCdppI%3D&reserved=0 > > > > > > > > Mobile: +44 7711 346 928 > > > > Twitter: @docpaulmiller > > > > > > On Fri, 28 Jun 2019 at 02:58, Heather Leslie < > > [email protected]> wrote: > > > >> Great discussion. > >> > >> > >> > >> I think there are semantic issues at play here as well ? the POMR use of > >> ?problem? vs the ?Problem??Diagnosis continuum? that is used as part of > >> the conclusion to a consult etc. Problems are problematic! Add in > Contsys > >> and then we start to get into tricky territory. > >> > >> > >> > >> In my discussions over the years, I think Ian?s view is closest to mine. > >> And in a world where the reality of getting up-to-date Medication Lists > or > >> Problem lists of raw/real problems, diagnoses and procedures is not > easy, > >> the notion of the synthesised, coordinated, connected POMR Problems > seems > >> like a distant pipe dream. > >> > >> > >> > >> The openEHR LINKs nicely allow for Marcus? and Richard?s dreams of > >> connecting items in the health record. > >> > >> > >> > >> But imagine curating this for each of our patients with chronic disease > ? > >> time and lack of funding will crush it in most clinical environments as > >> they stand at the moment. > >> > >> > >> > >> But let?s keep dreaming and planning. If we can put the building blocks > >> in place, and there are many that are ready to go within openEHR now, > with > >> CDS, smart UI, AI etc maybe much of this could be automated, or at least > >> collated presented to a clinician for verification. > >> > >> > >> > >> Regards > >> > >> > >> > >> Heather > >> > >> > >> > >> *From:* openEHR-clinical <[email protected]> > *On > >> Behalf Of *[email protected] > >> *Sent:* Friday, 28 June 2019 10:04 AM > >> *To:* For openEHR clinical discussions < > >> [email protected]> > >> *Subject:* Re: Problem orientation in OpenEHR > >> > >> > >> > >> Thanks for all the responses > >> > >> I guess I see "problem" as a high level construct, decided by an expert > >> clinician as a way of "coding" the client's various ongoing, significant > >> issues in a way that is relevant to management. It could be a formal > >> diagnosis like Diabetes or a less structured problem like "smoker". I am > >> not sure how this could be coded in a consistent way - the definition > of a > >> problem can be quite subjective and in general it is the task of a > >> sophisticated clinician. Short term issues like "Upper respiratory tract > >> infection" or even "abscess" would not normally be defined as problems > in > >> my practice. > >> > >> I agree with Marcus on the understanding - I have struggled with the > >> whole concept of OpenEHR for a long time as a sophisticated clinician > and > >> perhaps somewhat less sophisticated IT enthusiast. I see it as a data > >> modelling system accessible to clinicians to allow computable models - > >> which in turn will allow decision support. > >> > >> But I think the "problem" concept ids an important one > >> > >> Perhaps we should relax a bit - allow the clinician to create problems > at > >> their discretion which are not necessarily connected to other elements > of > >> the record. This is effectively how it works now. > >> > >> R > >> > >> > >> ----- Original Message ----- > >> > >> *From:* > >> > >> "For openEHR clinical discussions" <[email protected]> > >> > >> > >> > >> *To:* > >> > >> <[email protected]> > >> > >> *Cc:* > >> > >> > >> > >> *Sent:* > >> > >> Thu, 27 Jun 2019 17:05:35 -0300 > >> > >> *Subject:* > >> > >> Re: Problem orientation in OpenEHR > >> > >> In a slightly roundabout way, Links from Problem-SOAP Compositiions to > >> Entries committed at other times is essentially the equivalent of > tagging, > >> and indeed the UI could easily be built to make it look exactly like > >> tagging, by presenting a list of existing SOAP note problem names, and > the > >> 'tag this under problem X' action would create the relevant Link. > >> > >> Literal tagging causes some issues in versioned, medico-legal EHRs, > >> because you are updating the link target, not the logical link source, > when > >> there is nothing changing in the target. > >> > >> it seems to me we should think a bit more about (?semi-)persistent SOAP > >> Compositions, and maybe a related micro-service to make it easy to do > >> logical tagging that actually does the correct linking... > >> > >> - thomas > >> > >> On 27/06/2019 16:33, Marcus Baw wrote: > >> > >> If I wanted to solve POMR in a simple way without repetition, I'd use > >> Tagging > >> > >> You'd tag anything relevant to the Problem with that problem's Tag, you > >> index by Tags too, in a background job > >> > >> Then when searching by Problem you get all entries Tagged as relevant. > >> > >> M > >> > >> > >> > >> On Thu, 27 Jun 2019 at 19:32, Gunnar Klein <[email protected]> > >> wrote: > >> > >> I do agree pomr has an important role in primary care and I like the > >> proposal of Thomas to manage it in openEHR. I am not sure why pomr never > >> took on in hospitals. Larry Weeds idea was not restricted to primary > care. > >> > >> > >> > >> Gunnar Klein, GP an professor of health informatics > >> > >> > >> > >> _______________________________________________ > >> openEHR-clinical mailing list > >> [email protected] > >> > >> > https://eur01.safelinks.protection.outlook.com/?url=http%3A%2F%2Flists.openehr.org%2Fmailman%2Flistinfo%2Fopenehr-clinical_lists.openehr.org&data=02%7C01%7C%7Cd74c790266144f0784d708d6fbb90c4b%7C1faf88fea9984c5b93c9210a11d9a5c2%7C0%7C1%7C636973169532401308&sdata=mSG5dCHbdDAKk5tMBCyt7lmLHMJqe4bCF8jam78vAJw%3D&reserved=0 > >> > > _______________________________________________ > > openEHR-clinical mailing list > > [email protected] > > > > > https://eur01.safelinks.protection.outlook.com/?url=http%3A%2F%2Flists.openehr.org%2Fmailman%2Flistinfo%2Fopenehr-clinical_lists.openehr.org&data=02%7C01%7C%7Cd74c790266144f0784d708d6fbb90c4b%7C1faf88fea9984c5b93c9210a11d9a5c2%7C0%7C1%7C636973169532411316&sdata=rg2LhhycEAl%2FFptDUai4pTaNmhDBOGAUgPK0nDAHZhU%3D&reserved=0 > > > -------------- next part -------------- > An HTML attachment was scrubbed... > URL: < > https://eur01.safelinks.protection.outlook.com/?url=http%3A%2F%2Flists.openehr.org%2Fpipermail%2Fopenehr-clinical_lists.openehr.org%2Fattachments%2F20190628%2F06947c0d%2Fattachment.html&data=02%7C01%7C%7Cd74c790266144f0784d708d6fbb90c4b%7C1faf88fea9984c5b93c9210a11d9a5c2%7C0%7C1%7C636973169532411316&sdata=uEi6DWmpVXVsom%2F0GMWKJ6t%2B6H4GKKWUkwN0TWPcgqk%3D&reserved=0 > > > > ------------------------------ > > Subject: Digest Footer > > _______________________________________________ > openEHR-clinical mailing list > [email protected] > > https://eur01.safelinks.protection.outlook.com/?url=http%3A%2F%2Flists.openehr.org%2Fmailman%2Flistinfo%2Fopenehr-clinical_lists.openehr.org&data=02%7C01%7C%7Cd74c790266144f0784d708d6fbb90c4b%7C1faf88fea9984c5b93c9210a11d9a5c2%7C0%7C1%7C636973169532411316&sdata=rg2LhhycEAl%2FFptDUai4pTaNmhDBOGAUgPK0nDAHZhU%3D&reserved=0 > > > ------------------------------ > > End of openEHR-clinical Digest, Vol 81, Issue 19 > ************************************************ > _______________________________________________ > openEHR-clinical mailing list > [email protected] > > http://lists.openehr.org/mailman/listinfo/openehr-clinical_lists.openehr.org >
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