Procedures

Each participant, whether on site or off site will be considered a particular 'player' in each of the two scenarios (use cases) selected. The concept is that each site will be able to add to or modify the patient record and then send the complete record or a portion of it as requested, to the next provider.

How closely should these be planned in advance?

Potential Problem Areas

Date/Time Restrictions - Some participants may be using commercial or open source deployable applications that already have date/time detection limitations builtin for certain funtionalities. Since will will be simulating a long period of time in a relatively short period of time; as well as doing this across multiple time zones. What are the implications to the participating systems? Should we schedule all systems to be set to UTC and have scheduled datetime changes at specific times?
??????

Use Cases/ i.e. some simple Patient Journeys

Lets have a go at sketching out some simple journeys i.e.

Perhaps 2 or 3 patients that need 2 or 3 health record entries

eg 1. Young patient with minor illness/injury (a newborn is overcomplicated to start with.. mother/child record and all that)

ED visit

Subjective
- 10 year old boy attends with Cough & Fever
- Past Medical History, nil of note
- Allergy none
- Family History of Diabetes (mother)
- Social History- lives at home, goes to school
- Systems review- fever, cough, short of breath/ no GI/no GU complaints
Objective
- Examination - uncomfortable
- HR 130, RR 30, GCS 15, Temp 38oC
- Head and Neck; flushed appearance, mild dehydration, ENT Exam ok,
- Chest Examination, increased respiratory effort, intercostal recession, crepitations mid zone right side
- Abdominal examination, soft, generalised tenderness, no guarding, no masses
- CNS Examination, NAD
- Skin examination, no rashes
- Investigation.
  - Blood Glucose 25, Full Blood Count WCC 18, Urea & Creatinine Normal
  - Blood Gases Ph 7.2 Bicarbonate 5 mmol/L
  - Blood Type O positive
  - Chest Xray mid zone right side opacity
  - ECG ok
Assessment
- Problem/Diagnosis; Diabetic KetoAcidosis
- Problem/Diagnosis; Pneumonia

Plan
- Treatment
- Oxygen
- IV Fluid Saline 0.9% 500ml stat.
- IV Insulin Actrapid 5units + sliding scale
- IV Cefuroxime
- Referred & Admitted to Paeds team

Discharged 3 days later on Insulin regime

GP visit a month/months later (could be many simple variations on this one)

Subjective
- Patient well, no complaints
- Medications: Insulin long acting 20units/day
Objective
- Vital signs normal
- Urinalysis, Clear
- U&E test, Urea and Creatinine normal
- HBA1C High
Assessment
- Problem/Diagnosis; IDDM- Needs Insulin adjusting to HbAic
Plan
- Adjust Insulin with more longer acting insulin

ED visit some years later

Subjective
- Presenting complaint; Dizzyness and Collapse
- Missed out breakfast before work as late, running to bus
- Medication: Insulin, AntiHypertensive
- Allergy: Penicillin- Rash
Objective
- Vitals signs normal
- Blood Glucose Low
- Eye exam- Retinal changes Right eye

Assessment
- Problem/Diagnosis; Hypoglycemia
Plan
- Sublingual Glucose
- Recheck Blood sugar
- refer to GP for opthalmology followup

Opthalmology specialist clinic visit

Subjective
- Presenting Complaint: No visual problems
Objective
- Visual acuity 6/18 right eye
- Retina: venous abnormalities, large blot haemorrhages, cotton wool spots
Assessment
- Problem/Diagnosis; Diabetic retinopathy grade III
Plan
- Laser treatment to affected area

GP to GP transfer some years later

Subjective
- 55 year old moving locations
- Past History
  - Diabetes
  - Renal Disease
  - Retinal Disease
Objective
- Vitals normal
- Visual Acuity 6/18 right, 6/6 left
- U&E mild renal failure
- HbAic normal range
Assessment
- Problem/Diagnosis; IDDM- moderate control
Plan
- Please continue ongoing IDDM management (inc monitoring of renal and eye complications) this equals case 2. ie Older patient with a more chronic condition that needs some checkups

Technical

The method of information exchange will be to use W3C SOAP Version 1.2 as defined at http://www.w3.org/TR/soap12-part1/ and described in tutorial form http://www.w3.org/TR/2007/REC-soap12-part0-20070427/

Specific implementation should be discussed and/or on the openEHR implementers mailing list.