Monday, April 13, 2009

New HL7 Ballot: Signs of Hope, but Confusion Remains

In 2007 the HL7 Board of Directors identified the need to review existing HL7 documentation in light of multiple unclarities and inconsistencies, some of them referred to in this blog (and also here). In the recently released Ballot Version 0226 of May 2009, we are perhaps beginning to see some evidence of the workings of this review, most notably in the fact that a much-cited nonsense passage present in earlier versions of the RIM documentation, according to which

there is no distinction between an activity and its documentation,

has been removed.

This is an important step, given the fundamental unclarity which has pervaded the RIM hitherto as concerns whether the items which the RIM calls 'Acts' are real processes (intentional actions) or records of such processes. HL7's official answer to this question thus far has been, absurdly, that the issue is moot, because there is no distinction between real processes and the records of such processes.

We hope now that the opportunity will be taken for further steps towards much needed clarity as concerns the interpretation of 'Act'. In the mentioned Ballot documentation we read:

Acts are the pivot of the RIM: domain information and process records are represented primarily in Acts. Any profession or business, including healthcare, is primarily constituted of intentional and occasionally non-intentional actions, performed and recorded by responsible actors. An Act-instance is a record of such an action.

Contrast earlier versions, where we were told that: "An Act-instance is a record of such an intentional action" (italics added). Are there now also some non-intentional actions the records of which we are allowed to count as Act-instances? If so, which ones? And what is a 'non-intentional action'? And what of of non-intentional events of other sorts, for instance snake bites, accidental poisonings, processes of infection, drug interactions, symptoms of disease?

Following on in the text, we read:

An Act-instance represents a "statement," according to Rector and Nowlan (1991) [Foundations for an electronic medical record. Methods Inf Med. 30.]
What is the meaning of 'represents' in such assertions? And what (if any) is the distinction between an Act and an Act-instance? Are we to accept three distinct entities: the action performed in the real world, the record of this action (which record?), the statement in the electronic medical record? Or is the record identical with the statement in the electronic medical record.

Acts as statements are the only representations of real world facts or processes in the HL7 RIM. The truth about the real world is constructed through the combination (and arbitration) of such attributed statements only ...

Do the authors of this documentation really mean 'The truth about the real world'? Or do they rather mean something like: the picture of or beliefs about the real world implied by a given body of documentation? What if the patient is dead, but the records do not show it?

A factual statement may be made about recent (but past) activities, authored (and signed) by the performer of such activities, e.g. a surgical procedure report, clinic note, etc. Similarly, a status update may be made about an activity that is presently in progress, authored by the performer (or a close observer), and later superseded by a full procedure report. Both status update and procedure report are acts, distinguished by mood and state (see Act.statusCode) and completeness of information: neither has any epistemological priority over the other except as judged by the recipient of the information.
Is a surgical procedure report truly an activity? Are a status update and a procedure report truly 'acts, distinguished by mood and state'? If so, are they also Acts? Lingering unclarities such as these are not resolved by the list of 'examples' presented by HL7 in the same document to help us understand correct usage:

The kinds of acts that are common in health care include (1) clinical observations, (2) assessments of health condition (such as problems and diagnoses), (3) healthcare goals, (4) treatment services (such as medication, surgery, physical and psychological therapy), (5) acts of assisting, monitoring or attending, (6) training and education services to patients and their next of kin, (7) notary services (such as advanced directives or living will), (8) editing and maintaining documents, and many others.

If editing and maintaining documents are acts, then are the records (and if so which records?) of these processes of editing and maintaining documents Acts? What is the relation between 'acts' and 'Acts', and between both of these and activities (and actions)? And how can a goal be a kind of act? (or Act?)

1 comment:

Spero melior said...

The contradiction still exists, even if not in one sentence.

I find here:

"Act which represents the actions that are executed and must be documented as health care is managed and provided."


"Definition of Act:

A record of something that is being done, has been done, can be done, or is intended or requested to be done."

Which is it? Actions or records of actions?