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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 | |
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<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> | |
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