Background:
I have been digging into the FHIR DSTU2 specification to try and determine what is the most appropriate resource(s) to represent a particular patient's historical list of GPs/PCPs. I am struggling to find an ideal resource to house this information.
The primary criteria I have been using is to identify the proper resource is that it must provide values to associate a patient to a practitioner for a period of time.
Question:
What is the proper resource to represent historical pcp/gp information that can be tied back to a patient resource?
What I have explored:
Here is a list of my possible picks thus far. I paired the resource types with my thought process on why I'm not confident about using it:
Episode of Care - This seems to have the most potential. It has the associations between a patient and a set of doctors for a given time period. However, when I read its description and use-case scenarios, it seems like I would be bastardizing its usage to fit my needs, since it embodies a period of time where a group of related health care activities were performed.
Group - Very generic structure that could fit based on its definition. However, I want to rule out other options before taking this approach.
Care Plan - Similar to Episode of Care rational. It seems like a bastardization to just use this to house PCP/GP history information. The scope of this is much bigger and patient/condition-centric.
I understand that there may not be a clear answer and thus, the question might run the risk of becoming subjective and I apologize in advance if this is the case. Just wondering if anyone can provide concrete evidence of where this information should be stored.
Thanks!
That's not a use-case we've really encountered before. The best possibility is to use the new CareTeam resource (we're splitting out CareTeam from EpisodeOfCare and CarePlan) - take a look at the continuous integration build for a draft.
If you need to use DSTU 2, you could just look at Patient.careProvider and rely on "history" to see changes over time. Or use Basic to look like the new CareTeam resource.
Related
I am looking to find the best/recommended way to implement the MedicationRequest/MedicationAdministration workflow. Possiblities that I have explored are:
Using the MedicationRequest by itself, and at runtime, determine when the dosages should occur and if they fall withing the boundaries of the current shift, or
Using Tasks to create a limited amount of upcoming dosage Tasks, or
Using MedicationRequests resources based on the original MedicationRequest to indicate each separate dosage
Pros of option 1:
Smallest storage footprint
Cons of option 1:
Requires most run-time work (have to evaluate timing to determine if dosage is required this shift, more work determining missed dosages)
Pros of option 2:
Common use of Tasks could be used against other Orders (ProcedureRequests, etc.) for a common workflow (e.g. show all Tasks this shift)
Cons of option 2:
Default Fhir SearchPararmeters defined do not allow for search on Task.restriction.period (which I believe is how you define the period in which the Task is to be performed).
Only place to link MedicationAdministration to Task is supportingInformation, but the field definition (Additional information (for example, patient height and weight)) doesn't seem like it is appropriate to put the Task there. Possibly use Provenenace, and use that to link Task to MedicationAdministration in eventHistory, but this seems like a stretch.
Pros of option 3:
MedicationRequest.intent has order and instance-order as values. The documentation seems to indicate that this would be a good fit (overall request has intent=order, individual specific dosages would have instance-order)
MedicationRequest has a Fhir-defined search parameter on timing.event that could be used to find events for a specific period.
Cons of option 3:
http://hl7.org/fhir/us/meds/guidance.html#fetching-active-medications-orders states "A MedicationRequest resource query SHALL be all that is required to access the “all active medication orders”." The query example given is GET /MedicationRequest?patient=[id]&status=active{&_include=MedicationRequest:medication}. This kind of hints to me that they expect searches to be more done on status than time period. Not really a strong "con" against this approach, but definitely not a "pro" for using this method.
Any advice about the methods used by other implementations would be greatly appreciated.
The general design expectation is that you would creaste "instance" orders for each administration.
We are currently in the process of evaluating FHIR for use as part of our medical record infrastructure. For the EHR data (Allergies, Visits, Rx, etc..) the HL7 FHIR seems to have an appropriate mapping.
However, lots of data that we deal with is related to personal Fitness - think Fitbit or Apple HealthKit:
Active exercise (aerobic or workout): quantity, energy, heart-rate
Routine activities such as daily steps or water consumption
Sleep patterns/quality (odd case of inter-lapping states within the same timespan)
Other user-provided: emotional rating, eating activity, women's health, UV
While there is the Observation resource, this still seems best fit (!) for the EHR domain. In particular, the user fitness data is not collected during a visit and is not human-verified.
The goal is to find a "standardized FIHR way" to model this sort of data.
Use an Observation (?) with Extensions? Profiles? Domain-specific rules?
FHIR allows extraordinary flexibility, but each extension/profile may increase the cost of being able to exchange the resource directly later.
An explanation on the appropriate use of an FHIR resource - including when to Extend, use Profiles/tags, or encode differentiation via Coded values - would be useful.
Define a new/custom Resource type?
FHIR DSTU2 does not define a way to define a new Resource type. Wanting to do so may indicate that the role of resources - logical concept vs. an implementation interface? - is not understood.
Don't use FHIR at all? Don't use FHIR except on summary interchanges?
It could also be the case that FHIR is not suitable for our messaging format. But would it be any "worse" to go FIHRa <-> FIHRb than x <-> FIHRc when dealing with external interoperability?
The FHIR Registry did not seem to contain any User-Fitness specific Observation Profiles and none of the Proposed Resources seem to add appropriate resource-refinements.
At the end of the day, it would be nice to be able to claim to be able to - with minimal or no translation, ie. in a "standard manner" - be able to exchange User Fitness data as an FHIR stream.
Certainly the intent is to use Observation, and there's lots of projects already doing this.
There's no need for extensions, it's just a straight forward use. Note that this: " In particular the user fitness data is not collected during a visit and is not human-verified" doesn't matter. There's lots of EHR data of dubious provenance...
You just need to use the right codes, and bingo, it all works. I've provided a bit more detail to the answer here:
http://www.healthintersections.com.au/?p=2487
I'm investigating HL7-FHIR for use in a decision support context and was trying to find out how to extract accident information for a given patient. I had assumed this would be a resource type but I can't find anything that fits.
We don't have a specific resource for this information. Mostly, this sounds like a series of observations, and perhaps a context linking them together. It's the context piece that we haven't yet got (our initial focus was on PHR). That will definitely be in the next version, but for now, I guess you just use the observations directly
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The question is quite generic. What are the points that should be kept in mind to identify a valid use case? How to approach a use case?
A use case identifies, with specificity, a task or goal that users will be able to accomplish using a program. It should be written in terms that users can understand.
Wikipedia's description is overly formal. I'll dig through my other texts shortly.
In contrast, the original wiki's article is much more accessible.
An early article by Alastair Cockburn, cited positively by The Pragmatic Programmer, contains a good template.
This question, from just a few days ago, is very closely related, but slightly more specific.
The definition of use case is simple:
An actor's interactions with a system to create something of business value.
More formally:
a sequence of transactions performed
by a system that yield a measurable
set of values for a particular actor.
They're intended to be very simple: Actor, Interaction, Value. You can add some details, but not too many.
Using use cases is easy. Read this: http://www.gatherspace.com/static/use_case_example.html
The biggest mistake is overlooking the interaction between actor and system. A use case is not a place to write down long, detailed, technical algorithm designs. A use case is where an actor does something.
People interact with systems so they can take actions (place orders, approve billing, reject an insurance claim, etc.) To take an action, they first make a decision. To make a decision, they need information
Information
Decision
Action
These are the ingredients in the "Interaction" portion of a use case.
A valid use case could describe:
intended audience / user
pre-requisites (ie must have logged in, etc)
expected outcome(s)
possible points of failure
workflow of user
From Guideline: Identify and Outline Actors and Use Cases by the Eclipse people:
Identifying actors
Find the external entities with which
the system under development must
interact. Candidates include groups of
users who will require help from the
system to perform their tasks and run
the system's primary or secondary
functions, as well as external
hardware, software, and other systems.
Define each candidate actor by naming
it and writing a brief description.
Includes the actor's area of
responsibility and the goals that the
actor will attempt to accomplish when
using the system. Eliminate actor
candidates who do not have any goals.
These questions are useful in
identifying actors:
Who will supply, use, or remove
information from the system?
Who will
use the system?
Who is interested in a
certain feature or service provided by
the system?
Who will support and
maintain the system?
What are the
system's external resources?
What
other systems will need to interact
with the system under development?
Review the list of stakeholders that
you captured in the Vision statement.
Not all stakeholders will be actors
(meaning, they will not all interact
directly with the system under
development), but this list of
stakeholders is useful for identifying
candidates for actors.
Identifying use cases
The best way to find use cases is to
consider what each actor requires of
the system. For each actor, human or
not, ask:
What are the goals that the actor will
attempt to accomplish with the system?
What are the primary tasks that the
actor wants the system to perform?
Will the actor create, store, change,
remove, or read data in the system?
Will the actor need to inform the
system about sudden external changes?
Does the actor need to be informed
about certain occurrences, such as
unavailability of a network resource,
in the system?
Will the actor perform
a system startup or shutdown?
Understanding how the target
organization works and how this
information system might be
incorporated into existing operations
gives an idea of system's
surroundings. That information can
reveal other use case candidates.
Give a unique name and brief
description that clearly describes the
goals for each use case. If the
candidate use case does not have
goals, ask yourself why it exists, and
then either identify a goal or
eliminate the use case.
Outlining Use Cases
Without going into details, write a
first draft of the flow of events of
the use cases identified as being of
high priority. Initially, write a
simple step-by-step description of the
basic flow of the use case. The
step-by-step description is a simple
ordered list of interactions between
the actor and the system. For example,
the description of the basic flow of
the Withdraw Cash use case of an
automated teller machine (ATM) would
be something like this:
The customer inserts a bank card.
The system validates the card and prompts
the person to enter a personal
identification number (PIN).
The customer enters a PIN.
The system
validates the PIN and prompts the
customer to select an action.
The customer selects Withdraw Cash.
The system prompts the customer to choose
which account.
The customer selects
the checking account.
The system
prompts for an amount.
The customer
enters the amount to withdraw.
The
system validates the amount (assuming
sufficient funds), and then issues
cash and receipt.
The customer takes the cash and receipt, and then
retrieves the bank card.
The use case ends.
As you create this step-by-step
description of the basic flow of
events, you can discover alternative
and exceptional flows. For example,
what happens if the customer enters an
invalid PIN? Record the name and a
brief description of each alternate
flow that you identified.
Representing relationships between
actors and use cases
The relationship between actors and
use cases can be captured, or
documented. There are several ways to
do this. If you are using a use-case
model on the project, you can create
use-case diagrams to show how actors
and use cases relate to each other.
Refer to Guideline: Use-Case
Model for more information.
If you are not using a use-case model
for the project, make sure that each
use case identifies the associated
primary and secondary actors.
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I work for a CMMI level 5 certified company and one thing I hate about is the amount of documents we prepare (As a programmer I already hate documents). We have lots and lots of documents like PID(project initiation doc), Business requirements, System requirements,tech spec, Code review checklist, issue logs, Defect logs, Configuration management plan, Configuration management check list(s), Release documents and lots...
Almost 90% of these docs are just done for the sake of QA audit :) .. What do you think are the most important documents for a project? What documents can be used in the long run by another developer?
Please share your good practices here. I would like to use them for my own projects or the company I am planning to start in the long run.
Thanks
The key document is a good functional spec. There should be one and only one reference document for a system.
Overdoing documentation proliferates a large number of small requirements and spec documents every time someone changes a system or interface. For a system of any complexity, before long you have your spec distributed around several hundred assorted word, excel, visio and even powerpoint files. When this happens you lose clarity about what is current or even whether you have located and identified all pertinent documentation.
The BRD-SRD-Tech spec progression is based on an assumption that the business signs off the BRD, a business analyst signs off the SRD against requirements documented in the BRD and the technical specification is signed off against the SRD. This generates a web of sign-offs, multiple documents with redundant information and makes it difficult and clumsy to keep the spec documents up to date.
Because of this, subsequent requirements documentatation tends to take the form of a series of change request and supplemental requirement and spec docs, each with their own sign-off and audit process. You gain CYA and audit trail (or at least the appearance of an audit trail), but you lose clarity. There is now no definitive reference document for the system and it is difficult to establish what is current or relevant to any particular activity. The net result is that your business analysis process gets bogged down in forensic research, which adds overheads and latency to delivery schedules.
A spec document should be built in such a way that there is one definitive reference for any given system or subsystem. The document should be kept up to date and versioned. Get a good technical documentation tool like Framemaker, so your process can scale, and the document has some structural integrity of the sort lacking on Word.
For me the only real document I ever use is a spec. The more detail the better. However it doesnt need to be all completed at one time, and it doesnt need to be particularly formal. What is far more useful to me than documents that are checked and signed and double checked and double signed is always being able to get the latest version of a document. And being able to talk to people about what they have written, and get a decision in the case of any ambiguity. this is far more useful to me than anything else.
To sum up: a spec is the only document I have ever found useful, however it pales in comparison to having a project manager who knows the proposed system inside out, and can make sensible decisions based on what they know.
Documentation is like tofu -- most people hate it until they realize that under the right conditions, it can be really good.
The problem is that what you consider documentation is mostly made for documentation's sake. You, as a developer, don't see any immediate value in the documents you produce because you know you can do your job without all the TPS reports which you're required to make.
Unfortunately, I'm going to wager that there's not a lot you can do about in a company where you're being forced to eat raw tofu all the time. You'll probably just have to suck it up and write the docs which your company requires, but you can at least do one thing... you can write documents which at least are useful to you, and you can pass them along with your code for others who will maintain it.
Aside from inline documentation, you could set up a wiki to be used by yourself and people on your team. This type of documentation is searchable, which is already a big plus to developers, plus it's more of a living document instead of a homework-like paper you had to write. You already post to SO, so just think of your documentation as pooling your knowledge in a more useful place.
What do you think are the most important documents for a project?
Different people have different needs: for example the documents which the owner needs (e.g. the business contract) aren't the same as the documents which QA needs.
What documents can be used in the long run by another developer?
IMO the most important document (except for the source code) is the functional specification: because what the software is supposed to do (as opposed to, what it is doing) is the one thing that can't necessarily be reverse-engineered. See also How does a good developer keep from creating code with a low bus hit factor?
User Stories, burndown chart, code
I'm a fan of the old 4+1 views:
Use Case view (a/k/a user stories). There are several forms: proper use cases, forward-looking use cases that aren't as well defined and epics which need to be decomposed.
Logical view. The "static" view. UML Class diagrams and the like work well here as a design document. This also includes request and response formats for various protocols. Here is where we document the RESTful requests and responses. This includes the REST URI design.
Process view. The "dynamic" view. UML activity diagrams, sequence diagrams and statecharts and the like for here for design documents. In some cases, simple narratives work well. In other cases, there's a State design pattern, and it requires a combination of class diagrams and statecharts to show how the stateful objects interact.
This also includes protocols (e.g. REST). Here is where we define any special processing for the various REST requests.
This also includes an authentication or authorization rules, and any other cross-cutting aspects like security, logging, etc.
Component view. The pieces we're building for deployment. This includes the stuff we depend on, the structure of the modules and packages, etc. This is often a simple component diagram or a list of components and their dependencies.
Deployment view. We try to generate this from the code as deployed. Since we're using Python, we use epydoc to create the API documentation. We also use Sphinx to import module documentation into this view of the software.
This also includes the parameters, settings, and configuration details.
This, however, isn't sufficient.
When projects start, you have to work up to this through a series of sprints.
The first sprints build just the use case view.
Subsequent sprints build an "architecture" to implement the use cases. The architecture document has 4+1 views, but at a high level of abstraction. It summarizes the structure of the model schemas, the requests and replies, the RESTful processing, other processing, the expected componentry, etc. It never has a Deployment view. We generally reference operator guide and API documents as the deployment view of an architecture.
Then design-and-construction sprints build (and update) detailed 4+1 view documents for various components.
Then release sprints build (and update) the deployment views.
From the project point of view, the most important documents are those that normally include the word Plan, such as the Project Plan, Configuration Management Plan, Quality Plan, etc.
What you are describing is common in process improvements, and normally responds to two major causes. One is that the system really is overeaching and getting in the way of real work being done. Another is actually answered in your question: it is not that the documents are only done for the sake of audits, and your focus should not just be how usefull is the doc for other developers, but for the project or the company as a whole.
One usually looks at things from it's own perspective, sometimes it's necessary to look at the general picture.