Proposed definitions for health care encounter
Bill Hogan
A temporally-connected health care process with an organization and a
person as participants, and that is the realization of both the
organization’s health care provider role and the person’s patient
role.
Notes: it does not require direct human-human interaction the whole
time. Thus, it encompasses waiting in the waiting room after checking
in, being in one’s hospital room by oneself, etc. The common usage of
‘hospitalization’ or ‘inpatient encounter’ encompasses the entire time
from admission to discharge. Thus, gaps in human-human interaction
are not gaps in the hospitalization. Also, you could consider the
24X7 availability of staff, and 24X7 monitoring of the patient, as
processes and thus the realization is in fact continuous (i.e.
temporally connected).
More notes: includes office visits, hospitalizations, ED encounters,
same-day surgery encounters, etc. Excludes deciding on your own to
take supplements, because by yourself you are not an organization.
Which is good, because the common usage of healthcare encounter
excludes people treating themselves.
Health care process:
A social process that has at least one human participant and that
includes as parts the treatment, diagnosis, or prevention of disease
or injury--or the following of instructions of another human for
treatment/diagnosis/prevention--of a participant in the process.
Notes: requires only the patient as participant because some
processes, such as taking medications or following instructions on
one’s own, does not involve a provider. The prescribing, filling of
the prescription, selling, etc. of a medication all involve providers,
but the taking does not. What about taking supplements on one’s own?
Either (a) not a healthcare process or (b) the same person bears and
realizes both the provider role and the patient role. What about
parent following instructions of doctor by giving medication to a
child? This is a healthcare process because it is the following of
instructions of another human for treatment/etc. In other words, the
definition places no restrictions on who follows the instructions,
just that the follower of instructions and the giver of instructions
are different participants.
More notes: excludes animal care. Options are to (1) broaden
definition of health care process to say that the participant is an
organism instead of human only or (2) create a sibling of health care
process, ‘veterinary care’ or some such.
Patient (role): NOTE: This term is in the Ontology for Medically
Related Social Entities. DO NOT ADD TO OGMS. We already agreed that
the number of health care roles will proliferate beyond what OGMS
could/should accommodate, and that they should go in OMRSE. I put it
here because the definition of health care encounter relies on it.
The social role of a person, the realization of which is a health care
process, where the bearer of this role is the recipient of treatment,
diagnosis, or prevention of disease or injury, or on whom instructions
for the treatment/diagnosis/prevention of disease or injury are
carried out.
Note: must say “on whom instructions are carried out” to encompass
both adults and children. In the former case, the patient usually
carries out the instructions on himself (but not always—for example,
an elderly parent with dementia whose child carries out instructions
when the parent is unable); in the latter case, a caregiver (usually a
parent) carries out the instructions on the child.
Health care provider (role): NOTE: This term is in the Ontology for
Medically Related Social Entities. DO NOT ADD TO OGMS. We already
agreed that the number of roles will proliferate beyond what OGMS
could/should accommodate, and that they should go in OMRSE. I put it
here because the definition of health care encounter relies on it.
The social role of a person or organization, the realization of which
is a health care process, where the bearer of this role is doing the
treatment, diagnosis, or prevention of disease or injury, or who is
giving instructions for the treatment/diagnosis/prevention of disease
or injury.
Note: in most western nations, there is legal sanctioning and
regulation of particular provider roles such as physician, nurse,
hospital, etc., where providing health care in the absence of
sanctioning/licensing is illegal.
Definitions for Hospitalization, Outpatient encounter, and ED
encounter to follow once we have these definitions largely in hand.
Melanie Courtot
Thanks for the definitions - a few comments below.
Melanie
On 2-Feb-11, at 6:34 AM, Bill Hogan wrote:
> Health care encounter:
>
> A temporally-connected health care process with an organization and a
> person as participants, and that is the realization of both the
> organization’s health care provider role and the person’s patient
> role.
>
> Notes: it does not require direct human-human interaction the whole
> time. Thus, it encompasses waiting in the waiting room after checking
> in, being in one’s hospital room by oneself, etc. The common usage of
> ‘hospitalization’ or ‘inpatient encounter’ encompasses the entire time
> from admission to discharge. Thus, gaps in human-human interaction
> are not gaps in the hospitalization. Also, you could consider the
> 24X7 availability of staff, and 24X7 monitoring of the patient, as
> processes and thus the realization is in fact continuous (i.e.
> temporally connected).
>
> More notes: includes office visits, hospitalizations, ED encounters,
> same-day surgery encounters, etc. Excludes deciding on your own to
> take supplements, because by yourself you are not an organization.
> Which is good, because the common usage of healthcare encounter
> excludes people treating themselves.
>
What about doctor visiting you at home? If we replace organization
with person or organization, and as they bear the health care provider
role, it should still be ok and exclude self medication.
> Health care process:
>
> A social process that has at least one human participant and that
> includes as parts the treatment, diagnosis, or prevention of disease
> or injury--or the following of instructions of another human for
> treatment/diagnosis/prevention--of a participant in the process.
>
> Notes: requires only the patient as participant because some
> processes, such as taking medications or following instructions on
> one’s own, does not involve a provider. The prescribing, filling of
> the prescription, selling, etc. of a medication all involve providers,
> but the taking does not. What about taking supplements on one’s own?
> Either (a) not a healthcare process or (b) the same person bears and
> realizes both the provider role and the patient role. What about
> parent following instructions of doctor by giving medication to a
> child? This is a healthcare process because it is the following of
> instructions of another human for treatment/etc. In other words, the
> definition places no restrictions on who follows the instructions,
> just that the follower of instructions and the giver of instructions
> are different participants.
>
> More notes: excludes animal care. Options are to (1) broaden
> definition of health care process to say that the participant is an
> organism instead of human only or (2) create a sibling of health care
> process, ‘veterinary care’ or some such.
I would prefer the broad definition for health care process (i.e. use
organism), and then if needed subclasses "human care process" and
"veterinary care process" which would be defined as "health care
process and has_specified_input some human" and "health care process
and has_specified_input some (organism and not human)" respectively.
On a side note, OBI has "animal care protocol", which would be
realized as an animal care process - maybe it is worth requesting
addition of the process into OBI, and then OGMS would deal only with
health care process and human care process; it seems that animal care
may be out of OGMS scope, and OBI could import the OGMS health care
process if needed.
>
> Patient (role): NOTE: This term is in the Ontology for Medically
> Related Social Entities. DO NOT ADD TO OGMS. We already agreed that
> the number of health care roles will proliferate beyond what OGMS
> could/should accommodate, and that they should go in OMRSE. I put it
> here because the definition of health care encounter relies on it.
>
> The social role of a person, the realization of which is a health care
> process, where the bearer of this role is the recipient of treatment,
> diagnosis, or prevention of disease or injury, or on whom instructions
> for the treatment/diagnosis/prevention of disease or injury are
> carried out.
>
> Note: must say “on whom instructions are carried out” to encompass
> both adults and children. In the former case, the patient usually
> carries out the instructions on himself (but not always—for example,
> an elderly parent with dementia whose child carries out instructions
> when the parent is unable); in the latter case, a caregiver (usually a
> parent) carries out the instructions on the child.
There is a patient role in OBI, http://purl.obolibrary.org/obo/OBI_0000093
, so it may be worth suggesting its replacement once the OMRSE term is
in place.
>
> Health care provider (role): NOTE: This term is in the Ontology for
> Medically Related Social Entities. DO NOT ADD TO OGMS. We already
> agreed that the number of roles will proliferate beyond what OGMS
> could/should accommodate, and that they should go in OMRSE. I put it
> here because the definition of health care encounter relies on it.
>
> The social role of a person or organization, the realization of which
> is a health care process, where the bearer of this role is doing the
> treatment, diagnosis, or prevention of disease or injury, or who is
> giving instructions for the treatment/diagnosis/prevention of disease
> or injury.
>
> Note: in most western nations, there is legal sanctioning and
> regulation of particular provider roles such as physician, nurse,
> hospital, etc., where providing health care in the absence of
> sanctioning/licensing is illegal.
Similar note to above, there is health care provider role in OBI, http://purl.obolibrary.org/obo/OBI_0000207
.
>
> Definitions for Hospitalization, Outpatient encounter, and ED
> encounter to follow once we have these definitions largely in hand.
---
Mélanie Courtot
MSFHR trainee, TFL- BCCRC
675 West 10th Avenue
Vancouver, BC
V5Z 1L3, Canada
Bill Hogan
Thank you for your thoughtful comments!
I agree with extending the definition to "organization or person".
Also includes visits by home nurses (although they are usually members
of an organization, and thus the home nursing visit is also a
realization of that home nursing organization's role). The other
benefit this has is that when the doctor does see the patient in the
hospital, that counts as an encounter, too.
Which then means that encounters can overlap. But I wouldn't say that
the doctor's visit to see a patient in the hospital is necessarily
PART OF the hospitalization, because if the doctor is not a member of
the hospital organization, then his realizing his doctor role is not a
realization of the hospital's role or part of it. In this case, there
are two instances of encounter, whose temporal projections "overlap"
(more formally, the temporal projection of the hospitalization
includes the projection of the doctor's visit).
However, I would like to have as a child the encounter specific to
organizations only. Outpatient encounter, inpatient encounter, and ED
encounter are all children of this organization-specific health care
encounter. If a nurse sees you in the hospital, that is not by itself
a hospitalization. Ditto for the nurse in the ED and in the doctor's
office, etc.
If we decide to broaden to animals, we need to be careful to avoid
multiple inheritance. Animal hospitalization, human hospitalization,
animal outpatient encounter, human ED encounter, veterinarian farm
visit, etc. could wind up with >1 parent if we're not careful. We
need to determine the primary differentiation among health care
processes. If folks agree that the first differentiation is truly
animal vs. human, as opposed to something else like the level of
intensity of care (hospital vs office), that's fine.
Also, we need to consider other health-care processes like
registration, x-rayings, ct scannings, operations, endoscopies,
discharge planning (not sure the current definition encompasses some
of these more administrative processes), administering of medication,
taking of vital signs, etc.
I apologize for not knowing that OBI has 'patient' and 'healthcare
provider' already. I'm happy to go either way in OMRSE: import the
OBI terms and extend, or take them over.
Bill
Melanie Courtot
On 3-Feb-11, at 5:52 AM, Bill Hogan wrote:
> Melanie,
>
> Thank you for your thoughtful comments!
>
> I agree with extending the definition to "organization or person".
> Also includes visits by home nurses (although they are usually members
> of an organization, and thus the home nursing visit is also a
> realization of that home nursing organization's role). The other
> benefit this has is that when the doctor does see the patient in the
> hospital, that counts as an encounter, too.
>
I was initially thinking about something like "organization or its
representative", but then thought that representative would be hard to
define - do we mean spokeperson, member of the organization.... Even
if member, the person needs to bear the health care provider role -
I'd rather be examined by a doctor than by a receptionist :) With the
use of the role I believe we can avoid any issue and cover the cases
you mention.
> Which then means that encounters can overlap. But I wouldn't say that
> the doctor's visit to see a patient in the hospital is necessarily
> PART OF the hospitalization, because if the doctor is not a member of
> the hospital organization, then his realizing his doctor role is not a
> realization of the hospital's role or part of it. In this case, there
> are two instances of encounter, whose temporal projections "overlap"
> (more formally, the temporal projection of the hospitalization
> includes the projection of the doctor's visit).
>
If a doctor visits you when you're in the hospital, presumably he
would have been called by the hospital to give further advice on your
case, so would that still be a realization of the hospital role?
> However, I would like to have as a child the encounter specific to
> organizations only. Outpatient encounter, inpatient encounter, and ED
> encounter are all children of this organization-specific health care
> encounter. If a nurse sees you in the hospital, that is not by itself
> a hospitalization. Ditto for the nurse in the ED and in the doctor's
> office, etc.
>
So you would want to have:
- health care encounter (including home visits etc)
------ hospitalization
------ outpatient encounter (example nurse seeing non hospitalized
patient)
------ inpatient encounter (example doctor visiting his patient in
hospital). Additional restriction: part_of some hospitalization
------ ED encounter (example I have a bad cold and go to Emergency room)
Is that correct? Will there be outpatient and inpatient roles to match
the encounters?
If we define inpatient as being an hospitalized patient, should an ED
encounter a subclass of outpatient encounter? I believe the process is
person goes to Emergency room, becomes a patient when sees a doctor
(at this stage this is an outpatient care process). Doctor then
decides if hospitalization is required (if yes the patient becomes an
inpatient, but the emergency visit ends simultaneously) or not (and
patient stays outpatient and goes home)
For example I break my wrist, go to ER, they reduce the fracture and
put a temporary cast on it. All the care was done in the ER
department and I go home later that night. I think that still falls
under outpatient, even though extended care was provided by ER. Is
that right?
How is hospitalization defined? Is it a minimum length of time spent
in a hospital, a specific level of care?
Sorry if some questions are rather naive, I am not a health care
provider and am just trying to see how all elements fit together :)
> If we decide to broaden to animals, we need to be careful to avoid
> multiple inheritance. Animal hospitalization, human hospitalization,
> animal outpatient encounter, human ED encounter, veterinarian farm
> visit, etc. could wind up with >1 parent if we're not careful. We
> need to determine the primary differentiation among health care
> processes. If folks agree that the first differentiation is truly
> animal vs. human, as opposed to something else like the level of
> intensity of care (hospital vs office), that's fine.
I was thinking defining animal care and human care in term of
necessary and sufficient conditions, so that we would have a single
hierarchy for the care processes and then infer for the type of
organism. I can't think of an example for which the level of care
plays a role; if we need it I suspect we can always add it?
>
> Also, we need to consider other health-care processes like
> registration, x-rayings, ct scannings, operations, endoscopies,
> discharge planning (not sure the current definition encompasses some
> of these more administrative processes), administering of medication,
> taking of vital signs, etc.
>
It seems to me that there are at least 2 different types of processes,
one would be "medical interventions" (x-ray, scans, surgery etc) the
other would be "administrative processes" (registration, discharge,
enrollment in study etc)
I would say that a health care protocol is always (via its realizable
concretization) realized as a health care process that as part at a
minimum one medical intervention (at a minimum physical examination or
oral interrogation) and one administrative process (at a minimum
taking your name or some data regarding your age and sex for anonymous
clinics).
> I apologize for not knowing that OBI has 'patient' and 'healthcare
> provider' already. I'm happy to go either way in OMRSE: import the
> OBI terms and extend, or take them over.
In my opinion those terms would be better suited for OMRSE. If I
remember correctly when such terms were added into OBI there was
always a question of the social aspect of the role (as you mentioned
the nurse needs to be licensed etc). As I recall OBI always
acknowledged that those would be better taken care of by a specialized
resource, and they were added because there was none at the time. It
may be worth checking with the OBI developers how to best proceed. OBI
also includes investigation roles (for example PI role, sponsor role)
- are those in the scope of OMRSE?
Thanks,
Melanie
Bill Hogan
>
>> Melanie,
>>
>> Thank you for your thoughtful comments!
>>
>> I agree with extending the definition to "organization or person".
>> Also includes visits by home nurses (although they are usually members
>> of an organization, and thus the home nursing visit is also a
>> realization of that home nursing organization's role). The other
>> benefit this has is that when the doctor does see the patient in the
>> hospital, that counts as an encounter, too.
>>
>
> I was initially thinking about something like "organization or its
> representative", but then thought that representative would be hard to
> define - do we mean spokeperson, member of the organization.... Even if
> member, the person needs to bear the health care provider role - I'd rather
> be examined by a doctor than by a receptionist :)
If I implied otherwise (that health care provider role was not
necessary) then I apologize. I certainly never meant that.
> With the use of the role I
> believe we can avoid any issue and cover the cases you mention.
>
>> Which then means that encounters can overlap. But I wouldn't say that
>> the doctor's visit to see a patient in the hospital is necessarily
>> PART OF the hospitalization, because if the doctor is not a member of
>> the hospital organization, then his realizing his doctor role is not a
>> realization of the hospital's role or part of it. In this case, there
>> are two instances of encounter, whose temporal projections "overlap"
>> (more formally, the temporal projection of the hospitalization
>> includes the projection of the doctor's visit).
>>
>
> If a doctor visits you when you're in the hospital, presumably he would have
> been called by the hospital to give further advice on your case, so would
> that still be a realization of the hospital role?
>
More formally he has been credentialed by the hospital and been given
admitting privileges there. To maintain privileges, he must abide by
various hospital rules and regulations. And hospital staff must
follow his orders on his patients. So yes, it's a very closely
intertwined relationship. But it's going a bit too far to say he's
acting on behalf of the hospital.
I see now that what I implicitly had in mind was that there is exactly
one entity participating in the encounter as provider, and exactly one
participant as patient, per instance of encounter. So the
hospitalization is one encounter, each visit by the physician and/or
his partners, is another encounter.
I also see now that the hospitalization is one encounter instance, the
daily physician visits are yet other instances of encounter, and it is
still possible for the latter to be part-of the former. So I'm
softening towards physician visits being part-of the hospitalization.
Thinking about it conversely, it seems odd to say that the doctor
seeing you in the hospital is not part-of your hospitalization.
>> However, I would like to have as a child the encounter specific to
>> organizations only. Outpatient encounter, inpatient encounter, and ED
>> encounter are all children of this organization-specific health care
>> encounter. If a nurse sees you in the hospital, that is not by itself
>> a hospitalization. Ditto for the nurse in the ED and in the doctor's
>> office, etc.
>>
>
> So you would want to have:
> - health care encounter (including home visits etc)
> ------ hospitalization
> ------ outpatient encounter (example nurse seeing non hospitalized patient)
> ------ inpatient encounter (example doctor visiting his patient in
> hospital). Additional restriction: part_of some hospitalization
> ------ ED encounter (example I have a bad cold and go to Emergency room)
>
> Is that correct? Will there be outpatient and inpatient roles to match the
> encounters?
Yes, I was thinking of hospital, clinic (or some other, perhaps better
suited term), and emergency department roles. Perhaps also same day
surgery.
Encounters that occur other than face-to-face introduce a new
classification issue: telephone encounter, telemedicine encounter,
etc.
Also, when we break out by provider types, we have additional issues:
physician, nurse, cardiologist, gastroenterologist, physical
therapist, etc.
>
> If we define inpatient as being an hospitalized patient, should an ED
> encounter a subclass of outpatient encounter? I believe the process is
> person goes to Emergency room, becomes a patient when sees a doctor (at this
> stage this is an outpatient care process). Doctor then decides if
> hospitalization is required (if yes the patient becomes an inpatient, but
> the emergency visit ends simultaneously) or not (and patient stays
> outpatient and goes home)
> For example I break my wrist, go to ER, they reduce the fracture and put a
> temporary cast on it. All the care was done in the ER department and I go
> home later that night. I think that still falls under outpatient, even
> though extended care was provided by ER. Is that right?
I think level of severity/acuity of illness that require various
levels of service, etc. are primary and duration of encounter
(overnight) and setting (a particularly configured building) are
secondary.
The reason hospitalizations are longer encounters, and occur in
specialized buildings is because patients are sicker and require more
intensive levels of monitoring and care than you could provide at
home, for example. Someday in the future, maybe we'll be able to
treat people at home over a time period of several days with the level
of intensity we can provide only in hospitals today.
So I would be very averse to saying that duration of encounter, or
location, defines these subtypes of encounter.
And it also means that I am fairly confident that outpatient visit
(often aka ambulatory visit, clinic visit, outpatient encounter) ought
to be a sibling and not parent of ED encounter. The ED implies a
certain level of availability, intensity, and scope of services
provided that the clinic does not provide.
> How is hospitalization defined? Is it a minimum length of time spent in a
> hospital, a specific level of care?
>
As above, no on time, yes on "level of care".
A good place to start, for sure.
>> I apologize for not knowing that OBI has 'patient' and 'healthcare
>> provider' already. I'm happy to go either way in OMRSE: import the
>> OBI terms and extend, or take them over.
>
> In my opinion those terms would be better suited for OMRSE. If I remember
> correctly when such terms were added into OBI there was always a question of
> the social aspect of the role (as you mentioned the nurse needs to be
> licensed etc). As I recall OBI always acknowledged that those would be
> better taken care of by a specialized resource, and they were added because
> there was none at the time. It may be worth checking with the OBI developers
> how to best proceed. OBI also includes investigation roles (for example PI
> role, sponsor role) - are those in the scope of OMRSE?
OK, let's ask the OBI developers (aren't you a member of that group?).
Regardless, I think it best not to create redundant
identifiers/URIs/etc until such decisions have been made, so I still
feel guilty of at least a small faux pas.
Albert Goldfain
encounter' (as well as stubs for the proposed children of 'health care
encounter') in a minor release of OGMS today. Here is what I see as
the consensus proposal as it currently stands:
Health care encounter: A temporally-connected health care process that
has as participants an organization or person realizing the health
care provider role and a person realizing the patient role. The
health care provider role and patient are realized during the health
care encounter.
Health care process: A social process that has at least one human
participant and that
includes as parts the treatment, diagnosis, or prevention of disease
or injury--or the following of instructions of another human for
treatment/diagnosis/prevention--of a participant in the process.
I think these are good enough starting points and we can refine later as needed.
Another potential wrench might be the notion of a shared health visit...see
http://www.intelihealth.com/IH/ihtIH/c/333/7228/1366619.html
There is a good argument to count that as a single encounter and a
good argument to count that as N encounters (for a shared visit of N
patients).
-Albert