Re: [Gnumed-devel] EMR tree display of allergy

[James Busser]

On 20-Sep-08, at 6:44 AM, Rogerio Luz wrote:

> I hate to poke around in other people´s war ;-) but I don´t see  
> where we are in this discussion.
>
> Undisclosed is something kept secret, no? Something like:   
> Undisclosed HIV infection status, right?
>
> So why is Undisclosed worse than Unresolved?
>
> I personally translated it to something on the lines of "did not  
> want to say" ... so if this is NOT the case I need to retranslate  
> it :)

You are welcome to poke or insert yourself, although I did not  
consider or intend it to be any war :-)

Mainly I am trying to determine what value it gives to have a state  
that is other than:

1. the patient and/or collateral records affirm the apparent absence  
of allergy
2. the patient or collateral are able to inform us about specific  
allergies

Even when the patient or collateral advised us only about some  
allergies, it is possible that others had been omitted or forgotten,  
but we had not resolved at any point to split that hair.

We are then left with determining the value (i.e. how we would use)  
and state that is "in between".

In the original thread, it was pointed out that some software refuses  
to permit a prescription to be made without forcing the user into  
committing an allergy state that must only be one of #1 or #2.

The problem with this is that in the case of the patient who
- would not say (maybe adverse reaction to treatment for a sexually- 
acquired disease or psychiatric problem or medication for other  
condition they did not yet feel comfortable to share or to put into  
the record) or
- who cannot remember, or remembers that they were allergic to  
something but cannot remember what it was
the most appropriate course of action would be -- at the point of  
prescription -- this discussion:

"We did not yet pin down exactly your allergies, however I want to  
prescribe X. "X" is the following *kind* of drug. It is also known  
under trade or brand names as Y and Z. The main side effects to know  
about are A B C. Provided that there is no reason that you know or  
recall as being unable to take this medication, I would like you to  
trial it. Shall we proceed?"

In other words, the constraint that the patient did not want to put  
on record their allergy is too narrow.

Is there any agreement that once the question of allergy is asked, we  
want to be able to alter the state from "unasked" (which is more  
precise than "unknown") to something else? And that when the extent  
of triggers is not believed to be known (when we have reason to know  
or believe something may be missing) we want the ability to know or  
remind ourself -- at the point of prescription -- that this  
intermediate state exists?

I think the practical implications are important to understand. In  
the case of the patient who refuses to say, it may be helpful to be  
able to say "I understand if there is something that you are not yet  
comfortable to tell me, or cannot remember, however we want to keep  
things safe. And therefore it may or may not come about, at this or  
future visits, that I need to prescribe something to which you  
*might* be allergic. Is this what we are saying, that you have  
knowledge that you may be allergic, however you want to be reminded  
of this when I should prescribe something, so we can revisit the  
question depending on the condition or medication that I offer at the  
time?

Would we want to capture a comment with the intermediate state e.g.  
"prefers not to say" or "something but can't remember"