Re: [Gnumed-devel] Re: Cannot change the dates of the encounters

[James Busser]

On 6-Sep-08, at 9:38 AM, Karsten Hilbert wrote:

> Currently, the journal is retrieved like so:
> ...
> IOW, items are ordered by their date of clinical occurrence. This  
> will often but not
> always be the original modified_when. So this is sequenced as to  
> when things are
> thought to clinically have happened. Encounters are not taking into  
> account at all there.
>
> If you think we *should* - first and foremost - sequence by  
> encounter we'd have to
> rework that.
> ...
> What exactly should we regard as the "literally" chronological  
> journal ?
>
> Literally as in time-of-insertion or time-of-clinical-occurrence ?

Time-of-insertion, *and* the time-of-clinical-occurrence are  
important. Since the journal is the record, I was thinking in this  
context "literal" would refer to the insertion.

Time-of-clinical-occurrence is already the basis of the EMR tree, so  
I was thinking we could / should use the EMR journal to display along  
time of insertion.

Suppose you are the GP filling in for someone who is away for 4  
weeks. In between, care has already been given by one or even two  
others in the praxis.

The patient comes with questions about the possible cancer in their  
spine, not wanting to wait until their regular GP is back.

The tree presently has a health issue "vertebral abN query lymphoma"  
with a clinical date of 5 months ago. You open this item in the tree  
and beneath it, within the episode, you see several visits about  
exercise and physio but start to wonder why only after 5 months did  
anyone request a CT as recommended in the report. You might note in  
the document archive that although the report was itself dated by the  
radiologist as 5 months ago, it was only archived into GNUmed last  
week by a colleague, who is now themself on vacation.

If you look at the Journal the way that it works presently, GNUmed  
would not (?) present to you that this was part of the discussion of  
the last visit, coming about as a result of the praxis receiving a  
copy of the report ordered 5 months ago by a walk-in clinic doctor  
elsewhere. Assignment of a clinical_when of 5 months ago would move  
the information potentially several screens up in the Journal. Or  
maybe part of the last visit would concern the discussion, but it  
would not show the (late) entry of the radiology report, since that  
had been given a clin_when of 5 months ago and legitimate because  
after 5 months the condition of the spine could have changed.

IOW being able to see information in the order (time-of-insertion) it  
was entered can help to explain when clinicians became aware of  
different pieces of information. This then better helps to understand  
any irregularities in what one would otherwise have thought the care  
should have been.

IMO the need to easily ascertain this from the EMR is even more  
important when care is shared, since memory is not.. We are  
interested in the timeline of the illness, but if we are to imporve  
care we must also be able to ascertain unambiguously the timeline of  
the *care* which is affected by the timeline of the *documentation*  
(as proxy for information awareness).