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

[Karsten Hilbert]

> As each clin_health_issue is given care across a single or multiple 
> episodes, the name (description) of clin_health_issue can be better 
> tailored to take account of cumulative information but might diabetes 
> mellitus become
> DM, diet-ctrld -->
> DM, on oral Rx -->
> DM, on insulin
Personally, I would use "Metabolic Syndrome/DM" should
DM be the only currently known manifestation thereof (given,
of course, it *is* DM due to metabolic syndrome). What you
list here sounds more like episode names to me - IOW our
problem list.

> Presuming the patient over time develops complications, might we create 
> *additional* issues
> diab nephropathy - creat 150-180, prot .4g/dl
I certainly wouldn't. It all belongs to the metabolic
syndrome. The episode we are giving care in is for diab
nephropathy, however. If one includes a tiny little bit of
status info in that like you suggest here is up to ones
liking, I suppose. Interestingly Weed, Rogers, Margold and
others in the field do, too, even in the very first seminal
papers back around 1969.

> However the clin_health_issue table provides no means to view these as 
> related i.e. when sorting, the diving accident would be interposed 
> between them, and if the second issue had instead been labeled 
> "nephropathy, diabetic" many more items would sort interposed.
Interesting observation !

> In the meantime, various clinical narrative entries will have permitted 
> diagnoses to be coded in clin_diag. The sort order of whatever is the 
> coding system might go part way toward a sort order that puts 
> clinically-related items closer together in a list.
A good idea, too.

> If the health_issue is kept general (diabetes mellitus), it is still 
> possible to accumulate a new coded diagnosis with each SOAP note. Since 
> each of these clin_diag records could be related back to that one 
> general health_issue it could be tidy to express (nest) the accumulated 
> diagnoses underneath the general health issue.
Yes. Or the "episode names" which would be drawn from
soAp/AOE/diagnoses.

> This is harder to do if 
> the diagnoses are distributed across multiple health issues when each 
> just reflects various dimensions of a chronic disease.
That would mean the treating doc hasn't yet realized they are
dimensions of a chronic issue due to lack of data, lack of
insight - or she has done so on purpose.

> Probably it is not a great alternative, mainly because these dimensions 
> can easily be active at the same time, and would benefit from the 
> threading of assessments that could not otherwise be split out if all 
> lumped under one general health issue.
They would, however, show up under different episodes and
hence under different episode names.

BTW, I don't think we should use the health issue names for
the problem list but rather the episode names !  I do think
the user will be interacting with the episode name much more
than with the health issue name. The latter would turn up
mainly when adding episodes to health issues. Front desk staff
would attach encounters to *episodes*, not health issues.

> Maybe the most simple but fully flexible way is to just adjust the 
> naming of the issues, together with leading numbers, to control the 
> sort order?
That sounds very reasonable and in fact Weed/Hurst do it like
that. 

> Also, could the list of clin_health_issues could be filtered to remove 
> from view any which did not have a clin_narr row related to a clin_diag 
> row marked is_significant? Or is such a selection not very manageable 
> across 3 tables?
It is entirely possible.

Karsten
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