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Each participant, whether on site or off site will be considered a particular 'player' in each of the two scenarios (use cases) selected. The concept is that each site will be able to add to or modify the patient record and then send the complete record or a portion of it as requested, to the next provider.
How closely should these be planned in advance?
Potential Problem Areas
- Date/Time Restrictions - Some participants may be using commercial or open source deployable applications that already have date/time detection limitations builtin for certain funtionalities. Since will will be simulating a long period of time in a relatively short period of time; as well as doing this across multiple time zones. What are the implications to the participating systems? Should we schedule all systems to be set to UTC and have scheduled datetime changes at specific times?
- ??????
Use Cases/ i.e. some simple Patient Journeys
Lets have a go at sketching out some simple journeys i.e.
Perhaps 2 or 3 patients that need 2 or 3 health record entries
eg 1. Young patient with minor illness/injury (a newborn is overcomplicated to start with.. mother/child record and all that)
ED visit
- Subjective
- 10 year old boy attends with Cough & Fever
- Past Medical History, nil of note
- Allergy none
- Family History of Diabetes (mother)
- Social History- lives at home, goes to school
- Systems review- fever, cough, short of breath/ no GI/no GU complaints
- Objective
- Examination - uncomfortable
- HR 130, RR 30, GCS 15, Temp 38oC
- Head and Neck; flushed appearance, mild dehydration, ENT Exam ok,
- Chest Examination, increased respiratory effort, intercostal recession, crepitations mid zone right side
- Abdominal examination, soft, generalised tenderness, no guarding, no masses
- CNS Examination, NAD
- Skin examination, no rashes
- Investigation.
- Blood Glucose 25, Full Blood Count WCC 18, Urea & Creatinine Normal
- Blood Gases Ph 7.2 Bicarbonate 5 mmol/L
- Blood Type O positive
- Chest Xray mid zone right side opacity
- ECG ok
- Assessment
- Problem/Diagnosis; Diabetic KetoAcidosis
- Problem/Diagnosis; Pneumonia
- Plan
- Treatment
- Oxygen
- IV Fluid Saline 0.9% 500ml stat.
- IV Insulin Actrapid 5units + sliding scale
- IV Cefuroxime
- Referred & Admitted to Paeds team
Discharged 3 days later on Insulin regime
GP visit a month/months later (could be many simple variations on this one)
- Subjective
- Patient well, no complaints
- Medications: Insulin long acting 20units/day
- Objective
- Vital signs normal
- Urinalysis, Clear
- U&E test, Urea and Creatinine normal
- HBA1C High
- Assessment
- Problem/Diagnosis; IDDM- Needs Insulin adjusting to HbAic
- Plan
- Adjust Insulin with more longer acting insulin
ED visit some years later
- Subjective
- Presenting complaint; Dizzyness and Collapse
- Missed out breakfast before work as late, running to bus
- Medication: Insulin, AntiHypertensive
- Allergy: Penicillin- Rash
- Objective
- Vitals signs normal
- Blood Glucose Low
- Eye exam- Retinal changes Right eye
- Assessment
- Problem/Diagnosis; Hypoglycemia
- Plan
- Sublingual Glucose
- Recheck Blood sugar
- refer to GP for opthalmology followup
Opthalmology specialist clinic visit
- Subjective
- Presenting Complaint: No visual problems
- Objective
- Visual acuity 6/18 right eye
- Retina: venous abnormalities, large blot haemorrhages, cotton wool spots
- Assessment
- Problem/Diagnosis; Diabetic retinopathy grade III
- Plan
- Laser treatment to affected area
GP to GP transfer some years later
- Subjective
- 55 year old moving locations
- Past History
- Diabetes
- Renal Disease
- Retinal Disease
- Objective
- Vitals normal
- Visual Acuity 6/18 right, 6/6 left
- U&E mild renal failure
- HbAic normal range
- Assessment
- Problem/Diagnosis; IDDM- moderate control
- Plan
- Please continue ongoing IDDM management (inc monitoring of renal and eye complications) this equals case 2. ie Older patient with a more chronic condition that needs some checkups
Technical
The method of information exchange will be to use W3C SOAP Version 1.2 as defined at http://www.w3.org/TR/soap12-part1/ and described in tutorial form http://www.w3.org/TR/2007/REC-soap12-part0-20070427/
Specific implementation should be discussed and/or on the openEHR implementers mailing list.
thanks for the comments Stef. *MY* plan for this is as Tony pointed out on the mailing lists; to get a group of clinicians to develop this journey. I personally feel like I am hands-off at this point. When the journey is defined annd the archetypes selected then I can get back involved in operational planning again. 
Posted by Where/ how should we create such a list. I'm not a specialist in the gyneacology/ pediatric area but willing to help.
The newborn journey is actually one of the challenges for any system. At what point is the baby's record created and by whom. In the paper world the baby will get its number but many of the notes may form part of the mother's as the baby's record is likely to be a simple one, other than the details mentioned.
How about instead a young child presenting at A&E with asthma plus something else. Involvement of some different services (GP, ambulance crew, hospital medic), various tests, meds etc, AHPs. Is this more complicated than you want?
Pregnant women arriving in A&E after fall, again - tests, records, communications to other AHPs.
I'm not sure what you are trying to prove with your demo so it is difficult to judge the level of complexity (or otherwise) that you need in your patient journey.
Do you really need to develop new patient journeys? Many have been created already by clinicians working in eHealth projects, could we not get hold of one or two of them as a start? Easier to modify an existing one perhaps?
Hi
This is an exciting and important project. I am in to help with the patient journeys. Probably won't make it to SA.
I think SOAP charting is a good use case as such mostly free text documentation is very common. We could combine it with some structured information (problem list, medication, lab, allergies, vital signs).
I agree with Pauline that a newborn might make it too complex. Here is my suggestion:
- Young adult with newly diagnosed diabetes type I
- We could show how regular GP visits can be documented (insulin treatment, HbA1c & creatinin, monitoring risk factors etc).
- Emergency visit because of hypoglycaemia
- Referral to a specialist e.g. ophthalmo/nephro/... for specific test OR to gastroenterologist with clinical suspicion of autoimmune gastritis (here koray's endoscopy archetype or even his developing application could come into play)
- Change of GP! IMO this is a very important use case. Because both the old and the new GP use different but archetype-enabled systems the existing documentation can be transferred
What do you think?
Regards
-Thilo
Hi Tony and all
I like the journey and I think this one is enough to show the power of openEHR. Although relatively simple we shouldn't underestimate the challenge to create archetypes, implement systems and organise the connectathon.
Here a couple of medical remarks regading the journey (keep in mind that I am a greenhorn doctor 
):
- first ED visit
- O: maybe a blood pH or bicarbonates reading or is the high blood sugar enough for the the diagnosis diabetic ketoacidosis
- A: maybe a second diagnosis pneumonia
- ophthalmology visit (Is this at a GP or specialist practice? I don't know a GP that does laser treatment)
- O: fundoscopy: venous abnormalities, large blot haemorrhages, cotton wool spots
- A: diabetic retinopathy grade III
Regards
-Thilo
Hi Tim,
Don't know if I understand your plan correctly but here are some suggestions/ comments for the new born use case.
First of al one already has an interesting challenge since the mother will have her own record and en new record must be created for the newborn. When/ where is that done?
Obviously the data from the newborn will be in the new record but also some data has to been added to the mothers record since after the birth she probably will receive some treatment (stichtes if vaginal rupture occurred and/or medication to contract the placenta.
Form the newborn's point of view is miss the APGAR score (http://en.wikipedia.org/wiki/Apgar_score).
Don't know how complex we want to make it but maybe we can simulate a situation in which the baby is a bit blue an some bloodworks has to be done and added to the record. This then should be later on be included in the evalution a couple of hours after birth.
Hope this helps a bit.
Cheers,
Stef