Patient Care Special Interest Group Minutes January 14 & 15, 1993 Attendees Organizations Barbara Rackham NSI Nursing Systems, Inc. Shanon Wiler VBITREX Karen Keeter IBM/GSD Health Peggy Dalieris University Hospital, Denver James P. Fry Care Data Systems Scott West SpaceLabs Medical Tom Dean Bell Atlantic Healthcare Systems Virginia Graham IBAX Healthcare Systems Michael Cheung IBAX Healthcare Systems Catherine Rogers MUSC Medical Center, Charleston, SC Jeff Spears IBAX Healthcare Systems Kathy Byler Shared Medical Systems Lynda Hernandez Medicus Systems Corp, CA Kathy Milholland American Nurses Association Trey Hughes APACHE Medical Systems Dave Gallegus LA County-Dept. of Health Services Pat Zwilling Dairyland Computer Jim Hoath University of Washington, Seattle Lee Bishop HBO & Company Diane Klz University Hospital, Denver Randy Whitsell Sunquest Information Systems Mans Buitendijh SMS January 14 Documents from previous meetings were distributed and the group took a few minutes to discuss them. We began by looking at the Encounter model. Patient entity was reviewed and accepted. Then we began to work on the Encounter entity. Encounter was defined as every time a patient had a relationship with a healthcare provider. Comment was made that it may not be required to further break down encounter into care facility and care provider encounters, since there was only one attribute associated with each of those entities (identifier) and it appeared to be the same entity. No one could recall in detail the other attributes and the prior discussions that led us to model this way in the first place. It was suggested that we maintain a log of questions that need to be reviewed with Hans (who was not present) and other committees that we could not answer. That allowed us to move on to other issues. Next discussion was related to the concept of a "group encounter" (e.g., the family all go for a therapy session). This could not be handled in our current model. Jim Frey agreed to work off line with a few people to work thru issues related to encounters. A question arose about the concept of business rules. It was described as the relationship descriptions, and the guiding principles that led us to define the relationship in the first place. For example, "a patient can be related to other patients" (the business rule) leads us to model patient as a 0:N relationship with itself. Outcome Model Section _____________________ Question for Hans- clarify model notation- what the diamonds are supposed to be used for/mean. Group felt the name Outcome Model was incorrect description. For now, we have renamed it OAD- Observation, Assessment, Diagnosis Model. The definition was edited to say: "The OAD model shows the entities and relationships that describe the patient care related data perspective". Question- can you have an assessment without an encounter? The model currently implies NO. This was put in the question log. Kathy reminded everyone that patient care is "slippery"- not as cut and dry as ADT/Finance, hence the level of frustration the group feels. She proposed that we move on to Observation. Observation ___________ On attribute #4- remove the parenthetical and leave as simply "performance date/time". Add "transcription date/time". On attribute #2- change definition to say "Identifies the definition of the kind of observation type that was done. This is a pointer to the observation itself, which includes all the rules (ex of rule- Temp is measured in degrees Celsius)." On attribute #7- "Source" is who provided the value (patient, family member). All agreed source is an attribute. We were not sure if it should be an attribute of Observation or of Observation Qualifier. The business rule related to source is: "There is only one source per observation and the source is not a device". Suggestion was made to have the relationships formatted in sentence form for improved readability (Patient has zero or more observations). Note was made to ask Hans. Definition of Observation was discussed. Agreement was reached on: "The Observation entity represents an actual value. Observations may or may not be data collected in/for an assessment. The results are included in the Observation entity." Statement was made that as we move into Observation, we will probably be overlapping with OE/RR chapter work. Discussion again on Observations versus Assessments. Assessment was redefined (second sentence) to say "An assessment represents a collection of observations..." Several relationships shown in the model were missing from the text: 7.Encounter may have 0 or more observations 8.Observation has 0 or more qualifiers 9. Observation belongs to exactly one care facility encounter 10.Observation belongs to exactly one care provider encounter. Karen Keeter volunteered to do the minutes for Friday. Here noted that Karen and Lynda do not have to do minutes for the rest of the year! (Secretary for above- Lynda) January 15 Kathy Milholland opened with a list of three agenda items/goals for the morning. 1) Complete Section 2; 2) Proposal for finalizing section 2; 3) Agenda for Boston: - Review voting results - Discuss SIG meeting votes - Review/validate section 3 - Develop plans for additional work on 3 Question was raised about our status- Kathy explained that we are not a chapter. We do not intend to duplicate the work done in other chapters. Our focus is to develop a model for patient care so we can evaluate existing chapters and make enhancements (or justify a new chapter) where necessary. Hans B. was present, so we began with a review of some of the questions we had reserved for him. Q- Did he remember why we had a care facility and a care provider encounter? Hans said he thought we may need to distinguish between the facility and the person you have the encounter with. There may be attributes unique to one or the other (none documented to date). Some discussion ensued regarding the model Mead W. had presented in ADT and Inter-enterprise, which consisted of encounter, provider organization, practitioner and patient entities, with relationships between them. Question arose that from a patient care perspective, do we want to reflect facility encounters and the provider encounters that happen in them- or do we really only care about practitioner encounters? Question- Should Encounter, which is being discussed in many different chapters, be something that QA/Modeling creates a strawman for, which is then reviewed by all chapters to ensure that it meets their needs? This will prevent "reinventing the wheel" in each chapter and ensure that we all have the same view of "cross chapter" entities. Kathy will review this with the Technical Steering Committee. This same concept will apply to other entities, too. Much discussion of care facility/care provider encounter led to refining of model to remove these as subtypes and create a model similar to the one Mead presented. Entities are encounter, care facility, care provider(practitioner), provider organization, and patient. Hans pointed out that there inconsistencies between ADT and us as to how we use certain terms. Suggestion was made to look at ASTM definitions as a starting point. Can we get them for next meeting? Karen K. questioned whether we should really be trying to address the definition of encounters, or should we narrow our scope to include only "patient care" encounters. After much discussion, consensus was that we should leave the encounter entity as a "black box" and talk about Assessment (as we have defined it) as a subtype of encounter. We then tried to list other patient care related subtypes of Encounter that our SIG should be addressing. The list included: - Assessment/Evaluation - Observation - Interventions- (examples: treatments, therapy, education, giving a medication) - Planning (discharge planning, care plans being two examples) Kathy will also ask Mead to review the current thought process on Encounter with us at the next meeting. We will discuss with him the concept of group encounters at that time. Answer to question about diamonds in model- they are an artifact of Hans' modeling tool. You could use the tool to fill in a relationship name in the diamond if you could come up with one that made sense. OAD Model- suggestion to change that to TOAD (therapy, observation, assessment, diagnosis) was accepted. It was also noted that our attribute #1 "observation id", is used by Order Entry to refer to the pointer to a definition (which is our attribute #2 definition). To avoid confusion, we changed the name of attribute # 1 to "Observation Instance ID". Based on this new approach of subtypes of encounter, we decided to re-review the assessment and observation work of the prior day. There was a great deal of discussion related to the difference between an assessment and an observations. Below the conclusion are the details of the discussion. CONCLUSION: The conclusion of the discussion was that assessment and observation (as we had previously defined them) should be collapsed into a single entity called (for now) Observation Set. EDITORS NOTE: On further thought, as I wrote these minutes, I think Observation Set is not quite right, as there are still observations that are not a "set". How about Patient Care Observations (to distinguish them from Orders/Results Observations)? Observation Set can point to other instances of the same type (sometimes one of the instances may be called an "assessment" in nursing practice). This entity can be nested (you can have observation sets within an observation set), and can contain 1 or more observations AND/OR one or more other observation sets. Examples: Vital signs is an Observation Set that contains 3 observations- Temp, Resp, and BP. Admission is an Observation Set that contains observations (single elements) and a number of observations sets (you may weight the patient, do vital signs, and also do a neuro assessment all as part of an "admission observation set"). RATIONALE/DISCUSSION leading to conclusion: Can an assessment have no interpretation? YES. Nurses will call a form that they fill out an "assessment". It may or may not require them to reach a conclusion or make an interpretation. Hence, we can't define assessments as a collection of observations with at least one interpretation. Is an assessment, as defined by nursing, an observation? NO. Recommendation to add a #6 to the definition of assessment: 6. An interpretation of the collection of data. If interpretation is now an optional part of an assessment, what really does distinguish assessment from observation? Nothing? At this point, proposal as stated in conclusion above was voiced, discussed and accepted. Hans will take a first cut at the new combined entity and review with Karen Keeter, Virginia Graham, and Barbara Rackham and bring forth a proposed definition at the next meeting. With this well in hand, we moved to Observation Qualifier. This was described as a way to enumerate different attributes of an Observation Set. There are several options for how to handle these qualifiers: 1- Have a qualifier entity, but don't attempt to create a list of qualifiers (generally not acceptable approach) 2- Create a list of qualifiers that you know and add to it over time 3- Create a list as in #2 AND have a master file to communicate what qualifiers a system needs to send you 4- Have a master file that defines required qualifiers. Options were further clarified as the difference between a segment that predefines the qualifies in the segment (4). (For example: HDR Observation, Qualifier A, Qualifier D, Qualifier T) and the use of a code/value repeating set in the segment, into which any qualifier and it's value can be placed. (3). For example: HDR Observation Qualifier Code -- \Repeating segment / Qualifier Value -- Suggestion that we should look at current OBR OBX qualifiers as a starting point and see if the ones we think we need are there. Linda Joseph volunteered to look at this. Catherine Rogers will help her. The time was reaching an end, so Kathy summarized a revised plan for Boston: - Kathy would review discussion on common entities that she will have had with the Technical Steering Committee - Kathy will invite Mead to review encounter model - Group will review re-edited document and new definition of observation set - Group will review observation qualifiers work - Hans will try to convert the model to OO form, if he has time. If he does, we will begin in May to work from that new model. Meeting was concluded at 11:30 (Secretary, Karen Keeter) dkm:hl7:jan93.min