Hi, One of the things that has been holding me up is the conundrum around coded clinical documentation.
I would use OpenEHR exclusively but as I delve into the depths of integration I am getting nervous that the archetypes have not yet been mapped to LOINC or SNOMED. As an example comparison take a patients (non-birth) weight for example. In pediatric hospitals and for patients receiving chemo it has always been critical to differentiate between a carefully measured weight suitable to weight dose calculations versus a weight perhaps measured adhoc at an outpatient clinic. In SNOMED I find 27113001 : body weight - synonym of Body weight (observable entity) In OpenEHR we have openEHR-EHR-OBSERVATION.body_weight.v1.adl which defines the weight, clothing worn, and device used. In LOINC we have LOINC_COMPONENT PROPERTY TIME_ASPCT SYSTEM SCALE_TYP METHOD_TYP 3141-9 Body weight Mass Pt ^Patient Qn Measured 3142-7 Body weight Mass Pt ^Patient Qn Stated 50064-5 Body weight Mass Pt ^Patient Qn Ideal 8335-2 Body weight Mass Pt ^Patient Qn Estimated I expect the SNOMED term could be qualified - but I would have to search around to figure out with which term would be appropriate (illustrating the challenge). So I guess ultimately the question boils down to what is everyone/anyone else doing - OpenEHR - OpenEHR + LOINC - OpenEHR + SNOMED - All (tough especially as each system has its own set of terms and concepts of what is what) And perhaps what does your average EMR doc want? I am not talking about ICD9/10 or CPT codes as I need to do those for billing anyway. thanks! Greg http://www.patientos.org Open Source EMR in the making
