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| Message-ID: <LYRIS-500088-1927631-2007.06.14-16.24.22--nradov#axolotl.com@lists.hl7.org> | |
| From: "Werner Ceusters" <ceusters@buffalo.edu> | |
| To: "Dan Russler" <dan.russler@oracle.com>, "Gary Dickinson" <gary.dickinson@ehr-standards.com> | |
| Cc: "List EHR" <ehr@lists.hl7.org>, "Lloyd McKenzie" <lloyd@lmckenzie.com> | |
| Subject: Re: DRAFT EHR Lifecycle Model - Review and Comment Requested | |
| Date: Thu, 14 Jun 2007 16:21:41 -0400 | |
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| I have 2 remarks to start with. | |
| I'm flabbergasted by the statement that "acts do not have physical location= | |
| s". If I understand this right, then docters and nurses work "nowhere". What= | |
| about that as a justification for their salary ?! :-) | |
| I think you all agree that if Dr X gives patient Y an injection (in the nor= | |
| mal non-science fiction way), then that act takes place in the room where th= | |
| e docter and the patient are. If he does it by using a robot guided over the= | |
| internet while he being in Paris and the patient in the US, then the act ha= | |
| ppened for sure on planet Earth. I do agree that determining where "the act"= | |
| happened in situations like the latter is not trivial, the problem not bein= | |
| g that much the localisation, but rather what THE act IS. Although we would = | |
| still use the word "injection" for the latter, it is obviously something com= | |
| pletely different than the former, despite the fact that parts of the acts a= | |
| re similar (e.g. the needle being brought into the patient's body). | |
| This said, I have no problem with the fact that the statement that "an Act = | |
| occurs at a specific physical location" be removed from the document however= | |
| : it is not because you don't state "X" in a document, that "not X" should b= | |
| e true. | |
| Another point that I want to raise is the statement "An Act is documented b= | |
| y an Act Record instance". It should be specified what "instance" refers to = | |
| in this case, precisely in the light of what happens when that "instance" is= | |
| copied into other systems. Thus if act X is injecting patient U by physicia= | |
| n V with product W in place P at time T, then Act Record instance AR1 might = | |
| be the documentation of it by V (thus the Dr registered what he did) and Act= | |
| Record instance AR2 might be that the nurse who was in the room documented = | |
| act X. Thus we have 2 instances documenting act X. If this information gets = | |
| transfered and copied to other systems in persistent records, then I believe= | |
| "copies" of these Act Record instances are created, and not new instances. = | |
| Otherwise, act X would be claimed to be documented by 2, 4, 6, 8 .... instan= | |
| ces, which is actually not true. | |
| I know, the RIM being based on a Kantian philosophy makes it hard to deal w= | |
| ith (and for some even to see) this problem, but I think it is important. An= | |
| d oh, you want for sure a "use case" for this: well suppose that there is so= | |
| me legal argument about whether or not the injection was actually given. Are= | |
| ten copies of the same documentation instance more proof than just one ? = | |
| (note for Charlie: you can use this paragraph to build further on your file = | |
| to document my "inability to productively collaborate with the community at = | |
| large" and "Dr. Cuesters [sic] prefers to intermittently send sarcastic emai= | |
| ls to various list servers".) | |
| Note that may objection is not in the use of the word instance in that part= | |
| icular sentence. In fact, I believe it is good practice, even that the state= | |
| ment should read "An Act instance is documented by an Act Record instance", = | |
| and even that the entire document should be checked whether "instance" shoul= | |
| d not be used more often (I believe it does). | |
| But even then, it should be specified what "instance" means in each case, e= | |
| .g. a particular act in physical reality or an entry in a database which doc= | |
| uments that act. | |
| kind regards, | |
| Werner | |
| ----- Original Message -----=20 | |
| From: Dan Russler=20 | |
| To: Gary Dickinson=20 | |
| Cc: List EHR ; Lloyd McKenzie=20 | |
| Sent: Thursday, June 14, 2007 8:52 AM | |
| Subject: Re: DRAFT EHR Lifecycle Model - Review and Comment Requested | |
| Hi Gary, | |
| I like this work a lot. | |
| On quick review, I encountered this line which I think should be deleted. | |
| "An Act occurs at a specific physical location" | |
| In the past, our discussions in modeling specifically excluded this state= | |
| ment. The use cases that were discussed included healthcare delivered over t= | |
| he internet. If the patient is in one location, the physician in another loc= | |
| ation, the nurse in a third location, and the EHR is in a fourth location, w= | |
| here did the Act occur? For example, in telemedicine, the patient may be in = | |
| one location and the physician is listening on a remote stethescope in anoth= | |
| er location? Or observation is being performed via camera? Or the surgery is= | |
| being performed via a robot over the internet (as accomplished between US a= | |
| nd Paris)? | |
| We came to the conclusion that participants have physical locations, but = | |
| that acts do not have physical locations. | |
| In review of the rest of the document, I did not see that anything else n= | |
| eeded to be changed because the "physical location of an act" comment was de= | |
| leted. | |
| Also, in M&M, a dynamic model discussion is occurring. This document shou= | |
| ld be sent to M&M for review before the dynamic model work is completed to m= | |
| ake sure that M&M work and the EHR work are consistent. | |
| Thanks, Dan | |
| Gary Dickinson wrote: | |
| Dear EHR TC Members, | |
| Within the EHR Interoperability project team, we have spent the past =20 | |
| several months working to develop and refine a model for the =20 | |
| lifecycle of EHR "Act Records", expanding and refining record =20 | |
| lifecycle events specified in Section 3.19 of the EHR =20 | |
| Interoperability Model and in ISO 21089, "Trusted End-to-End =20 | |
| Information Flows". This effort has resulted in our Draft HL7 EHR =20 | |
| Lifecycle Model (now v0.13, dated 23 May 2007). | |
| Per discussions on the last EHR TC teleconference, I'm distributing =20 | |
| the current Draft EHR/LM for review and comment (within the EHR TC). =20 | |
| Also attached is an initial proposal from Ann Wrightson (HL7-UK) for =20 | |
| additional EHR lifecycle events related to the interim progression of =20 | |
| EHR records. This proposal is awaiting UK consensus and will be =20 | |
| considered in the next EHR/LM update. | |
| Please take an early opportunity to review these documents and offer =20 | |
| your suggestions (not later than 15 July). Submit comments on the =20 | |
| draft EHR/LM to Gary Dickinson (gary.dickinson@ehr-standards.com) and =20 | |
| on the UK proposal to Ann Wrightson (Ann.Wrightson@csw.co.uk). | |
| Thank you for your consideration. | |
| Regards, | |
| Gary | |
| ************************************************ | |
| To access the Archives of this or other lists or change your list settings = | |
| and information, go to: http://www.hl7.org/listservice----------------------= | |
| ------------------------------------------------------ | |
| =20 | |
| ************************************************=20 | |
| To access the Archives of this or other lists or change your list setting= | |
| s and information, go to: http://www.hl7.org/listservice=20 | |
| ************************************************ | |
| To access the Archives of this or other lists or change your list settings = | |
| and information, go to: http://www.hl7.org/listservice | |
| ------=_NextPart_000_0108_01C7AEA0.17932C70 | |
| Content-Transfer-Encoding: quoted-printable | |
| Content-Type: text/html; | |
| charset="iso-8859-1" | |
| <!DOCTYPE HTML PUBLIC "-//W3C//DTD HTML 4.0 Transitional//EN"> | |
| <HTML><HEAD><TITLE></TITLE> | |
| <META http-equiv=3DContent-Type content=3Dtext/html;charset=3DISO-8859-1> | |
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| <STYLE></STYLE> | |
| </HEAD> | |
| <BODY text=3D#000000 bgColor=3D#ffffff> | |
| <DIV><FONT face=3DArial size=3D2>I have 2 remarks to start with.</FONT></DI= | |
| V> | |
| <DIV><FONT face=3DArial size=3D2></FONT> </DIV> | |
| <DIV><FONT face=3DArial size=3D2>I'm flabbergasted by the statement that "a= | |
| cts do=20 | |
| not have physical locations". If I understand this right, then docters and= | |
| =20 | |
| nurses work "nowhere". What about that as a justification for their salary= | |
| =20 | |
| ?! :-)</FONT></DIV> | |
| <DIV><FONT face=3DArial size=3D2>I think you all agree that if Dr X gives p= | |
| atient Y=20 | |
| an injection (in the normal non-science fiction way), then that act takes p= | |
| lace=20 | |
| in the room where the docter and the patient are. If he does it by using a = | |
| robot=20 | |
| guided over the internet while he being in Paris and the patient in the US,= | |
| then=20 | |
| the act happened for sure on planet Earth. I do agree that determining wher= | |
| e=20 | |
| "the act" happened in situations like the latter is not trivial, the proble= | |
| m not=20 | |
| being that much the localisation, but rather what THE act IS. Although= | |
| we=20 | |
| would still use the word "injection" for the latter, it is obviously someth= | |
| ing=20 | |
| completely different than the former, despite the fact that parts of the ac= | |
| ts=20 | |
| are similar (e.g. the needle being brought into the patient's=20 | |
| body).</FONT></DIV> | |
| <DIV><FONT face=3DArial size=3D2>This said, I have no problem with the fact= | |
| that the=20 | |
| statement that "an Act occurs at a specific physical location" be removed f= | |
| rom=20 | |
| the document however: it is not because you don't state "X" in a document, = | |
| that=20 | |
| "not X" should be true.</FONT></DIV> | |
| <DIV><FONT face=3DArial size=3D2></FONT> </DIV> | |
| <DIV><FONT face=3DArial size=3D2>Another point that I want to raise is the = | |
| statement=20 | |
| "An Act is documented by an Act Record instance". It should be specified wh= | |
| at=20 | |
| "instance" refers to in this case, precisely in the light of what happens w= | |
| hen=20 | |
| that "instance" is copied into other systems. Thus if act X=20 | |
| is injecting patient U by physician V with product W in place P a= | |
| t=20 | |
| time T, then Act Record instance AR1 might be the documentation o= | |
| f it=20 | |
| by V (thus the Dr registered what he did) and Act Record instance AR2 might= | |
| be=20 | |
| that the nurse who was in the room documented act X. Thus we have 2=20 | |
| instances documenting act X. If this information gets transfered and c= | |
| opied=20 | |
| to other systems in persistent records, then I believe "copies" of the= | |
| se=20 | |
| Act Record instances are created, and not new instances. Otherwise, act X w= | |
| ould=20 | |
| be claimed to be documented by 2, 4, 6, 8 .... instances, which is actually= | |
| not=20 | |
| true.</FONT></DIV> | |
| <DIV><FONT face=3DArial size=3D2></FONT> </DIV> | |
| <DIV><FONT face=3DArial size=3D2>I know, the RIM being based on a Kantian p= | |
| hilosophy=20 | |
| makes it hard to deal with (and for some even to see) this problem, but I t= | |
| hink=20 | |
| it is important. And o</FONT><FONT face=3DArial size=3D2>h, you want for su= | |
| re a "use=20 | |
| case" for this: well suppose that there is some legal argument about whethe= | |
| r or=20 | |
| not the injection was actually given. Are ten copies of the same documentat= | |
| ion=20 | |
| instance more proof than just one ? (note for Charlie: you= | |
| can=20 | |
| use this paragraph to build further on your file to document my "<FONT=20 | |
| face=3D"Times New Roman" size=3D3>inability to productively collaborate wit= | |
| h the=20 | |
| community at large" and "Dr. Cuesters [sic] prefers to intermittently send= | |
| =20 | |
| sarcastic emails to various list servers".)</FONT></FONT></DIV> | |
| <DIV><FONT face=3DArial size=3D2></FONT> </DIV> | |
| <DIV><FONT face=3DArial size=3D2>Note that may objection is not in the use = | |
| of the=20 | |
| word instance in that particular sentence. In fact, I believe it is good=20 | |
| practice, even that the statement should read "An Act instance is documente= | |
| d by=20 | |
| an Act Record instance", and even that the entire document should be checke= | |
| d=20 | |
| whether "instance" should not be used more often (I believe it=20 | |
| does).</FONT></DIV> | |
| <DIV><FONT face=3DArial size=3D2>But even then, it should be specified what= | |
| =20 | |
| "instance" means in each case, e.g. a particular act in physical reality or= | |
| an=20 | |
| entry in a database which documents that act.</FONT></DIV> | |
| <DIV><FONT face=3DArial size=3D2></FONT> </DIV> | |
| <DIV><FONT face=3DArial size=3D2>kind regards,</FONT></DIV> | |
| <DIV><FONT face=3DArial size=3D2></FONT> </DIV> | |
| <DIV><FONT face=3DArial size=3D2>Werner</FONT></DIV> | |
| <BLOCKQUOTE=20 | |
| style=3D"PADDING-RIGHT: 0px; PADDING-LEFT: 5px; MARGIN-LEFT: 5px; BORDER-LE= | |
| FT: #000000 2px solid; MARGIN-RIGHT: 0px"> | |
| <DIV style=3D"FONT: 10pt arial">----- Original Message ----- </DIV> | |
| <DIV=20 | |
| style=3D"BACKGROUND: #e4e4e4; FONT: 10pt arial; font-color: black"><B>Fro= | |
| m:</B>=20 | |
| <A title=3Ddan.russler@oracle.com href=3D"mailto:dan.russler@oracle.com">= | |
| Dan=20 | |
| Russler</A> </DIV> | |
| <DIV style=3D"FONT: 10pt arial"><B>To:</B> <A=20 | |
| title=3Dgary.dickinson@ehr-standards.com=20 | |
| href=3D"mailto:gary.dickinson@ehr-standards.com">Gary Dickinson</A> </DIV= | |
| > | |
| <DIV style=3D"FONT: 10pt arial"><B>Cc:</B> <A title=3Dehr@lists.hl7.org= | |
| =20 | |
| href=3D"mailto:ehr@lists.hl7.org">List EHR</A> ; <A title=3Dlloyd@lmckenz= | |
| ie.com=20 | |
| href=3D"mailto:lloyd@lmckenzie.com">Lloyd McKenzie</A> </DIV> | |
| <DIV style=3D"FONT: 10pt arial"><B>Sent:</B> Thursday, June 14, 2007 8:52= | |
| =20 | |
| AM</DIV> | |
| <DIV style=3D"FONT: 10pt arial"><B>Subject:</B> Re: DRAFT EHR Lifecycle M= | |
| odel -=20 | |
| Review and Comment Requested</DIV> | |
| <DIV><BR></DIV>Hi Gary,<BR><BR>I like this work a lot.<BR><BR>On quick re= | |
| view,=20 | |
| I encountered this line which I think should be deleted.<BR><BR>"<SPAN=20 | |
| style=3D"FONT-SIZE: 12pt; FONT-FAMILY: Arial">An Act occurs at a specific= | |
| =20 | |
| physical location"<BR><BR>In the past, our discussions in modeling=20 | |
| specifically excluded this statement. The use cases that were discussed= | |
| =20 | |
| included healthcare delivered over the internet. If the patient is in one= | |
| =20 | |
| location, the physician in another location, the nurse in a third locatio= | |
| n,=20 | |
| and the EHR is in a fourth location, where did the Act occur? For example= | |
| , in=20 | |
| telemedicine, the patient may be in one location and the physician is=20 | |
| listening on a remote stethescope in another location? Or observation is = | |
| being=20 | |
| performed via camera? Or the surgery is being performed via a robot over = | |
| the=20 | |
| internet (as accomplished between US and Paris)?<BR><BR>We came to the=20 | |
| conclusion that participants have physical locations, but that acts do no= | |
| t=20 | |
| have physical locations.<BR><BR>In review of the rest of the document, I = | |
| did=20 | |
| not see that anything else needed to be changed because the "physical loc= | |
| ation=20 | |
| of an act" comment was deleted.<BR><BR>Also, in M&M, a dynamic model= | |
| =20 | |
| discussion is occurring. This document should be sent to M&M for revi= | |
| ew=20 | |
| before the dynamic model work is completed to make sure that M&M work= | |
| and=20 | |
| the EHR work are consistent.<BR><BR>Thanks, Dan<BR><BR></SPAN><BR>Gary=20 | |
| Dickinson wrote:<BR> | |
| <BLOCKQUOTE=20 | |
| cite=3DmidLYRIS-390383-1922690-2007.06.13-17.25.18--dan.russler%23oracle.= | |
| com@lists.hl7.org=20 | |
| type=3D"cite"><PRE wrap=3D"">Dear EHR TC Members, | |
| Within the EHR Interoperability project team, we have spent the past =20 | |
| several months working to develop and refine a model for the =20 | |
| lifecycle of EHR "Act Records", expanding and refining record =20 | |
| lifecycle events specified in Section 3.19 of the EHR =20 | |
| Interoperability Model and in ISO 21089, "Trusted End-to-End =20 | |
| Information Flows". This effort has resulted in our Draft HL7 EHR =20 | |
| Lifecycle Model (now v0.13, dated 23 May 2007). | |
| Per discussions on the last EHR TC teleconference, I'm distributing =20 | |
| the current Draft EHR/LM for review and comment (within the EHR TC). =20 | |
| Also attached is an initial proposal from Ann Wrightson (HL7-UK) for =20 | |
| additional EHR lifecycle events related to the interim progression of =20 | |
| EHR records. This proposal is awaiting UK consensus and will be =20 | |
| considered in the next EHR/LM update. | |
| Please take an early opportunity to review these documents and offer =20 | |
| your suggestions (not later than 15 July). Submit comments on the =20 | |
| draft EHR/LM to Gary Dickinson (<A class=3Dmoz-txt-link-abbreviated href=3D= | |
| "mailto:gary.dickinson@ehr-standards.com">gary.dickinson@ehr-standards.com</= | |
| A>) and =20 | |
| on the UK proposal to Ann Wrightson (<A class=3Dmoz-txt-link-abbreviated hr= | |
| ef=3D"mailto:Ann.Wrightson@csw.co.uk">Ann.Wrightson@csw.co.uk</A>). | |
| Thank you for your consideration. | |
| Regards, | |
| Gary | |
| ************************************************ | |
| To access the Archives of this or other lists or change your list settings = | |
| and information, go to: <A class=3Dmoz-txt-link-freetext href=3D"http://www.= | |
| hl7.org/listservice">http://www.hl7.org/listservice</A></PRE><PRE wrap=3D"">= | |
| <HR width=3D"90%" SIZE=3D4> | |
| </PRE></BLOCKQUOTE><BR><BR>**********************************************= | |
| **=20 | |
| <BR>To access the Archives of this or other lists or change your list set= | |
| tings=20 | |
| and information, go to: http://www.hl7.org/listservice=20 | |
| </BLOCKQUOTE><BR> | |
| =0D<BR> | |
| ************************************************=0D<BR> | |
| To access the Archives of this or other lists or change your list settings = | |
| and information, go to: http://www.hl7.org/listservice | |
| </BODY></HTML> | |
| ------=_NextPart_000_0108_01C7AEA0.17932C70-- | |