Pete:

Nothing like a good debate... but maybe reduced to a few key points:

>Some of the advantages - the 'loose structure' which sounds very
>appealing up front, turns out to be a major limitation when one tries to
>use the medical record for other tasks, or in other geographical
>locations.

I think that this depends upon how much responsibility one wishes to
allocate directly to computational components, and how much to human
judgment.  My view of a DSS is that it is no more than that, a support
system that, like an automobile, needs a driver. Hard to send a car to
the supermarket to do the shopping...

At 19:30 28/12/96 PST, you wrote: [PJ is >>>, > TL is >>]

>>>...How
>>>can we create EMR's which are usable for purposes other than that
>>>for which they were recorded?
>>
>>This is exactly where we see the contribution of SGML to be, in which the
>>many loosely structured documents that contribute to the clinical record,
>>by virtue of sufficient and appropriate markup, become the stakeholder
>>neutral and task-neutral carriers of information, interpretable and
 >                                                  ^^^^^^^^^^^^^
>>extractable by intelligent agents.
>                ^^^^^^^^^^^^^^^^^^

>And this is exactly where I see the problem. For markup to be sufficient,
>the DTD would need to be very carefully defined to be as context free as
>possible - task, geographically etc. Without this one cannot be confident
>that one is interpreting the record in the same way as the author.

We certainly look at the functions of markup in different ways, and
appear to have quite a different view of foundations. I don't look at
SGML as a technical solution, but rather, as the linguists have
discovered, as a means of formulating fundamental aspects of
syntax and semantics to extract meaning in an ever changing world.
With this in mind, it remains a workbench that requires the
construction of numerous compatible tools.

>I see the central problems to be these shareable tags, which everyone
>understands, agrees on the definition in all contexts of use. This isn't a
>problem that is solved by SGML - this is a terminology, ontology problem.

That is correct, SGML merely provides a means to state how the problem
has been approached in an indirect (thus flexible) and processable manner.

>It is a much bigger, more fundamental problem - and this is what seems
> to be getting glossed over. This foundation needs to be in place before
> issues of technical solutions become useful. Otherwise we're building
> castles on sand.

This is also correct, but the foundation need not be a fixed set of
definitions in the form of a fixed vocabulary. To my mind we are trying
to do two things with a common set of conventions: 1) As you suggest,
extract a context free outline that serves as a general framework of
common agreement and expectation; and 2) reintroduce and specify
the particular context of a particular circumstance by annotation.
One can add the already well explored coding tags as a third component.

At some level, to achieve 1), the context should not even be medicine or
healthcare more broadly. It should be a true test of such an outline that
it be domain independent (one is tempted to say, just as SGML is domain
independent). We have tentatively started to work on this problem, and
suggest a sketched outline -- by no means definitive, but useful for
demonstration purposes. Just as one can identify a formalism called a
"memo" which has certain expected components, one can identify
another called a "report." (In many ways a report resembles another
conventional structure called a "logical proof," where a problem has
been formulated and solved in one way and is now presented for the
audience in another, cleaned up arrangement -- one would seldom
suppose that any significant problem was ever solved the way a proof
is presented.) Likewise, a report is a rearrangement of observations,
facts and  conclusions in an expected format. Such a report has
identifiable pieces, although in any given instance some may be
missing and others may be markedly elaborated upon. (In the same
way that books have chapters, sections, and paragraphs.) One kind
of medical document is a report, which may come in many specific
flavors from numerous different sources. Only the most general
outline is common to all, but tagging this outline starts the process.

Here (with a distinctly medical flavor in vocabulary) is a tentative
working outline to start things off:

1) the source of the problem;
2) the (sometimes subjective) problem context;
3) objective data; and
4) the assessment (stated as problems or diagnoses); with
5) a plan that can be further divided into
    5a) actions preemptively taken (not everything can wait);
    5b) next steps that follow from the assessment; and
    5c) follow-up to test the accuracy of the assessment and
	  affect the reliability of the intended result.

More narrowly defined, this suggests in one venue a chief
complaint, followed by the now familiar SOAP, but it might
also apply to a report on TWA 800. Some reports will fall short
of suggesting a plan -- or it is implicit in the assessment.  This
would be true of a surgical pathology report, where the diagnosis
is often chosen with an implicit recommendation in mind.
Indeed, the terminology may differ from institution to institution
depending upon how the surgeons respond.

It is this unstated "village context" about which you are
complaining, and it arises because communication is largely
behavioral. We need tools to navigate in such an imperfect world,
but we must accept its existence. Logical inference can help us a
lot. One is reminded that it is very hard to keep explicit data about
a patient confidential, even if the name identifiers are removed,
because the patient can often be identified circumstantially, and
the disease inferred from the therapy.

Here again it is a matter of man machine interaction, with the
scope for judgment left to an educated human being. A well tagged
document makes this combined navigation easier (and on revisited
documents, cumulatively easier).

[big snip]  (much of the discussion treats these same issues again,
we agree on many aspects)

>On the contrary. I have tried specifically designed EMR's. I have tried
>tagging as a solution. It solved none of the problems I mentioned - a) it
>doesn't record missing distinctions which become necessary for use in a
>different task, b) it doesn't make explicit what shift in meaning is
>necessary when the context of use is different.

Part b is a matter of human insight, which can be added to annotate
a document, or the document source may suggest (or even declare)
the viewpoint.

Part a is mitigated by a more interactive on-line system, where certain
kinds of data are automatically collected as an audit trail attached to
the data as the transactions are made, and as information is shifted
from one user to the next as a part of work-flow management. In one
format, this audit trail is a separate part of the file, in the SGML
version, it is captured as tags in line.

Tom


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