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Re: [Gnumed-devel] Episode selection and creation

From: J Busser
Subject: Re: [Gnumed-devel] Episode selection and creation
Date: Tue, 13 Sep 2005 10:39:27 -0700

At 8:02 AM +1000 9/13/05, Ian Haywood wrote:
Karsten Hilbert wrote:
 On Mon, Sep 12, 2005 at 07:42:41AM +1000, Ian Haywood wrote:

What should happen if the user had selected a health issue
from the problem list but which already has an open episode
of age < 90 days ? I think we then need to ask the user for
guidance, no ?

IMHO I would like it silently added to the open episode.

 Sounds OK to me. What about the *name* of the episode ? The
 > user may wonder how to find his notes ...

If the EMR tree by default opens with all subitem triangles "closed" it will be an extra step for the user to have to open the triangles to identify whether there exists an open episode.

Options would include
- pre-opening the triangles for issues that have open episodes.
- appending to the issue line some indication (symbol or episode name) the fact of an open episode
- give no indication, however when a user clicks on an issue
---> if there is no open episode, start one BUT
---> if an open episode exists,
-------> either default the new encounter to belong to the open episode or
-------> notify the user "Append to (open) episode "<Episode name> initiated <date>, last encountered <date>?" and if the user answers "no" then close the episode and begin another. I guess closure of the episode would be dated the current date/time because that is when the judgement was made to close the episode. It should still be possible to identify the date of the last encounter within the episode.

I do have a question about the decision to close an open episode from the tree. What if an open episode contains a plan that is incomplete? How would one know, except by inspecting the content of the encounters? So if the episode perhaps *should* stay open, maybe its better for the user (who declines to append) to have to make an *informed* decision to close the episode, and maybe that can only reasonably be done by viewing it. Depends if we have any agreement on what it means to 'close" an episode. I think it should carry some meaning such as "symptoms expected to resolve" (although you would not know until later) or "care completed". A patient may have failed to return within 90 days on account of personal problems and I am not sure what is to be gained by having automatically "closed" the episode, is there some inherent (or EMR performance-based) advantage to closing it arbitrarily?

I also have a question about a constraint to have only one open episode. I don't disagree but it does have consequences. It means that a patient who, within their diabetes, has active problems of poor control and foot ailments, they cannot have one open episode of each inside the top-level issue of diabetes. So there would be two choices, correct? Bury/blend every aspect of diabetes care inside diabetes "episodes" some of which will pertain to education, some of which will pertain to hypoglycemia, some to weight loss, some to diet, some to foot care, and many to a combination of two of these. Or to split some out e.g.
- diabetes mellitus (control)
- diabetes mellitus (foot care)

While I do little primary care, I imagine that between followup visits, phone management, patient-initiated visits, and dealing with contacts from the diabetes centre and nurses plus lab results, there might easily be a couple of entries per month just for diabetes so over the course of --- say --- 10 years there could be 2-3/mo x 12mo/yr x 10 yrs = 240-360 entries. That is a lot.

So would there be a view that (for example) when dealing with this patient's feet, looking back over their foot care (& ulcer) history to review its course, the specialists involved, when were the most recent contacts, there would be fewer visits to need to browse if they were split out under
- diabetes mellitus (foot care)

Would this also simplify the export (once we are able to do so) of a *subset* of EMR information, say on one health issue, upon referral to a specialist?

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