I'm flabbergasted by the statement that "a= cts do=20 not have physical locations". If I understand this right, then docters and= =20 nurses work "nowhere". What about that as a justification for their salary= =20 ?!  :-)
I think you all agree that if Dr X gives p= atient Y=20 an injection (in the normal non-science fiction way), then that act takes p= lace=20 in the room where the docter and the patient are. If he does it by using a = robot=20 guided over the internet while he being in Paris and the patient in the US,= then=20 the act happened for sure on planet Earth. I do agree that determining wher= e=20 "the act" happened in situations like the latter is not trivial, the proble= m not=20 being that much the localisation, but rather what THE act IS. Although= we=20 would still use the word "injection" for the latter, it is obviously someth= ing=20 completely different than the former, despite the fact that parts of the ac= ts=20 are similar (e.g. the needle being brought into the patient's=20 body).
This said, I have no problem with the fact= that the=20 statement that "an Act occurs at a specific physical location" be removed f= rom=20 the document however: it is not because you don't state "X" in a document, = that=20 "not X" should be true.

Another point that I want to raise is the = statement=20 "An Act is documented by an Act Record instance". It should be specified wh= at=20 "instance" refers to in this case, precisely in the light of what happens w= hen=20 that "instance" is copied into other systems. Thus if act X=20 is injecting patient U by physician V with product W in place P a= t=20 time T, then Act Record instance AR1 might be the documentation o= f it=20 by V (thus the Dr registered what he did) and Act Record instance AR2 might= be=20 that the nurse who was in the room documented act X. Thus we have 2=20 instances documenting act X. If this information gets transfered and c= opied=20 to other systems in persistent records, then I believe "copies" of the= se=20 Act Record instances are created, and not new instances. Otherwise, act X w= ould=20 be claimed to be documented by 2, 4, 6, 8 .... instances, which is actually= not=20 true.

I know, the RIM being based on a Kantian p= hilosophy=20 makes it hard to deal with (and for some even to see) this problem, but I t= hink=20 it is important. And oh, you want for su= re a "use=20 case" for this: well suppose that there is some legal argument about whethe= r or=20 not the injection was actually given. Are ten copies of the same documentat= ion=20 instance more proof than just one ?   (note for Charlie: you= can=20 use this paragraph to build further on your file to document my "inability to productively collaborate wit= h the=20 community at large" and "Dr. Cuesters [sic] prefers to intermittently send= =20 sarcastic emails to various list servers".)

Note that may objection is not in the use = of the=20 word instance in that particular sentence. In fact, I believe it is good=20 practice, even that the statement should read "An Act instance is documente= d by=20 an Act Record instance", and even that the entire document should be checke= d=20 whether "instance" should not be used more often (I believe it=20 does).
But even then, it should be specified what= =20 "instance" means in each case, e.g. a particular act in physical reality or= an=20 entry in a database which documents that act.

kind regards,

Werner
----- Original Message -----
Fro= m:=20 = Dan=20 Russler
To: Gary Dickinson
Sent: Thursday, June 14, 2007 8:52= =20 AM
Subject: Re: DRAFT EHR Lifecycle M= odel -=20 Review and Comment Requested

Hi Gary,

I like this work a lot.

On quick re= view,=20 I encountered this line which I think should be deleted.

"An Act occurs at a specific= =20 physical location"

In the past, our discussions in modeling=20 specifically excluded this statement. The use cases that were discussed= =20 included healthcare delivered over the internet. If the patient is in one= =20 location, the physician in another location, the nurse in a third locatio= n,=20 and the EHR is in a fourth location, where did the Act occur? For example= , in=20 telemedicine, the patient may be in one location and the physician is=20 listening on a remote stethescope in another location? Or observation is = being=20 performed via camera? Or the surgery is being performed via a robot over = the=20 internet (as accomplished between US and Paris)?

We came to the=20 conclusion that participants have physical locations, but that acts do no= t=20 have physical locations.

In review of the rest of the document, I = did=20 not see that anything else needed to be changed because the "physical loc= ation=20 of an act" comment was deleted.

Also, in M&M, a dynamic model= =20 discussion is occurring. This document should be sent to M&M for revi= ew=20 before the dynamic model work is completed to make sure that M&M work= and=20 the EHR work are consistent.

Thanks, Dan

Gary=20 Dickinson wrote:
```Dear EHR TC Members,

Within the EHR Interoperability project team, we have spent the past =20
several months working to develop and refine a model for the =20
lifecycle of EHR "Act Records", expanding and refining record =20
lifecycle events specified in Section 3.19 of the EHR =20
Interoperability Model and in ISO 21089, "Trusted End-to-End =20
Information Flows".  This effort has resulted in our Draft HL7 EHR =20
Lifecycle Model (now v0.13, dated 23 May 2007).

Per discussions on the last EHR TC teleconference, I'm distributing =20
the current Draft EHR/LM for review and comment (within the EHR TC).  =20
Also attached is an initial proposal from Ann Wrightson (HL7-UK) for =20
additional EHR lifecycle events related to the interim progression of =20
EHR records.  This proposal is awaiting UK consensus and will be =20
considered in the next EHR/LM update.

Please take an early opportunity to review these documents and offer =20
your suggestions (not later than 15 July).  Submit comments on the =20
draft EHR/LM to Gary Dickinson (gary.dickinson@ehr-standards.com) and =20
on the UK proposal to Ann Wrightson (Ann.Wrightson@csw.co.uk).

Regards,

Gary

************************************************
To access the Archives of this or other lists or change your list settings =
and information, go to: http://www.hl7.org/listservice```
```=

```

**********************************************= **=20
To access the Archives of this or other lists or change your list set= tings=20 and information, go to: http://www.hl7.org/listservice=20
=0D
************************************************=0D
To access the Archives of this or other lists or change your list settings = and information, go to: http://www.hl7.org/listservice ------=_NextPart_000_0108_01C7AEA0.17932C70--