While working on the automation of the KPI calculation for SANER, some interesting (or less interesting) differences in the organizational presentation and / or in the workflow occurred, which affect the recording of different information.
These deviations may depend on the EHR implementation of the FHIR standard or the US core or other national guidance, or simply on which components of an EHR a provider uses or does not use to track certain types of activity.
Why did this encounter take place? This question can be answered in several ways:
- The encounter has an admission diagnosis from X.
- The encounter has a reason code of X.
- The encounter refers to a condition coded with X.
- The encounter refers to an observation coded with X with the value Y.
- During the encounter with a code of X, a condition is recorded
- During the encounter, an observation with a code of X with a value of Y is recorded
The patient died:
- The patient is discharged with a disposition that indicates a deceased person.
- The patient is identified as deceased.
- The patient has a deceased date.
- The patient is discharged to a location that indicates that the patient has passed away.
Medication (in hospital) was started on X day and ended on Y day
- The request date is X and the final administrative reference order is Y.
- The timing in the sequence stands for X and Y. The sequence is updated after a termination sequence (e.g. in cases such as “until the patient is better”).
- Just look at the medication administration records.
- Review the medication statement records.
- Other combinations from 1-4 above.
Until such representations are standardized, systems that attempt to automate some of these questions must find different ways to address these differences.
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