Episodes of Care (Design Page)

Background

During the OpenMRS Implementers meeting in 2009, we designed a way to expand on single-form encounters into the notions of visits and episodes of care. Encounters become a representation of a clinical transaction (a combination of orders, observations, notes, and/or metadata collected at a point in time) and are grouped within visits (e.g., clinic visit, hospitalization, emergency room visit, etc.). Episodes of Care are a grouping of encounters and/or visits related to a single topic (e.g., all encounters relating to a pregnancy).

Definitions

	Description	Examples

	Description	Examples
Encounter	A clinical transaction. One or more providers generating a set of data (orders, labs, notes, and/or observations) for a patient at a point in time.	An encounter form entered during a patient visit A doctor writes some orders and a note in one "ordering session" during a hospitalization A set of lab results delivered to the EMR
Visit	A group of one or more encounters that typically occur within a contiguous span of time.	A clinic vist A hospitalization
Episode of Care	A collection of visits and/or individual encounters that a related to a condition or treatment plan.	A pregnancy Treatment of hepatitis over 1 hospitalization and multiple clinic visits

Designing Episodes of Care

Per the notes taken during the implementers meeting 2009, the episode table would be designed as:

episode

column	description

column	description
episode_id	internal primary key
patient_id	patient to whom episode applies (is this redundant, since we're grouping visits & encounters which already link to patient?)
episode_topic	defines the type of episode, probably a link to a concept (e.g., pregnancy)
start_date	date on which episode began (could be earlier than first encounter/visit)
end_date	date on which episode ended (could be later than last encounter/visit)
voided	true if episode voided
voided_by	who voided episode
date_voided	date episode was voided
creator	who created this row
date_created	when row was created

episode_visit_map

column	description

column	description
episode_visit_map_id	internal primary key
episode_id	link to an episode
visit_id	link to a visit that is within the linked episode
voided	true if voided
voided_by	who voided link of visit to episode
date_voided	date link of visit to episode was voided
creator	who created this row
date_created	when row was created

We would link visits to an episode only when all encounter(s) within the visit are part of the episode.

episode_encounter_map

column	description

column	description
episode_encounter_map_id	internal primary key
episode_id	link to an episode
encounter_id	link to an encounter that is within the linked episode
voided	true if voided
voided_by	who voided link of encounter to episode
date_voided	date link of encounter to episode was voided
creator	who created this row
date_created	when row was created

We would link encounters to episodes when other encounters in the same visit are not part of the episode.

Relationship to programs

There is a similarity to programs, which track programs of care. Episodes of care differ in that they only represent a grouping of encounters & visits -- i.e., episodes do not have to be part of a patient program of care and episodes would not directly reference study protocols, workflows/states, etc. Once episodes of care are realized within OpenMRS, then programs could link to episodes to define the set of encounters/visits that are part of the program of care.

Since each program requires a concept (program.concept_id), an episode of care (and all of the visit/encounters it contains) can be related to a program by setting the episode_topic to this concept.