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Intentionality of Act and the Future of Observations

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This page documents a Resolved,
but not fully actioned MnM Hot
Topic, i.e. a methodology issue requiring a resolution from Modeling and
Methodology.

Contents

1 Resolution

1.1 Harmonization
Action

2 Background

3 Problem

4 The Proposal

4.1 Rationale

4.2 Points of
Concern

4.3 Considerations

4.4 Possible
Guidance

Resolution

MnM call 20060605:

Motion (Charlie McCay): This INM request for guidance (as of 20060605, see
history page) will become M&M harmonization proposal for the next
Harmonization meeting.

Second(Mead Walker): 10-0-0 (passed)

Harmonization Action

Update the definition of Act to clarify the above and remove
"intentionality" from the definition of Act.

Add guidance explaining the difference between SUBJ and VALUE

Background

There were discussions at the last few HL7 modeling harmonization events
regarding a revision on the way we think about acts.

Here is a fragment of the Act Definition:

Acts are the pivot of the RIM; all domain information and processes are
represented primarily in Acts. Any profession or business, including healthcare,
is primarily constituted of intentional actions, performed and
recorded by responsible actors. An Act-instance is a record of such an
intentional action. Intentional actions are
distinguished from something that happens by forces of nature (natural events).
Such natural events are not Acts by themselves, but may be recorded as observed
(Observation).

Problem

Some questions that came up are:

Is an accidental administration of insulin to a patient a
SubstanceAdministration, can it be called an "intentional action"?

Is a snake bite or bee sting a SubstanceAdministation, can it be called an
"intentional action"?

Snake bites and bee stings are "intentional acts." The bee decides to give
its life to defend the hive, and the snake not only decides to bite, but to
envenomate, as well. ...pete gilbert

Is a gun-shot bullet a SubstanceAdministration?

An abdominal surgecy is a Procedure, is someone stabbing a knife
performing a procedure? Is it an intentional action?

Is a car accident an intentional action?

When a child swallows the contents of a bottle of poison is that an
intentional action?

The Proposal

The Proposal has been to remove the requirement for Acts to be called
intentional, and instead say that a snake bite can be called a substance
administration, someone stabbing me with a knife is performing an Act, and a
gun-shot hitting me in a cross-fire is also an Act. Car accident is an act as
well and so is me being hit by a lightning strike.

So, all distinctions between acts that are ordered scheduled and billed for
vs. those events of nature would go away. When the Act class was still called
"Service" this kind of change was unthinkable, now it is a notion that is
seriously entertained.

Rationale

The reason why people want this change is that it allows them to use the Act
attributes and participations (time, performer, etc.) to describe any incident
just like acts.

Points of Concern

The downside of this is that it causes a great shift in the modeling of
Observations. In the past, people would use Observations to describe events of
nature, and unintended incidents such as gunshot wounds or car accident
injuries. In fact there is still a sizable group of people who would like to
think of procedure history (e.g., appendectomy 20 years ago) as an Observation
in a collection of "patient history" Observations. I think the RIM was trying to
make that appendectomy a Procedure regardless of whether it is recent and known
from first hand reports or if it is only known through patient recollection or
even hearsay. But now we would be moving even more information items that used
to be understood as Observations over into being other specific Acts such as
Procedures or SubstanceAdministrations.

Considerations

If we are to move forward and allow snakebites, gunshots and swallowing
poison to be fully represented as Acts, rather than just Observations, we need
to come up with some guidelines. Specifically, we need to answer the following
questions:

1. Are there some things that should always be modeled as Acts, and never
Observations (keeping in mind that Observations are a type of Act)?

2. Are there some things that should be modeled as Observations and never as
discrete Acts?

3. Are there some things that can appropriately be modeled either way, and if
so, what's the criteria for deciding which approach to use?

4. Might there be circumstances where we would want both an Observational and
an 'Act' view of the same event in an instance, and if so, how do we model the
relationship between them?

Possible Guidance

Observations related to the gathering and recording of information about
past occurrences should generally be captured as discrete acts representing
those occurrences, rather than observations

The author and informer attributes of the Act can convey some of the
information about who is making the "observation" by reporting the action

Where the desire is to capture a primary action of "gathering and
recording data", Observation may be used, even if the information gathered is
historical. Doing so allows additional details about the actual "observation"
such as supervisor, activityTime, methodCode, etc. that cannot be conveyed by
simply stating the historical "Act" with an author and an informer.

A new ActRelationship, constrained to having a source of type Observation,
should be added that allows the conveying of "Value". Thus an Observation can
convey it's value in the Value attribute (when you're just capturing a free
text report of multiple Acts and don't have enough information to
differentiate or expose them as separate acts) or by creating child Acts
related through the "value" ActRelationship

Retrieved from "http://wiki.hl7.org/index.php?title=Intentionality_of_Act_and_the_Future_of_Observations"

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