- The purpose of this note is to provide a global model of the care
process.
- In the past with paper and pencil the options were very limited. Different actors did take handwritten notes for themselves. Mostly narrative notes in personal style at the occasion of every contact with the patient, the new notes below the previous ones.
- Many old records contain a great mass of facts, but no synthesis. In the past few medical schools did pay attention at methods how to manage the global care of a patient in a team. Medicine has often be practiced as an art without any rigorous method.
- Information exchanges between care providers were limited to some
letters. Letters can be seen as pictures made at a given point in
time and becoming soon obsolete. Moreover when a new care provider
did become involved he had difficult to get information.
- The trend is that a larger number of actors become involved as a mean in the care of one patient.
- The development of many excellent new technologies is of course good, but would not be very useful without improvement of the coordination between the many specialists in charge of the same patient.
- Simply moving the old habits on electronic devices would not much
improve the situation, without taking advantage of the new
technologies.
- Quality and safety improvements of medical decisions by means of
requiring more explicit and more rigorous documentation about the
decision processes. Although doctors are always saying they have no
time, one of their most important mission should be to formulate
clearly their assessments and the motivations of their decisions. A
responsibility which cannot be delegated.
- Better follow up of patient health issues, by means of the
flexibility provided by informatics.
- Educational purposes facilitating discussions and training of junior
professionals.
- Efficiency of the care process since the resource are limited.
- Health Issues:
- Definition:
- "Health Issues" are any kind of health concern, requiring
attention:
- Complaints and abnormal findings are Health Issues and need more investigations.
- Having several abnormal observations one will try to make an abstraction and to identify one or a few hypothesis, each with a provisional probability level.
- A little later having an obvious "Diagnose" the question becomes how to apply an efficient treatment ?
- For individual patient care purpose, Health Issues have
always an attribute representing the "degree of belief" of
the author, i.e. the probability. "Clinical modifiers"
are indeed critical for individual patient care,
particularly the degree of belief, the intensity, the type
of evolution, etc...
Remark: this in contrast with studies on large populations which aggregate similar cases in ICD classes, as black or white.
- Health Issues include "Risk Factors". For example known preventable diseases, require attention about vaccinations. Psycho-social issues could also be included in the problem list.
- Although closed, past history problems should remain
archived as having sometimes potential consequences or some
risk of recurrence.
- Negative issues:
- Normal finding of a check-up may be seen as "negative
issues". Negative issues may be useful to record as an
indication about how far a check-up has been performed and
about which groups of risks are likely to be excluded in
different domains.
- There is not rigorous border between positive and
negative issues. Negative issues are simply issues having
a very low probability.
- In general nursing records pay more attention to negative
issues than doctors. For example the validity scales.
- Normal finding of a check-up may be seen as "negative
issues". Negative issues may be useful to record as an
indication about how far a check-up has been performed and
about which groups of risks are likely to be excluded in
different domains.
- "Health Issues" are any kind of health concern, requiring
attention:
- Health Issues are a kind of assessments about facts, as
understood by a professional, generally a doctor as well by other
members of the care team and the patient himself.
Based on the same objective facts, more than one assessment could be made and must be recorded associated with the name of the author.
The assessment made by the patient himself my be useful and recorded as the "reason for encounter".
- Multiple issues:
- The approach is "patient-centric" the patient being at the foreground. Usually patients may have more than one issue at the same time. The overview must include all health issues of the patient. Elderly patients have as a mean a larger number of problems.
- Every issue need to be identified and followed.
- Of course some issues are more important than others.
Current critical issues should appear at the foreground in
summaries.
- Solved issues which are closed, remain in archive labeled as
"past history".
- Multidisciplinary care:
- The model must include the role of all care providers, including the patient himself or his relative.
- Integration is critical. In earlier deployments softwares were very fragmented and intended to make life easier to only one specialized target group of professionals, e.g. family doctor, or nurses, or radiologist, or surgeon or lab, or ... or ... every time as specific softwares having low interoperability. And also more attractive contracts from a pure commercial point of view.
- Economics:
- Health concerns are the motivation to spend, well or not,
much efforts and money for diagnostic and therapeutic
activities. Formal academic diagnose codes, if available at
all, provide a less precise evaluation of the patient needs.
- Health concerns are the motivation to spend, well or not,
much efforts and money for diagnostic and therapeutic
activities. Formal academic diagnose codes, if available at
all, provide a less precise evaluation of the patient needs.
- Comparisons with other models:
- This model is intended to cover the complete care process
from A to Z, across organizations boundaries, while many models
focus exclusively on hospital from admission to discharge.
- Some other models focus on economic aspects, looking mainly at the production of services which can be charged.
- This model is intended to cover the complete care process
from A to Z, across organizations boundaries, while many models
focus exclusively on hospital from admission to discharge.
- Definition:
- Iterative model:
- Health Issues are continuously iterating between the 3
fundamental concepts:
- ( 1 ) "Observations":
- Any kinds of observed facts. In general there are few discussion about recorded facts. In some cases the precision could be increased.
- ( 2 ) "Health
Issues":
- Assessment about a group of observations, as understood by a given actor.
- Several actors could have different opinions about the
same set of facts. Different opinions may be recorded.
Of course the responsible author of any assessment must always be included, e.g. patient himself, nurse, GP, specialist in a given domain.
- The precision of an Health Issue is usually evolving
through several versions, when more information become
available. Starting by a "Reason for Encounter" as
formulated by the patient himself, the next versions will
be improved versions will be improved step by step by GP
and specialists.
- ( 3 ) "Activities":
- In function of the current Heath Issues activities will be decided, done one self or ordered from third parties (e.g. lab tests)
- Activities may be intended as well as getting more
information, as well as treatments, and sometimes as
both.
- If several activities are considered, hteir relative priorities may matter: the question is "What to do first?" For example in an emergency situation try to stop the bleeding before ordering XRays!
- Activity packages may include a set of predefined elementary activities. For example a pre-operative checkup.
- Activities may include "Evaluation Steps":
- Although every incoming new information will implicitly trigger a new rapid evaluation of the consequences, a more comprehensive evaluation could be necessary from time to time. Sit down and review the case with some partners in the care team.
- The decision to request advice from a specialized consultant can also be seen as a kind of "Activity".
- The same in case of a call to a computerized decision support procedure.
- In principle any activity will provide a "Result".
Typical results are answer on a question, the result of a
lab test, the report of a specialized consultant, the
evolution after a prescription, etc...
This "result" will normally be recorded as new observations.
New observations will leads to new versions of the assessment of some Issues.
- ( 1 ) "Observations":
- Only one generic iteration cycle involving different actors:
- Main actors:
- The patient himself:
- The patient feels some observations.
- He makes a provisional assessment which can be a "Reason for Encounter"
- The activity is here to ask an appointment and to go
to a consultation.
- First line nurse:
- Make a preliminary professional evaluation and give
advice about the relative urgency of the problem.
- Make a preliminary professional evaluation and give
advice about the relative urgency of the problem.
- The GP:
- The same schema, getting information, making a more
precise assessment of the Issues, taking activities in
order to get more information and a little later in
order to prescribe treaments.
- The same schema, getting information, making a more
precise assessment of the Issues, taking activities in
order to get more information and a little later in
order to prescribe treaments.
- Optional specialist:
- Having received a request from the GP, he will get
more information and make a more accurate assessment in
his domain.
- Having received a request from the GP, he will get
more information and make a more accurate assessment in
his domain.
- The patient himself:
- No need to draw different iterations cycles:
- In fact there is no sharp border between diagnostic
activities and therapeutic ones:
- A prescription may be at the same time a test and a treatment trial.
- The result of a treatment provide insights about the
intended diagnose.
- In fact there is no sharp border between diagnostic
activities and therapeutic ones:
- Main actors:
- Iteration frequency:
- Iteration should be seen as a continuous process, regardless
of the context in primary care and hospitals.
- Very variable from a few minutes during one consultation or during an admission to month between controls of a chronic disease.
- Iterations may occur at any time, not only when seeing the
patient. For example receiving a notification about a lab
test result, may trigger a new understanding of an Issue and
lead to new activities.
- When there are multiple issues, the timing of every issue will usually be different. The most severe issues will usually go through more frequent iterations.
- When no more iterations will occur for a given delay, that issue could be declared closed.
- Iteration should be seen as a continuous process, regardless
of the context in primary care and hospitals.
- Mile Stones:
- The iterative patient record is intended to be maintained up
to date at any time. A mile stone is the activity of making a
more coprehensive review at a given point in time.
- That said it will be useful to know who did review the case,
with which qualification and at what time:
- No more separate one shot documents like "discharge letters", but just declarations as "Reviewed by Doctor XXXX at time TTT".
- Moreover the system must be able to retrieve all what was known at a given point in the past.
- Handover:
- It will no more be necessary to write ad hoc "handover" when a new team is coming and the the previous actors are leaving.
- Assuming that everything has been well maintained, the leaving actors need to review briefly the cases. They just need to underline the most critical points needing immediate attention.
- The new team will have easy to begin looking at these
critical points. A kind of "Patient List" showing only
these most critical informations.
Of course they may click in order to zoom on more details.
- The iterative patient record is intended to be maintained up
to date at any time. A mile stone is the activity of making a
more coprehensive review at a given point in time.
- Health Issues are continuously iterating between the 3
fundamental concepts:
- Collaborative care team:
- Problems:
- Multiple actors:
- One patient need usually care from several care
providers, as well from multidisciplinary team, as well
successive actors following each other in the same role,
day and night.
- One patient need usually care from several care
providers, as well from multidisciplinary team, as well
successive actors following each other in the same role,
day and night.
- Multitasking:
- One care provider is usually in charge of a group of
patients. A care provider is constantly moving to a next
patient. When a given patient will come back after a few
minutes, an hour, a month or a year later, the care
provider need to become again quickly aware of the
situation of that particular patient. Moreover in the
mean time other actors may have provided more insights.
- One care provider is usually in charge of a group of
patients. A care provider is constantly moving to a next
patient. When a given patient will come back after a few
minutes, an hour, a month or a year later, the care
provider need to become again quickly aware of the
situation of that particular patient. Moreover in the
mean time other actors may have provided more insights.
- Multiple actors:
- Approaches:
- A common work methodology is very important in order to share information in an efficient way.
- The first question is how far the actors are really willing to collaborate? If yes, they should be willing to write in a way intended to be easily understood by their partners in the future.
- The exact rules of collaborative work need to be further
explored, making experimental prototypes in Open Source. As
far as already known essential requirements include:
- On-line access to a continuous iterative process,
providing always up to date information, rather than
messages exchanges.
- Problem Orientation in order to try to solve problems.
- Access to common shared patient information and extraction of specific presentations intended for different actors having different roles in the patient care. For example problem list, activity lists, handover, etc...
- Navigation in the patient record in several ways, among
others in order to retrieve all the information related to
a given problem, a given context, a given author, the
evolution of a given parameter, etc... and with links to
medical knowledge.
- Care Team management and Role Based Access Rights.
- .....
- On-line access to a continuous iterative process,
providing always up to date information, rather than
messages exchanges.
- Problems:
-
( A ) Information about the patient
(A.1) Observations:
All the observed facts, with time and author and context of acquisition.
New observations will be added here, resulting from new activities
(A.2) Assessments of Health Issues:
The problem list as seen by the different members of the care team.
An up to date overview of the situation, which may evolve with time in new versions.
(A.3) Activities, Care Plan Considered actions and relative priorities Validated orders, with their relative priorities.
Scheduled actions In progress, overview of the current care plan
Reported ( B ) General medical knowledge - Knowledge about Health Issues
- Thesaurus of well known medical problems and related recommendations.
- Continued education, training
material.
- Knowledge about Resources:
- Which lab test are available and the meaning of their outcomes
- Images
- Pharmaceutical products and their properties
- .......
- Classifications : ICPC, ICD, ...
- ....
( C ) Action manager
One action initiated at a time, starting from the top of the priority list, out of a large pool of possible actions, maybe as much as 20.000 different possible actions.
In principle every action will provide some kind of "result". That reported information comes back as an input in the an "observation about the patient" (in the top left space above).Ask a question to patient (out of thousends possible questions)
Physical examination Order lab, images, functional tests, .... Evaluation by human, sit down and think (several thousands possible hypothesis according to the ICD classification)
Evaluation by a computer model Advice request to a specialist
Validate a "Milestone" review Prescription (out of about 5000 products in pharmacies)
Require an admission, a surgery etc .........
- Knowledge about Health Issues
- ( A ) Patient information (top left
yellow side):
- ( A.1 ) Observations, facts about the particular patient
- The information already known about the patient. The focus
is here on an accurate report about the facts, without any
assumptions.
- In begin there is of course very few information, but every
iteration will provide more.
- The information already known about the patient. The focus
is here on an accurate report about the facts, without any
assumptions.
- ( A.2 ) Health Issues:
- Assessment of Issues based on the observed facts. Maybe more than one hypothesis with their respective levels of probabilities.
- Problem Lists may contain several Health Issues to be
analyzed one at a time.
- ( A.3 ) Action, the workflow of orders:
- Status of Activities:
- Considered:
- Proposed activities with:
- Motivation in function of one or more Issue(s)
- Relative priority.
- Proposal may be provided by students, junior
professionals, as well by some automated decision
procedure created by a reliable external authority.
- Proposed activities with:
- Validated:
- By the responsible authority.
- By the responsible authority.
- Schedulled:
- If necessary a time slot has been booked by a
resource.
- If necessary a time slot has been booked by a
resource.
- Ongoing:
- For example the patient did arrive at the lab.
- For example the patient did arrive at the lab.
- Reported:
- Report is available and validated.
- Report is available and validated.
- Declared:
- Activities declared to have been completely performed and valid for billing.
- If involved in a scientific survey, declaration to epidemiological data bases, after removing the patient identification.
- Considered:
- Central decision node:
- At every iteration take the validated action with the
highest priority score !
- At every iteration take the validated action with the
highest priority score !
- Status of Activities:
- ( A.1 ) Observations, facts about the particular patient
- ( B ) General knowledge bases (top right green side)
- Here in general a relatively static information space.
- Knowledge about Health Issues:
- Inventory of typical health issues. A clear standardization
of "health issues" is not yet available as we would need in
practice. Unfortunately official standards focus on academic
final diagnosis as intended for epidemiologic surveys.
- Recommendations related to known issues are partially
available.
- Inventory of typical health issues. A clear standardization
of "health issues" is not yet available as we would need in
practice. Unfortunately official standards focus on academic
final diagnosis as intended for epidemiologic surveys.
- Knowledge about Resources in the environment:
- Access to many types of reference informations is necessary, with access to the relevant properties of these objects.
- A large range of information about healthcare professionals,
regional hospitals, municipalities, lab tests, available
products in pharmacies, refundable medical acts as defined by
the social security, etc ...
- Epidemiological classifications:
- Classifications are necessary for studies on large populations, intended for management and scientific purposes. See the ICD, international Classification of Diseases.
- Interfaces:
- There is a need for better standardization of all interfaces to these resources. This should be made available in the public domain.
- Here in general a relatively static information space.
- ( C ) Action manager and ongoing
activities (bottom space in blue)
- "Given all what is known up to now, what should be done next ?
"
- One at a time take the top priority of the activity list and initiate the intended activity.
- In principle whatever the content of an activity may be, a "Result" will be expected. This Result will increment the knowledge about the patient in ( A.1 ) which could be token in account in the next iteration.
- "Given all what is known up to now, what should be done next ?
"