Re: [Gnumed-devel] Episode selection and creation

[Ian Haywood]

J Busser wrote:

> - pre-opening the triangles for issues that have open episodes.
that's the idea.

> 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?
Simply this -- to cut down the number of interruptions in workflow
so users will actually accept the interface.

Note we don't close an episode until the patient re-presents after 90 days.
It's difficult to see how a "true" episode (see below) would still be active
after not seeing the patient for 90 days. Sure, it could happen, and the user 
should be able to manually override
closure of the episode that 1% of the time, but it's not worth interrupting the
user the other 99 times.
If you want the popups, they can be turned on.

I think there is a cultural issue here. Remember we have no nurse-practitioners
or "physician-assistants" in Australia. Our consultations (well not mine, I've 
just started in GP)
are *fast*. Richard and Horst each see ~40 patients a day: no time for popups.

> I also have a question about a constraint to have only one open episode.
Personally, my whole understanding of episodes hangs by this thread.

> 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? 
You are trying to make episodes into "sub-issues": they are not.

> - diabetes mellitus (control)
> - diabetes mellitus (foot care)
Yep. Diabetic ulcers can last for ages, but surely you or the nurse would
see the patient every couple of months, so the episode remains open.


> 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?
Indeed.

Richard Terry wrote:
> The more and more I play with this type of data entry in my consultations, , 
> the more I'm coming around to Malcom Irelands view (and I suspect Horsts and 
> David Guest's as well) that we need a large single textbox to collect all the 
> information we type in,  use our own intelligence to aggravate and format 
> this within this text box, and use the smarts such as popup phrase wheel to 
> provide the time saving mechanisms to save typing complete words/phrases, , 
> provide the popup structured data entry edit area's when needed (eg 
> vaccination, scripts, past history item etc).
I'm inclined to agree, and not only because it's ten s**tloads easier 
programmatically ;-)
We are still going to be able to tag SOAP some of the text, we know "BP 140/90" 
is sOap, for example,
but it will still leave a "residuum" of text which is untaggable.
Can we have a "U" (Unknown) for clin_root_item.soap_cat?
Remember it's not either/or: even Karsten (AFAIK) doesn't object to an 
alternative
notes-entry widget.
The question becomes, how to link the notes or parts of notes to the various
episodes.
There are two ways:
        - link the *whole* set of notes to one or more problems (currently 
forbidden by the backend schema)
        - have multiple (presumably tabbed) notes panels, each linked to *one* 
(or no) episode.
I'm inclined to the latter, because if you have a comment in the notes you want 
to link to
3 of the patients 4 problems, what does that really mean? You are better 
linking it to none
(that's allowed)


Ian Haywood