HISTORY DATA SET IN EPR
Dear All, In HISTORY DATA SET,if seen carefully,the data can be divided into two broad categories. a.The format. b.The descriptive data. The history format is more or less structured all over the world. The descriptive part is mainly in the History of Present Illness in which the Onset Duration and Progess(ODP) of each complaint is given in chronological order. The rest of the history format is not so descriptive and can be easily strucutured. In History of present illness if we assign a indentifier for each Chief compliant which is going to be described later in terms of ONSET DURATION PROGESS, we have already been able to structure a large part of history. Again a sypmtom list classified according to the systems can be provided. I have already incorporated this in the system which I have designed. Plus if we incorporate CPGs in the system we will be to provide a smaller but comprehensive symptom set. I leave the thread OPEN for discussion. DR ANIKET JOSHI __ Do you Yahoo!? Yahoo! SiteBuilder - Free, easy-to-use web site design software http://sitebuilder.yahoo.com - If you have any questions about using this list, please send a message to d.lloyd at openehr.org
HISTORY DATA SET IN EPR
Great comments... It's always good to see this whole mess from the point of view of the most concerned eyeballs: those of patients. Often, the disconnect that patients perceive between their reported problems and prescribed solutions, is due to them having been intentionally insulated from a reasoning process that most would not understand anyway. Personally, I prefer to gauge each patient's ability to understand my medical reasoning... by feeding a little of it to them and seeing what sort of response it elicits. There are many reasons why patients often WANT to remain insulated from the medical decision making... but the ones who want/demand to be included have a right to be. I believe that the patient view of one's medical record should include a patient-understandable view of not just what had been ordered for them... i.e., done to them... but of the reasoning that led to it. How much to show them, of course, is the $64K question. Doctors are nervous about this whole subject area... as are their malpractice insurers. But we cannot ignore the steadily increasing level of sophistication within the patient community... of patient access through the Internet to best practice guidelines. Some patients arrive nowadays, armed with pretty darned good differential diagnosis lists to accompany their well-articulated complaints and symptoms. Some even have very good understandings of each possible diagnosis and the state of the art treatment protocols. For this reason, the Institute of Medicine content recommendations (reflected in the present version 1.0 of the HL7 EHR ballot) includes 4 main care settings: in-patient, out-patient, nursing home, and personal health record. The last is the patient's view of the record... presumably with certain write privileges for address, contact information, etc., and in the reporting of symptoms and complaints. This is bold new territory for us... but I think that we will all win with greater and more informed participation from the patients who desire it. Without a robust patient-view of the EHR to point them to, however, these type patients are likely to drive doctors nuts with questions. Hence, the doctor's inclination to keep them well-insulated from his medical thinking. 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: 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: Monday, August 11, 2003 10:25 AM Subject: Re: HISTORY DATA SET IN EPR Hi Christopher, Good response. Comments in text. -ThomasClark Christopher Feahr wrote: 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. 'model' conveys different information to different communities. A Patient Process Diagram would be interesting whereby current and historical Patient information is combined with Healthcare Industry available information and the interaction between Patient and Provider and compared with the results of the 'visit' and subsequent 'results' to determine possible and actual 'outcomes'. To me 'model' infers a static process whereby known data sets are processed to obtain known results. A Process Diagram, a component in a larger dynamic structure, should what information is available, how it is process and what the 'outcomes' are. This in turn should be compared with the 'outcomes' that actually occur, the measurement occurring at a later stage (from Control Systems). 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. Somehow the Patient's input does not get integrated with the Provider-related information which is why many issues arise between Patients and Providers. Looked at from the Patient's perspective, the Healthcare Industry is like a machine with a microphone that one can talk into and perhaps get a response in the form of a list of drug prescriptions and advice (take more aspirin). Consistency can be missing, presuming an on-going condition(s), and cause the Patient
HISTORY DATA SET IN EPR
Hi Christopher, Christopher Feahr wrote: For this reason, the Institute of Medicine content recommendations (reflected in the present version 1.0 of the HL7 EHR ballot) includes 4 main care settings: in-patient, out-patient, nursing home, and personal health record. The last is the patient's view of the record... I think I'm a little lost here. I've read HIPPA, the regs and the preample, and my understanding is that the patient now has a legal right to copies of his medical record and a right to contest the contents of that record. Are you saying that the IOM / HL7 are taking the position that the physician can decide to withhold portions of that record? Where can I find out more about this? Best regards, Bill - If you have any questions about using this list, please send a message to d.lloyd at openehr.org
Hazards and risks of large central data repositories
Apropos my recent post to this list about the large hazards to confidentiality posed by large, centralised health data repositories [1], see this report of a serious security breach at the data centre of Acxiom, one of the world's largest consumer database companies, with a multi-billion dollar turnover and an undoubtedly large IT security budget: http://www.charlotte.com/mld/observer/business/6483972.htm Note that it was an insider job - the consensus is that the insider threat model is the one to really worry about, as unpalatable as that is. Tim C [1] The risk of a security breach is no less, and may be much greater in smaller health data repositories, but the collective hazard is less because the records of a much smaller number of people are stored in such smaller repositories. - If you have any questions about using this list, please send a message to d.lloyd at openehr.org
HISTORY DATA SET IN EPR
RE: Are you saying that the IOM / HL7 are taking the position that the physician can decide to withhold portions of that record? No... not at all! You can read the HL7 ballot package and join the ballot pool at www.hl7.org/ehr (reduced fee for non-HL7 members of $100 to join the pool... reading/downloading the documents is free.) IOM and HL7 were essentially asked (this Spring) by CMS/HHS to collaborate on an EHR standard. IOM released it's recommendations a couple weeks ago regarding content requirements for the EHR. 4 principal record-views were contemplated by IOM and included as care setting profiles in the HL7 ballot. One of these would be a patient-view of his own EHR, with the ability to change/add certain data. This does not alter the HIPAA mandate in any way... although direct patient access to an up-to-date EHR would probably cut down on requests to providers for paper copies of health records. The issue of who could/should/would have read/write access to ANY EHR is still very much a matter of discussion. There is nothing about rights of access or stewardship or any other security issues in the present EHR ballot. 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: Bill Walton bill.wal...@jstats.com To: openehr-technical at openehr.org Sent: Monday, August 11, 2003 1:53 PM Subject: Re: HISTORY DATA SET IN EPR Hi Christopher, Christopher Feahr wrote: For this reason, the Institute of Medicine content recommendations (reflected in the present version 1.0 of the HL7 EHR ballot) includes 4 main care settings: in-patient, out-patient, nursing home, and personal health record. The last is the patient's view of the record... I think I'm a little lost here. I've read HIPPA, the regs and the preample, and my understanding is that the patient now has a legal right to copies of his medical record and a right to contest the contents of that record. Are you saying that the IOM / HL7 are taking the position that the physician can decide to withhold portions of that record? Where can I find out more about this? Best regards, Bill - 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
HISTORY DATA SET IN EPR
Hi Karsten, please see comments in-line. thanks. 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.hilb...@gmx.net To: openehr-technical at openehr.org Sent: Monday, August 11, 2003 3:53 PM Subject: Re: HISTORY DATA SET IN EPR 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... Does *more* information also mean *more information that's accurate* ? Likely not if data providers are significantly limited by a restricted set of codes. Reasoning for this in Slee, Slee, Schmid The endangered Medical Record. My proposal is to structure what is possible to structure... but to do it with a standard. Any health information that is still too fuzzy for the chosen structure will have to be written freehand, as we do now. 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. While technically enticing, practically, uhm, no, no way (lest I misunderstand your intent). Well... yes... I'm dreaming a little... I'll grant you that. But we should be attempting to increase/improve the structure of our records and data anyway... in order to improve care. Even if this still has to be mapped to the payer's old 5-character dumb codes, the claim-coding process will be potentially more automatic and better supported by the record in the event of payer audit. If we could point today (in the US) to the system that I am imagining... one in which payers could reach out as needed and query EHR systems for data to support adjudication, then payers would be hard-pressed to justify the enormous provider-expense of serving this information to them on silver claim-platters. By the end of 2003 I suspect that we will have more payer-specific variants of the HIPAA 837 transaction than we ever had of the NSF and UB92 combined. At the end of the day, each payer wants a virtually unique data set to support its claims. I think we should point them to the EHR-landfill and hand them a shovel... I have patients to see! but doctors should be able to agree on just the right degree of precision to support the medical job... What, doctors agreeing on something ? Yes, I'm being cynical :-) I'll admit... doctors do not make this easy! But doctors have agreed in the sense that they have not objected to standards of care concepts and evidence based clinical practice guidelines. I believe that the acceptable minimum level of precision is documentable from existing literature. Practitioners can always add non-structured notes and information as necessary to beef up the precision of any structured/coded record information. I' assuming that whatever precision level makes the doctors happy will also be sufficient for payers and governments. That I tend to agree to. and I'm suggesting that information should be reduced as much as possible to a standard set of codes. If that means to reduce what I can put in my clinical notes then No, thanks. I use the fuzziness of German when writing progress notes to myself in order to capture the degree of fuzziness of the specific ailment at hand and augment that with commonly used scales (GCS, APGAR, Janda, ...) to map my notes to more standard values when writing referral letters etc being sent to colleagues. Of course I am not perfect in this and could make use of a tool that facilitates my correctly applying standard scales. Karsten -- 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
