Re: [Gnumed-devel] Storage and and representation (formatting?) of past history items

[James Busser]

On 13-Jan-08, at 12:50 PM, Karsten Hilbert wrote (in reply to J  
Busser's q):

> > would items that were
> > entered via progress notes always appear either in free-standing  
> > episodes
> > or in their own line *with* triangles beside them to show that  
> > they are
> > episodes with 1 or more encounters?
> Progress note items would appear as belonging to either
>
> - a freestanding episode
> - an episode belonging to a health issue
>
> root
>  issue
>   episode
>    encounter
>   episode
>    encounter
>  issue
>   episode
>    encounter

Please remind me whether "root" serves as the underlying,  
foundational, fundamental medical disorder (such as a disease that  
can affect multiple systems, such as sarcoidosis or systemic lupus  
erythematosis) that can be found any any stage of a patient's health  
to explain multiple issues whose cause may until then have been  
without explanation ("idiopathic") ...

... or does "root" above refer to "clin_root_item" which is not meant  
to be used for any "clinical" purpose except to make possible the  
electronic "inheritance" function of being able to link related parts  
across multiple tables?

The reason that I ask is because a patient could, for example,  
present with hematuria that turns out to be due to kidney stones and  
that episode may subside over a few encounters, only to become active  
after many months or a few years with more problems, so these may be  
considered multiple episodes of kidney stones where kidney stones  
(nephrolithiasis) is entered as the "issue" (= clin_health_issue?)

So... what happens if the patient develops pancreatitis and is found  
to have elevated calcium (hypercalcemia) and it turns out they they  
have hyperparathyroidism. It is probably reasonable to be able to  
record in the EMR tree that this patient has had issues of

- hematuria (although maybe this is disagreed, from the point of view  
that, as a manifestation of the kidney stones, the hematuria was just  
a symptom and it is satisfactory to just leave hematuria as the name  
(label) of the enclosing episode that becomes nested under kidney  
stones)

- kidney stones as an "issue" which is believed to have caused the  
hematuria (even though the kidney stones themselves may have been  
caused by hypercalcemia caused by hyperparathyroidism)

- pancreatitis (although again could be hidden as an episode label  
inside hyperparathyroidism)

- hyperparathyroidism (later found to be a parathyroid adenoma)

Basically what I am appreciating is that if a patient's many  
manifestations of their problems become "hidden" by virtue of their  
living at the level of the episode names, then when one reviews a  
patient, for example presenting with some abdominal pain, and the  
doctor looks at their EMR tree, they will not see pancreatitis unless  
they click open sufficient numbers of the child-indicator triangles.  
This suggests to me that we may need a control that will at least  
expand all child items to their first level. Could/should such a  
control "live" in the right-click (control-click) contextual menus  
that are already offered in the EMR tree? I am thinking that at the  
level of the top-most item (the patient name which doubles as the EMR  
menu) we can offer "Open all to..." and then a submenu "issue level /  
episode level / encounter level". At successively more-deeply nested  
levels of the tree (for example at the level of any one health issue)  
the menu item would just say "Open to..." instead of "Open all to..."  
and the options would be fewer. For example at the level of the  
"9/2000 extraterrestrial infection", the existing "Health Issue Menu"  
items
        Edit details
        Delete
would be joined by
        Open to...
with submenus
                episode level
                encounter level

Lastly is there a desire to avoid keyboard bindings like Command/ 
Control/Alt + key for example modifier+O for Open, modifier+E for edit?