Re: [Gnumed-devel] Questions about Episode/health issue

[Karsten Hilbert]

On Sun, Jun 26, 2005 at 11:18:51AM +1000, Richard wrote:

> I've got your 2.4 code running successfully in 2.6 now
Good.

> and I will gradually 
> change the non-critical gui-code which prevents various windows from running 
> under 2.6 to make it compatible over the next week or so
Thanks.

> Latest CVS + running gnumed via:
> 
> sh gm-0_1-from-cvs.sh
> 
> I've a question - one I've always been confused about, however as the 
> functionality of this program seems atrocious,
I notice that you seem to be the only person on this list using
derogatory terms when characterizing work someone else has done.

> perhaps if someone will help 
> me understand how it is meant to function and what things mean,
Sure, we'll have to explain that many times over. An attempt
is in the Wiki in the User Manual but it needs improvement.
Please do read it and suggest amendments.

http://salaam.homeunix.com/twiki/bin/view/Gnumed/BasicEmrConcept

I am improving it as we speak.

> I may be able 
> to help improve it for the ordinary user.
That would be helpful.

> 1) IN my attempts to use it I'm confronted by an active problem list, which 
> contains both annotated 'health issues', and 'episodes' - what is the 
> difference and conceptually just how is one meant to use them
The important concept or "thing" is the episode. The episode
is what most would think is a problem in the problem list.
An episode of illness is a circumscribed span of time in which
a problem with the patient's health is dealt with. The problem
is - so to speak - the name or label of that episode.

OTOH, health issues are facts about the patient's health.
Now, there are thousands of such facts. And most of them are
only of temporary interest and importance. However, some facts
are of long-term importance and significance. Such facts are
often categorized into past medical history, operations, etc.
In fact, we also count past medical history items as health
issues. However, our definitions is a bit more allowing: "A
health issue is a fact about the patient's health that is of
long-term significance". In most cases this will be something
that amounts to a chronic illness/disability the patient
suffers from. Perhaps an example may help:

Patient has

coag level (Quick/TPZ ?) of 20%
 - clearly a fact of poor health (unless intended)
 - may be an "active problem" - an episode name - as long as
   we don't have an explanation

ethyl-toxic cirrhosis of liver
 - clearly a fact about the patient's health of
   long-term significance, likely the cause of the above
 - episode can now be renamed to "liver cirrhosis/c2h5oh"
 - it may be turned into a health issue if desired

Eventually it turns out that in this patient it is very hard
to get the coag levels under control. First this may become
prominent as
- an episode of "decompensated coags factors"
- later to be recognized as part of the health issue "liver cirrhosis/c2h5oh"
- but perhaps found to be important and frequently enough to
  warrant it's own health issue "poor coag controllability" or
  demanding an amendment of "liver cirrhosis/c2h5oh" into
  "liver cirrhosis/c2h5oh/poor coags"

This is about evolution of case knowledge.

Now, the list of active problems show *open* episodes plus
*clinically relevant* health issues. Both are clearly
"problems" with the patient's health.

The annotation in the problem list shown in the progress notes
section only serves to make it less suprising when an episode
selector will be presented and when not -- once you understand
the concept.

> 2)I note that double clicking on something referenced as a 'episode', brings 
> up a new tab to allow the entry of clinical notess
As we want it.

> 3)I note that double clicking on a health issue, brings up a prompt asking 
> for 
> a tag for an episode ?? don't understand the sense of this.
Clinical data can only ever be part of an episode. If you
double click a health issue you either want to select an
existing episode or create a new one within that health issue.
That's what this widget is for. If you want an unassociated
new tab use the appropriate button at the bottom left.

> in any event - all these - health issues + episodes seem to end up on the 
> same 
> active problem list?
No, only those that *are* problems. Eg neither closed episodes
nor the (currently) clinically not relevant episodes.

> Any attempt to review the patients progress notes anywhere dosn't seem to be 
> very easy - eg the EMR tree is ambiguous
How is that ?

> and hard to navigate
How ?

I do agree the tree has quite some room for improvement. It
isn't yet the best tool for answering "What happened during
the last 3 encounters ?" and such.

> the EMR Journal which seems to be the best
It is a) very ugly, b) totally ignores the benefit one could
draw from grouping into *at least* episodes, c) does not
display when an encounter crosses the date boundary.

It's main purpose in life is to allow doctors to get some idea
of the EMR in a view they used to see.

> isn't updated unless you close down the 
> program and re-load it.
This issue is still unresolved. No one came up with a
solution so far.

> the EMRDUMP ?what is the purpose of this???
The EMRDUMP is not part of the release 0.1. What are you
referring to ?

> Also saving an episode took an inordinately long time.
Which number do you attach to "inordinately" ?

> BTW, I'm not trying to be picky about this. I genuinely want to help and 
> understand this, otherwise I wouldn't have spent nearly two hours of my 
> sunday morning attempting to see how this works.
I know. I am truly thankful that you do put up with my
"explaining away" your concerns :-)

Karsten
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