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

[Jim Busser]

On Jul 21, 2004, at 10:35 AM, Jim Busser wrote:
> On Jun 30, 2004, at 6:33 AM, Karsten Hilbert wrote:
> > > - 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 [state] "active".
> > Yes and no. Except that I would propose to define aPs
> > backwards using this algorithm:
> >
> > 1) grab all AOEs that are labelled "permanently relevant"
> > 2) look at active episodes (how to determine that is up for grabs)
> > 3) of those grab the most recent AOEs
>
> the schema for clin_narrative presently makes no provision for a 
> soAp/is_aoe row to be designated "permanently relevant" - how is this 
> to be achieved in the schema?

Suggest we provide the field "is_significant" (like what is in the 
table clin_diag)

Presumably the main function is to more easily exclude, during a review 
or summary of a patient, the "clutter" (clinically speaking.

Within any episode of care, once an AOE is decided to be significant, 
would it be reasonable for the AOEs for all subsequent encounters 
within the episode to default "significant'?

We do already have in clin_diag the means to categorize individual 
entries as is_chronic, is_active, is_definite, is_significant and this 
already permits the means to select or exclude various groups of 
records whose parent soAp row (whether AOE or not) remains easily 
accessed to provide a helpful context.

Is there relevance to categorizing parent clin_health_issues as 
significant or is this best achieved backwards from significant AOEs.

And if it makes more sense to define / select backwards then does 
clin_diag already achieve this for us, so that if the clin_diag is 
significant, then the encounter episode from which the diagnosis was 
coded is also significant (even if it was not categorized that way). So 
maybe we don't need is_significant in the AOEs and health issues 
(clin_narrative and clin_health issue tables) - we instead

1) grab all clin_diag that are "is_active", optional expansion to 
"is_significant" and "is_chronic"
2) from these, identify the parent soAp row
3) identify for these episode-encounters the latest AOE rows
4) also include the latest AOEs for any episodes whose last encounter 
is within the timeout

I haven't yet figured out if, after a patient has had a diagnosis 
attached, how that diagnosis is later re-used on that same patient. 
There is value identifying the original/oldest/first encounter for any 
diagnosis. There is value to updating those clin_diag records as over 
time their state (or our assessment) can change as to whether it is 
chronic, active or significant but ,aybe it is better for this to be - 
in database audit terms - an update of that clin_diag record rather 
than another copy. There would be value in that one record to preserve 
the original encounter-episode information (add field 
fk_orig_narrative) as well as the encounter-episode at which it was 
updated.