Can clinicians agree?

There have been a number of robust discussions in recent weeks around the claim that clinicians achieve consensus around computable definitions for clinical content. All discussions have been with MDs, some with substantial experience in various international standards organisations. All have been extremely sceptical…

The first challenge: “—What is a heart attack?” – and the response, —“5 clinicians, 6 answers” – and they are probably very accurate!

The second: —“What is an issue vs problem vs diagnosis?” – I’m told that this has been an unresolved issue in HL7 for 5 years+!

—And the third, from an obstetrician: “The midwives want all this rubbish that we don’t” – perhaps an unfortunate way of expressing the absolutely correct need for different clinicians to have screens presented that are relevant to the patient and the immediate clinical task at hand. —Different clinicians have different needs.

—However these are all essentially HUMAN PROBLEMS! Issues about communications, synonyms, value sets, screen display/layout. IT will not solve these issues – as always, the clinicians need to work out the issues amongst themselves. So where CAN we achieve consensus?

Within the openEHR Clinical Knowledge Manager environment we are gaining some traction in achieving clinician agreement to the structure required to define clinical concepts as archetypes – the ‘first principles’ of clinical concepts, if you like. The approach is inclusive of everyone’s needs and requirements, rather than requiring an arbitrary decision on the minimum data set or a priority data set – so we aim, as best we can, for a maximum data set.

For example, the framework to express a Diagnosis is largely not contentious:

  • Diagnosis name
  • Status
  • Date of initial onset
  • Age at initial onset
  • Severity
  • Clinical description
  • Anatomical location
  • Aetiology
  • Occurrences
  • Exacerbations
  • Related problems
  • Date of Resolution
  • Age at resolution
  • Diagnostic criteria

And for a Symptom:

  • Symptom name
  • Description
  • Character
  • Duration
  • Variation
  • Severity
  • Current intensity
  • Precipitating factors
  • Modifying factors
  • Course
  • Aetiology
  • Occurrences
  • Previous episodes
  • Associated symptoms

This notion of achieving clinician (and other domain expert) consensus and standardisation of clinical concepts is a major focus of the openEHR archetype work.

Bear in mind that while agreement can be achieved on the clinical content structure, this is only the first step in ensuring that clinicians are able to enter, retrieve and exchange meaningful clinical data.

So if we can achieve consensus around these archetypes, do clinicians then have to agree on a standard Discharge Summary or Antenatal Record or Report? The answer: only if is useful to do so. Clinical diversity can be allowed if the archetype pool is stable & governed/managed. By tightly governing the archetypes at international or national level, these are effectively the common ‘lingua franca’ that enables sharing of health information.

Template creation is the next openEHR layer – these aggregate the archetypes together to represent the requirements for a specific clinical activity and then constrain them down from their fully inclusive state to something that is ‘fit for use’ for a given clinician in a given clinical situation. Terminology subsets are also integrated in appropriate places into the archetypes (sometimes) and templates (usually) to round out the expressiveness needed by computable clinical models in clinical care – neither the structure nor the terminology can do this in isolation.

Once a critical mass of these archetypes are published we will be able to support a breadth clinical diversity across eHealth projects – the need for rigid, inflexible messages and documents to support any health information exchange has been largely overcome. Clinicians will only need to agree these types of messages or documents where there is a measurable benefit for doing so, and at all other times they can focus on ensuring that they express their archetype-based clinical records as flexibly as they need to for patient care. Sure, the human factors remain unresolved – but not even the most perfect EHR will solve these issues!

So can clinicians agree? Yes! It is happening in many areas related to data structure, creating a solid framework for our electronic health records. Archetypes are the tightly managed building blocks; templates enable safe and flexible expression of clinical and patient records – allowing the best of both worlds, both governance AND clinical diversity to flourish… and the clinicians are finally able to actively participate in shaping their EHRs.

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