Stream: implementers
Topic: Encounter Centric System
Alex Goel (Oct 27 2020 at 18:06):
I'm writing data to an encounter-centric system. The issue with my diagnostic use case below for cancer is that the only patient encounters are with referring physicians. The Radiology exam is tracked as a procedure and so is the pathology exam, in which the subject is the specimen. Does the biopsy count as an encounter? How would I tie all these resources together? I attached a copy of the draft bundle we're putting together (Note: all the references aren't complete yet) BundleJoseAdrenalMedMorph.xml
- Patient visits family doctor
- Patient is referred for diagnostic radiology exam
- Radiological procedure is done on patient
- Radiologists reads scans and report states that patient should be sent for biopsy.
- Patient is referred for a biopsy/specimen collection procedure so that a sample can be collected for pathological analysis due to suspicion of cancer discovered in previous radiology exam.
- Patient goes for biopsy (procedure might be a fine needle aspiration (FNA) biopsy or surgical biopsy)
- Assuming that this counts as patient encounter where specimen is collected
- Specimen is sent to lab and tissue diagnosis is performed
- Record a specimen in FHIR (aren't doing this yet, but assuming we should)
- Results are communicated back to referring physician who informs the patient of their diagnosis
Lin Zhang (Oct 27 2020 at 18:30):
Generally, the subject should be the patient. And the specimen will still the specimen. Encounters are between the patient and providers (maybe a virtual one).
Lin Zhang (Oct 27 2020 at 18:33):
And a special case for the subject may includes the mother and her baby/babies.
Yunwei Wang (Oct 27 2020 at 19:22):
biopsy is a Procedure. The result is a DiagonisticReport
Elliot Silver (Oct 27 2020 at 23:03):
@Alex Goel, let's see if we can break this down. I've got some ideas, but can't fill this out completely.
- Patient visits family doctor
- Encounter1
- Patient is referred for diagnostic radiology exam
- ServiceRequest1
** encounter = Encounter1
- Radiological procedure is done on patient
-
Encounter2
** basedOn = ServiceRequest1
** reasonReference = Procedure1 (hmm, this has Procedure1 and Encounter 2 pointing at each other. I must be misinterpreting something.) -
Procedure1
** basedOn = ServiceRequest1
** encounter = Encounter2
At this point, you probably decide that this is more than a one-off sort of thing, and decide to tie everything together with an EpisodeOfCare. I believe this is an extension on most resources, but is an element on Encounter.
- EpisodeOfCare1
** update Encounter1.episodeOfCare, Encounter2.episodeOfCare
** add extension to ServiceRequest1, Procedure1
- Radiologists reads scans and report states that patient should be sent for biopsy.
-
DiagnosticReport
** basedOn = ServiceRequest1
** encounter = Encounter2
** episodeOfCare extension = EpisodeOfCare1 -
optionally, ImagingStudy is created, populated, and referenced.
- optionally, Observations are recorded
- Patient is referred for a biopsy/specimen collection procedure so that a sample can be collected for pathological analysis due to suspicion of cancer discovered in previous radiology exam.
- ServiceRequest2
** reasonReference = DiagnosticReport1
(Unclear if this is part of the imaging encounter, or a new referring physician encounter)
- Patient goes for biopsy (procedure might be a fine needle aspiration (FNA) biopsy or surgical biopsy)
-
Encounter3
** episodeOfCare = EpisodeOfCare1
** basedOn = ServiceRequest2
** reasonReference = Procedure2 -
Procedure2
** basedOn = ServiceRequest2
** encounter = Encounter3
** reasonReference = DiagnosticReport1
- Assuming that this counts as patient encounter where specimen is collected
Agree.
- Specimen is sent to lab and tissue diagnosis is performed
- Procedure3
There may be a linking between procedure2 and 3 but I'm not sure how to model it -- is one a sub-procedure of the other? Are they both under a "collect and analyze" procedure?
- Record a specimen in FHIR (aren't doing this yet, but assuming we should)
- (Someone else can fill this in)
- Results in multiple Observations tied to the procedure
- Results are communicated back to referring physician who informs the patient of their diagnosis
-
Encounter 4 (physician informs patient)
** episodeOfCare = EpisodeOfCare1
** reasonReference = ProcedureXX -
potential Communication to record that the referring physician told the patient.
Alex Goel (Oct 27 2020 at 23:44):
@Elliot Silver Thanks! That's exactly what I was looking for and more
Alex Goel (Oct 28 2020 at 13:41):
@Elliot Silver what do you think about using a CarePlan to track context instead of an EpisodeOfCare? Eliminates need for extension
Lin Zhang (Oct 28 2020 at 14:01):
It depends, I think. Future is different from past and present.
Elliot Silver (Oct 28 2020 at 15:25):
I don't think of EpisodeOfCare as past vs CarePlan as future. A CarePlan is just that: a plan laid out with targets, etc. to address a condition. It may be a historical, prospective, or ongoing plan to address some issue. I think of a CarePlan as something like: lose weight, build knee strength, address recurring panic attacks. Care may be delivered with or without a plan. On the other hand an EpisodeOfCare ties together multiple events related to a condition, but doesn't indicate a target. I see them as quite different things.
In your case, you might be able to argue that the plan is "figure out what's wrong", but more realistically, I suspect that once you get the lab results back, a plan for "treat malignant tumour" will be created.
I wouldn't shy away from an extension, especially one which is defined in FHIR core.
Lloyd McKenzie (Oct 28 2020 at 15:29):
EpisodeOfCare is just a grouper - you just tag a resource and it becomes part of that group. With CarePlan you need to provide some sort of context as to how all of the pieces of data relate and fit into an overall plan.
Last updated: Apr 12 2022 at 19:14 UTC
