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Re: [Gnumed-devel] clin_health_issue - some thoughts

From: Karsten Hilbert
Subject: Re: [Gnumed-devel] clin_health_issue - some thoughts
Date: Fri, 19 Nov 2004 17:08:46 +0100
User-agent: Mutt/

> Use case for episodes
Thanks !

> A nondiabetic student has a "spell" (note avoidance of gnumed 
> "episode")  of possible hypoglycemia leading to a series of visits, 
> tests etc which can be clustered within one gnumed episode. The spell 
> may have presented with any among headaches, confusion, feeling 
> faint, diaphoresis, shakiness. Let us say it was bad enough that it 
> led to an ambulance being called with a capillary glucose level of 
> 2.5. The AOE becomes "hypoglycemia NYD" and after evaluation it is 
> determined that they were eating poorly prior to exams and had some 
> alcohol so the AOE becomes "hypoglycemia, ?fasting ?EtOH".

> I am not sure whether to code a diagnosis - I am reluctant to code an 
> alcohol "disorder"
me, too

> and ICD9 otherwise offers me only 251 "disorders 
> of pancreatic internal secretion"
ICD9 is insufficient, then. In GnuMed you can attach any
number of codes, eg. from ICD10 or from the Terry-Ireland
classification without foregoing the ability to also attach an
- however appropriate - ICD9 code (if you *have* to do that
for, say, reimbursement).

> The patient is cautioned. They 
> have had no recurrence in the 14 days since the original spell 
> including 2 followup visits. Maybe the gnumed episode (or at least 
> the clinical problem) is inactive. Maybe only time will tell.
As Ian points out the more time progresses without anything
noteworthy happening the more likely the episode is going to
remain closed. There may or may not be a dormant,
as-yet-unrecognized health issue behind it but we need to
concern ourselves with that just yet. Maybe a year later
another spell will occur, maybe not, and translate into an
episode of care.

> To bind these episodes as having some possible relationship to each 
> other, I would have to establish / create a "clin_health_issue" which 
> could inherit the most recent AOE. This AOE might, depending on that 
> second spell, be another "hypoglycemia, ?fasting ?EtOH" but what if 
> the second spell had no incriminating causes? The second spell might 
> have become "hypoglycemia, r/o insulinoma" and might be reasonable to 
> put as a new gnumed episode.
That is possible, yes.

> If the clin_health_issue takes its description (name) from the most 
> recent episode's AOE, then the name given to the issue may have 
> become too narrow - maybe the student, now embarassed, is hiding a 
> drinking problem.
It is precisely my job to harbour and act on such suspicions.
I am the one to notice the fishy things about the episodes and
act and reorder accordingly. 

> Maybe clin_health_issue should just be 
> "hypoglycemia".
Likely so, or "recurrent hypoglycemia OUO" (of unknown origin)

> Maybe the clin_health_issue, when it spans a great 
> many episodes, needs to be able to be given a name that communicates 
> somethign about the episodes as a whole, not just the AOE of the very 
> last episode.
That's the precise reason why initially I had explicit name fields
in both clin_episode and clin_health_issue. I agree we might
be better off removing that field from clin_episode and
getting that value from the attached narrative. I am less
certain with the health issues. That's why I started moving
the backend to the new concept with episodes only, for now.

> If there are later further episodes, and we establish the presence of 
> an insulinoma, it can be reflected in the AOE and this can "float" to 
> become the description for the "clin_health_issue" and presumably in 
> a tree listing we could see several episodes, each able to be 
> displayed as named somewhat differently on account of preserving the 
> names of their varied AOEs?
Yes, this is how I imagine things :-)

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