Thomas,
When I said I thought "the SNOMED people had already modeled complaints,
signs/symptoms, diagnosis, treatment plans prognosis, outcomes... the
whole 9 yards."... I was using the term "model" in the sense of a
"representation" of those individual concepts... for example, to
represent in a computer-understandable way, the fact that "Mrs. Jones is
complaining that her neck hurts".   I was not suggesting, that we
could/should try to model the relationship between her coded symptoms
and her eventual treatment plan.  The doctor in your example must still
record the fact of her neck pain and the fact of his Rx order for
Prozac.  Standard practice guidelines also suggest that he record the
medical reasoning he used to support his [apparent] diagnosis of
"depression".  If I were handling the case, I would probably also record
the fact that she requested pain medication and my reasoning for not
prescribing it.

Doctors DO develop "shorthand" for documenting even complex patient
comments, questions, complaints, etc., if they come up repeatedly.
There should always be a comment field for the weird stuff that is not
EXACTLY like any of the coded concepts.  But it would be extremely
useful to have 80% of that "charted" information in a structured/coded
form.  I think this is the promise of SNOMED CT.  Doctors will likely
support such a system if it allows them to easily put MORE information
in the record than they do today... with the added bonus that everyone
else (AND their computers) can read and understand at least 80% it!

When I said that we should model the concepts, I was also assuming that
we would model the processes that use the concept/information... so that
we can be sure that we have structured the information in a way that
supports its use.   CPT-4 is a good example of a concept-coding
methodology that was invented primarily to support insurance claim
adjudication... not so much, the practice of medicine. 30+ years ago, I
key payers, including Medicare approached the AMA (present owner of the
CPT code set) and requested set of codes for representing medical
procedures on claims... and this is what they came up with.  Today, we
can conceive of representational models, in which the same basic facts
of the case are represented in ways that are much more useful  in
medical decision support and research.  If payers preferred their 30 yrs
old code set, we should only need to explain our new concept model to
them and let them tell us how it maps to their old CPT codeset.
Eventually, they should reprogram their adjudication systems to consume
the doctor's coded information, as it exists natively in the EHR.  Not
only will the content be richer and more potentially useful to the
payer, but instead of sending a traditional "claim", the doctor could
simply send the payer a standard "invoice" for services, with a pointer
to the EHR data... if the payer cared to look at it.

One brief comment on "precision": I'm not suggesting that greater
precision is invariably better or always worth the extra effort to carry
it along in our record systems.  It may become controversial in a few
cases, but doctors should be able to agree on just the right degree of
precision to support the medical job... with the informaticists pushing
them toward the minimum level of granularity and precision, so that the
system is not overly complex.  I' assuming that whatever precision level
makes the doctors happy will also be sufficient for payers and
governments.

Presently, each doctor and EMR software vendor is cooking up his own
shorthand-language, and I'm suggesting that information should be
reduced as much as possible to a standard set of codes.

Christopher J. Feahr, O.D.
Optiserv Consulting (Vision Industry)
Office: (707) 579-4984
Cell: (707) 529-2268
http://Optiserv.com
http://VisionDataStandard.org
----- Original Message ----- 
From: "Thomas Clark" <lakew...@copper.net>
To: "Christopher Feahr" <chris at optiserv.com>
Cc: "Karsten Hilbert" <Karsten.Hilbert at gmx.net>;
<openehr-technical at openehr.org>
Sent: Sunday, August 10, 2003 12:39 PM
Subject: Re: HISTORY DATA SET IN EPR


> Christopher Feahr wrote:
>
> >Karsten,
> >I agree that the medical concepts shhould be carefully modeled
first...
> >then extract the necessary terminologies... then build the necessary
> >code lists.  I have not wanted to pay the $500 licence fee to look at
> >SNOMED CT, as it will be free for all in 3 months... so I apologize
for
> >my ignorance there... but my understanding was the the SNOMED people
had
> >already modeled complaints, signs/symproms, diagnosis, treatment
plans,
> >prognosis, outcomes... the whole 9 yards.  If that is true (seems too
> >good to be true!) then it may only require a (simple??) mapping of
> >SNOMED CT to a collection of EHR Archetypes.
> >
> >My presumption, given the magnitude of the task of producing such a
> >granular model... not to mention, the massive physician input and
> >necessary vetting, for which there is no efficient mechanism...I am
> >assuming that the SNOMED modeling effort is still at a very high
> >level.of abstraction.  Can anyone fill ne in on the present state of
> >this work?  SNOMED CT claims to already have "350,000 coded medical
> >concepts", but since it was constructed by a group of pathologists, I
am
> >assuming that other care domains are not represented in great detail.
> >
> >Regards,
> >-Chris
> >
> >Christopher J. Feahr, O.D.
> >Optiserv Consulting (Vision Industry)
> >Office: (707) 579-4984
> >Cell: (707) 529-2268
> >http://Optiserv.com
> >http://VisionDataStandard.org
> >----- Original Message ----- 
> >From: "Karsten Hilbert" <Karsten.Hilbert at gmx.net>
> >To: <openehr-technical at openehr.org>
> >Sent: Sunday, August 10, 2003 4:55 AM
> >Subject: Re: HISTORY DATA SET IN EPR
> >
> >
> >
> >
> >>>The concept of modelling the symptoms in a genric manner manner and
> >>>
> >>>
> >have
> >
> >
> >>>these called up whenever there is a need to record the details.
> >>>
> >>>
> >>I am not sure I fully understand what you want to say. What do
> >>you mean by "modelling the symptoms" ?
> >>
> >>Symptoms could be recorded as free text. This approach you
> >>describe as inadequate. It *is* inadequate if the goal is to
> >>process the input computationally. The solution is not,
> >>however, to use (inadequate) coding systems as is discussed in
> >>Slee, Slee, Schmidt, "The Endangered Medical Record" (excerpt
> >>available from http://www.tringa.com ).
> >>
> >>Another approach would be to really *model* symptoms based on
> >>openEHR archetypes. This promises to offer some degree of
> >>computationality yet preserve the free text. Others in this
> >>list have more experience with that.
> >>
> >>Data-mining, however, shouldn't be the aim of an EMR. It
> >>should be focussed on patient care. Data-mining will occur
> >>with aggregates of extracts *from* EMRs.
> >>
> >>Karsten Hilbert, MD
> >>-- 
> >>GPG key ID E4071346 @ wwwkeys.pgp.net
> >>E167 67FD A291 2BEA 73BD  4537 78B9 A9F9 E407 1346
> >>-
> >>If you have any questions about using this list,
> >>please send a message to d.lloyd at openehr.org
> >>
> >>
> >
> >-
> >If you have any questions about using this list,
> >please send a message to d.lloyd at openehr.org
> >
> >
> >
> Hi All,
>
> Precision and accuracy are two attributes that do not seem to fit the
> detection and reporting of symptoms. It also seems that neither are
> appropriate since healthcare knowledge is in a continual state of
> evolution.
>
> SARS is a recent example; many other exist. Many Patients complain
> about healthcare problems that are ignored or result in a diagnosis
> that makes literally no sense. I know of a Patient who has a neck
> operation, went to the original Physician complaining about severe
> problems and requesting pain-killer medication for those times when
> the pain was especially severe.
>
> The Physician wrote a prescription for Prozac but no pain killer. One
> can only presume that the symptoms suggested that the Patient should
> at least feel good about being in so more pain.
>
> Credibility will be really hard to establish in cases such as this.
> Moreover,
> the diagnosis would have to be rational and logical and based upon
> credible, proven history, the Patient's and the community. I think I
have
> just eliminated the human Provider from the equation.
>
> Modeling is a great effort but fails quickly when it incorporates
humans.
> I have no objections to humans, I object to incorporating humans in a
> procedure that involves accuracy and precision. They are better at
> receiving dissimilar information, evaluating it, developing
alternatives,
> making decisions and following a course of action as long as it
appears
> to be the right thing to do.
>
> Automatic, knowledge-based processes and procedures could serve the
> Patient and Provider well. Modelling the Patient-Provider is very
difficult.
>
> -Thomas Clark
>
>
> -
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> please send a message to d.lloyd at openehr.org

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