[COAS-List] Re: Relationship (Service?)

["Peter Nicklin" <peter.nicklin@newcastle.ac.uk>]

Jinny

I am sending this message to the COAS list because there are COAS 
comments.  For the COAS folk who have not been following this debate, 
we are thinking about the possible role of a relationship service, as 
described below by Jinny......


Jinny wrote..............
> The way I see it, there are two types of relationships we are talking
> about: demographic relationships (that can be obtained from the
> demographic service) and others (shall we call them clinical?). The
> dmeographic relationships would be accesible from the demo-service. It is
> the other type of relationships, like physician-isPrimaryCareOf-patient
> type relations that we need a relationship service for.

Let's take the example of "physician-isPrimaryCareOf-patient" from 
your message because it's a good one.  The difficulty I have with a 
simple -relationship- service to handle this is that there are 
clinical actions and findings that must use this relationship as a 
context.  So, when the patient is referred to hospital it has 
been done by a primary care physician and therefore the 
"physician-isPrimaryCareOf-patient" relationship is relevant to that 
referral (in the UK, it is the responsibility of primary care 
physicians to control initial referrals to secondary care).  
Therefore relationships are very much part of the Patient record 
(whatever that may be).

To some extent this point is implicitly taken on board by COAS, 
because the latest COAS model has an "Observation Qualifier" which, 
inter alia, is intended as a means of recording the identity of the 
"observer".  On reflection, I would say that COAS should be thinking 
about recording the identity of the -relationship- between the 
observer and observed (usually the patient) rather than just the 
identity of the observer.  In so many clinical contexts it is the 
relationship that authorises (or legitimates) the observation and 
also provides extra information that is integral to the observation 
itself (e.g. a proposed action by the clinician with key 
responsibility for the patient would be more seriously considered tha 
a proposal from someone more peripherally involved).  To rephrase, 
the relationship has medico-legal and clinical importance.  Against 
this, it might be argued that if activity A was performed by 
clinician C in the context or relationship R between C and Patient P, 
then the very fact that C performed A on P whilst R was current would 
tell us what we needed to know about C's authority.  I wouldn't 
accept this.  C may have more than one relationship with P  (and we 
need to know which is the actual context) or may even be acting 
outside the authority of R.

So, do we need an actual relationship service, or are relationships 
so deeply embedded into other services, such as Record locator, 
Demographics, Encounter management, Enterprise management and even 
COAS and CIAS that, ultimately, a relationship service would 
imply a separation of concerns that would be impossible to achieve?  
On the other hand, the appearence of relationships in so many places, 
suggests the need for reuse.

I don't know the answer to this - but I do know that it is important 
to the Roadmap to get it sorted out.

Regards

Peter

_____________________________________________________________________
Peter Nicklin, NHS IMC,
c/o CHSR, 21 Claremont Place, Newcastle Upon Tyne, NE2 4AA, UK
Tel: +44 191 230 3614   Fax: +44 191 230 4563  Mobile: +44 831 198319
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