Re: [Gnumed-devel] need assessment from fellow clinicians

[James Busser]

Methinks an even bigger challenge than billing!

A few thoughts that may help/guide convergence and some questions to determine 
if we 
are of the same understanding:

- active problems (aPs) are a subset of all of a patient's problems, so aPs can 
(best?) be regarded as those problems that have the attribute "active". Yet 
problems, while active, can have further attributes:
...active-uncontrolled (by definition most "active" & likely source of RFEs)
...active-controlled (parameters [like symptoms, measures] satisfactory)
...inactive-dormant (able to recur)
...inactive-cured (unable to recur e.g. appendicitis post appendectomy)
- if we assert that the following, though codable to diagnoses, are also 
appropriate 
to consider "problems', then each of a patient's Diabetes, Hypertension, Asthma 
and 
Back pain can, if coded as controlled or uncontrolled, be automatically 
understood 
to be "active" whereas once the back pain improves, or the diabetes proved to 
be 
gestational or steroid-related, these could be coded "dormant" thus understood 
to be 
"inactive". These are more functionally informative than active/inactive, 
provide 
more useful thresholds by which to expand and contract data displays while 
sparing 
the need to manually update a separate active/inactive attribute.
- the aPs would arise from the latest AOE per episode, I am wondering therefore 
if 
aP table records are just a subset of specially-attributed AOE records, and 
whether 
during any one episode the AOE approximates an active-uncontrolled problem and 
whether it is upon conclusion of an episode that an AOE becomes an aP that is 
considered either active-controlled or inactive (-dormant or -cured as the case 
applies) --- see also below, concerning "forced closure" of an episode when a 
problem is not yet controlled ---

Reason for Encounter (RFEs)
- initiation may be
...by doctors (as in followups or recalls or periodic health exams)
...by patients (as in new, or worsening, or recurrent complaints) or
...by others (a concerned relative, a community nurse, an employer)
- presumably a Gnumed doctor initiating an encounter would desire to designate 
the 
inciting aP or, if none yet exists, input a value into the AOE that is able to 
be 
either kept, or modified, at the time of the encounter
- supposing a Gnumed doctor initiates an encounter to reassess the hypertension 
of a 
patient last seen 6 or 12 months before, is a new episode being created/opened, 
with 
the potential to range from a one-encounter episode (if the BP is under 
control) or 
a multi-encounter episode (if the hypertension proves to be active-uncontrolled)

- if within any one "open" episode more than one problem is being dealt with, 
does 
the episode remain "open" until the last of the problems achieves the status 
active-
controlled (or can an episode be "forced" closed if the patient and doctor 
agree 
that partial control is all that can be achieved until the patient can later 
engage 
again in a future episode)

If multiple RFEs across multiple encounters within an episode prove to pertain 
to a 
single disorder, together with its investigations, treatments and any side 
effects, 
I could understand that a single AOE could meaningfully give:

> the gist thereof in one catchy phrase.
Suppose a patient begins thiazide for hypertension, gets a rash and gout, takes 
NSAIDs, and gets a GI bleed, all before hypertension control is achieved.

In such a case, where within an open episode of care the encounters span more 
than 
one problem, we don't open multiple overlapping episodes, do we?  But if we 
don't, 
and there is therefoe only one AOE, it will have to provide a phrase to 
paraphrase 
multiple problems e.g.
"BP high, thiazide for hypertension, got a rash and gouty flare, stopped 
thiazide, 
started ACE, GI bleed on NSAIDs, scoped for large gastric ulcer, Rx PPI, 
stable, BP 
controlled"
If the above is what is intended, then the AOE would not equate to an aP, would 
it?