TEMPLATE AMD assessment (AMD assessment)

TEMPLATE ID	AMD assessment
Concept	AMD assessment
Description	Register the assessment of the diagnostic tests used to analyze the progression of wet AMD, and determine the most suitable therapeutic decision in consequence.
Purpose	Register the assessment of the diagnostic tests used to analyze the progression of wet AMD, and determine the most suitable therapeutic decision in consequence.
References
Authors	name: Aitor Eguzkitza; organisation: Universidad Pública de Navarra - Complejo Hospitalario de Navarra; email: aitor.eguzkiza@unavarra.es; date: 2016-07-29
Other Details Language	name: Aitor Eguzkitza; organisation: Universidad Pública de Navarra - Complejo Hospitalario de Navarra; email: aitor.eguzkiza@unavarra.es; date: 2016-07-29
Other Details (Language Independent)	MetaDataSet:Sample Set : Template metadata sample set Copyright: © openEHR Foundation Owner: Aitor Eguzkitza, aitor.eguzkiza@unavarra.es Speciality: Ophthalmology
Language used	en
Citeable Identifier	1013.26.125
Root archetype id	openEHR-EHR-COMPOSITION.report-result.v1
Result Report	Result Report: Document to communicate information to others about the result of a test or assessment.
Image test analysis	Image test analysis: Describes the analysis of image based diagnostic tests, to find clinical findings which can be relevant to decide a diagnosis for a specific disease.
Fundoscopic examination of eyes	Fundoscopic examination of eyes: Record of clinical findings on fundoscopy of eyes
Data
Any event	Any event: *
Data
Clinical Description	Clinical Description: Descriptive overview of examination findings
Test Result	Test Result: Details of the funduscopic examination test result for each eye.
Side	Side: Determines the eye on which the test was performed.Matches to DICOM Laterality (0020,0060) attribute. Left eye Right eye
Structural description	Structural description: General description of the structures in the eye fundus
Optic Disc	Optic Disc: Description of optic disc
Macula	Macula: Description of macula
Retinal arteries	Retinal arteries: Description of retinal arteries
Retinal veins	Retinal veins: Description of retinal veins
Retinal background	Retinal background: Description of retinal background
Vitreous	Vitreous: Description of vitreous humour
Clinical results	Clinical results: Information of diagnostic interest obtained in the test
Other findings	Other findings: Narrative description of clinical findings not considered in the SLOT Value set: terminology:Snomed?subset=Findings%20in%20posterior%20pole%20of%20eye&language=en-GB
State
Mydriatic used	Mydriatic used: True if mydriatic is used Assumed value: false
Ophthalmic tomography examination	Ophthalmic tomography examination: Record of clinical findings using optical coherence tomography with ophthalmic purposes.
Data
Any event	Any event: Default, unspecified point in time or interval event which may be explicitly defined in a template or at run-time.
Data
Clinical description	Clinical description: A term, commonly coded, expressing an overall interpretation of the OCT test.
Test result	Test result: Details of the ophthalmic tomography examination test result for each eye.
Side	Side: Determines the eye on which the test was performed.Matches to DICOM Laterality (0020,0060) attribute. Matches to DICOM Laterality (0020,0060) attribute. Left eye Right eye
Structure analyzed	Structure analyzed: The anatomic structure analyzed in this study. Matches to DICOM Anatomic Region Sequence (0008,2218) attribute. Values permitted are defined by DICOM standard (PS 3.16) inside the table with Context ID 4211 (Ophthalmic OCT Anatomic Structure Imaged). Value set: ac0001
Clinical findings	Clinical findings: Every finding considered clinically relevant, found on posterior chamber of the eye. Value set: ac0002
Clinical decision	Clinical decision: Defines the process of making a decision about the diagnosis of a specific disease.
Clinical Synopsis	Clinical Synopsis: Narrative summary or overview about a patient, specifically from the perspective of a healthcare provider, and with or without associated interpretations.
Data
Synopsis	Synopsis: The summary, assessment, conclusions or evaluation of the clinical findings.
Problem/Diagnosis	Problem/Diagnosis: Details about a single identified health condition, injury, disability or any other issue which impacts on the physical, mental and/or social well-being of an individual. Clear delineation between the scope of a problem versus a diagnosis is not easy to achieve in practice. For the purposes of clinical documentation with this archetype, problem and diagnosis are regarded as a continuum, with increasing levels of detail and supportive evidence usually providing weight towards the label of 'diagnosis'.
Data
Problem/Diagnosis name	Problem/Diagnosis name: Identification of the problem or diagnosis, by name. Coding of the name of the problem or diagnosis with a terminology is preferred, where possible.
Clinical description	Clinical description: Narrative description about the problem or diagnosis. Use to provide background and context, including evolution, episodes or exacerbations, progress and any other relevant details, about the problem or diagnosis.
Body site	Body site: Identification of a simple body site for the location of the problem or diagnosis. Coding of the name of the anatomical location with a terminology is preferred, where possible. Use this data element to record precoordinated anatomical locations. If the requirements for recording the anatomical location are determined at run-time by the application or require more complex modelling such as relative locations then use the CLUSTER.anatomical_location or CLUSTER.relative_location within the 'Structured anatomical location' SLOT in this archetype. Occurrences for this data element are unbounded to allow for clinical scenarios such as describing a rash in multiple locations but where all of the other attributes are identical. If the anatomical location is included in the Problem/diagnosis name via precoordinated codes, this data element becomes redundant.
Date/time of onset	Date/time of onset: Estimated or actual date/time that signs or symptoms of the problem/diagnosis were first observed. Data captured/imported as "Age at onset" should be converted to a date using the subject's date of birth.
Classification of age related macular degeneration	Classification of age related macular degeneration: Classifies the condition and argues the diagnostic decision for age-related macular degeneration.
AMD classification	AMD classification: Clinical grade determined for age-related macular degeneration. No AMD Early AMD Intermediate AMD Dry advanced AMD atrophic Exudative or wet AMD Ungradable
Diagnostic criteria	Diagnostic criteria: Clinical findings supporting the diagnose or grading. Small drusen Intermediate drusen Numerous intermediate drusen Large drusen Geographic atrophy Geographic atrophy involving foveal center Choroidal neovascularization (CNV) Serous or hemorragic detachment Retinal hard exudates Fibrovascular proliferation Disciform scar (subretinal fibrosis)
Clinical findings	Clinical findings: Overall findings on the patient considered in the diagnostic classification. Value set: ac0001
Comments	Comments: Additional comments that clarify the diagnostic decision made.
Contraindication	Contraindication: Identification of a treatment, test or procedure which should not be provided to the subject of care, for clinical reasons.
Data
Contraindication	Contraindication: Identification of a contraindication to a treatment, test or procedure, including a class of medications or vaccines. Coding of the identified 'Contraindication' with a terminology is desirable, where possible.
Rationale	Rationale: Description of evidence or rationale for the contraindication. Please note: an optional URI link to evidence within the health record is also permitted using Reference Model attributes. As this URI link may not be accessible from a message or by receiving clinical system it is desirable that a narrative description of the rationale should be explicitly stated. Very low VA (below 0.1 in first clinical encounter) Healed lesions (Identified signs of previous treatments) Multimorbidity (Coexistence of additional alterations on the retina) Reaction to anti-VEGF (Suspicion of hypersensitivity to agents used in intravitreal injections) No response to treatment (VA decreased below 0.1 three consecutive reviews) Morphologic deterioration of the lesion
Protocol
Last updated	Last updated: The date this contraindication was last updated.
Review date	Review date: Date when due for review by a clinician. In some circumstances, contraindications are not intended to be indefinite or lifelong, and this contraindication should be reconsidered in the context of changing clinical circumstances. For example: if a family member is no longer taking immunosuppressive therapy, then live vaccines could safely be administered to the subject of care again and the contraindication is effectively obsolete.
Recommendation on the treatment of AMD	Recommendation on the treatment of AMD: A suggestion, advice or proposal for clinical management.
Data
Recommendation	Recommendation: Narrative description of the recommendation. May be coded, using a terminology, if required. Do not treat Intravitreal anti-VEGF injection High dose Antioxidant Vitamin and Mineral Supplements Photodynamic Therapy (PDT) Thermal Laser Photocoagulation Surgery
Rationale	Rationale: Justifications for the recommendation. Visual acuity decrease with macular fluid Macular fluid New macular haemorrhage
Patient's admittance	Patient's admittance: Decision-making regarding to inscribe or not a patient into a screening process.
Enrollment in a long-term healthcare process	Enrollment in a long-term healthcare process: Manages the enrollment of patients in a specific long-term healthcare process.
Data
Healthcare process	Healthcare process: Identification of the healthcare process about which the enrollment of a specific patient is discussed.
Description	Description: Narrative description about the healthcare service to which the patient has been proposed for admittance.
Admittance	Admittance: If true, the patient meets the criteria required to be inscribed in the healthcare process. Assumed value: true
Criteria	Criteria: Narrative description of criteria considered to make a decision with regard to patient's admittance into the healthcare process. Very low VA Healed lesions Multimorbidity Reaction to anti-VEGF VA decrease Morphologic deterioration
Protocol
Date decision	Date decision: Date at which decision was made about the enrollment or exclusion of the patient with regard to the healthcare process.
Decision review	Decision review: Next revision date scheduled for the current decision of enrollment.
Next step planning	Next step planning: Decision-making concerning the planning of next assessment for the diagnostic tests carried out.
Diagnostic report request	Diagnostic report request: Request for a diagnostic report involving the study of specific diagnostic tests.
Request	Request: Current Activity.
Description
Service requested	Service requested: Identification of the service requested. This is often coded with an external terminology. Remote assessment of wet AMD Review of AMD state at the retinologist's office
Description of service	Description of service: A detailed narrative description of the service requested.
Reason for request	Reason for request: A short description of the reason for the request. This is often coded with an external terminology. Completed the diagnostic tests necessary for assessment Patient not responding to treatment
Reason description	Reason description: A narrative description explaining the reason for request.
Intent	Intent: Stated intent of the request by the referrer.
Urgency	Urgency: Urgency of the request. Emergency Urgent Routine
Date &/or time service required	Date &/or time service required: The date and time that the service should be performed or completed.
Latest date service required	Latest date service required: The latest date that is acceptable for the service to be completed.
Protocol
Requestor Identifier	Requestor Identifier: The local ID assigned to the order by the healthcare provider or organisation requesting the service. This is also referred to as Placer Order Identifier.
Receiver identifier	Receiver identifier: The ID assigned to the order by the healthcare provider or organisation receiving the request for service. This is also referred to as Filler Order Identifier.
Request status	Request status: The status of the request for service as indicated by the requester. Status is used to denote whether this is the initial request, or a follow-up request to change or provide supplementary information.
Service request	Service request: Request for a health-related service to be supplied by a healthcare provider or agency. For example equipment request.
Request	Request: Description of the requested service.
Description
Service name	Service name: Identification of the service requested, by name. Coding of the 'Service name' with a coding system is desirable, if available. Follow-up schedule for the treatment of wet AMD Repeat anti-VEGF injection to treat wet AMD
Service type	Service type: Category of service requested. For example: hospital vs home care delivery.
Description	Description: Narrative description of the service requested. Follow-up comprised by VA, NMR, OCT tests
Reason for request	Reason for request: A short phrase describing the reason for the request. Coding of the 'Reason for request' with a coding system is desirable, if available.
Reason description	Reason description: Narrative description about the reason for request.
Intent	Intent: Description of the intent for the request. For example a referral with the intent of having specialist care take over the care of the patient, or advice on how to proceed with an investigation or treatment. This data element allows multiple occurrences to enable multiple choice selection in user interface. Stable state of wet AMD Progressive state of wet AMD
Urgency	Urgency: Urgency of the request for service. Specific definitions of emergency and urgent will vary between clinical contexts, clinical systems and the nature of the request itself, so have not be defined in this archetype. If explicit timing is required then the Service period should be clearly stated. Coded Text Emergency Urgent Routine Text
Service due	Service due: The date/time, or acceptable interval of date/time, for provision of the service. In practice, clinicians will often think in terms of ordering services as approximate timing, for example: review in 3 months, 6 months or 12 months. As clinical systems need more exact parameters to operate on, this '3 months' will usually be converted to an exact date 3 months from the date of recording and stored using this data element.
Service period start	Service period start: The date/time that marks the beginning of the valid period of time for delivery of this service. This date/time is the equivalent to the earliest possible date for service delivery. For example: sometimes a certain amount of time must pass before a service can be performed, for example some procedures can only be performed once the patient has stopped taking medications for a specific amount of time.
Service period expiry	Service period expiry: The date/time that marks the conclusion of the valid period of time for delivery of this service. This date/time is the equivalent to the latest possible date for service delivery or to the date of expiry for this request. For example: a service may be required to be completed before another event, such as scheduled surgery.
Indefinite?	Indefinite?: The valid period for this request is open ended and has no date of expiry. Record as TRUE to record explicity that the request has no expiry date.
Protocol
Requestor Identifier	Requestor Identifier: The local ID assigned to the order by the healthcare provider or organisation requesting the service. This is also referred to as Placer Order Identifier.
Receiver identifier	Receiver identifier: The ID assigned to the order by the healthcare provider or organisation receiving the request for service. This is also referred to as Filler Order Identifier.
Request status	Request status: The status of the request for service as indicated by the requester. Status is used to denote whether this is the initial request, or a follow-up request to change or provide supplementary information.
Analysis of clinical encounter	Analysis of clinical encounter: Analysis of completion of specific healthcare procedures in terms of quality.
Efficiency of healthcare procedure	Efficiency of healthcare procedure: Parameters of interest for an objective study of the efficiency for a specific healthcare procedure.
Data
Procedure type	Procedure type: Identifies the type of clinical encounter or healthcare procedure analysed. Specially useful when different types are compared.
Description	Description: Narrative description of the clinical encounter or healthcare procedure analysed.
Start date	Start date: Date/time of onset of the encounter or healthcare procedure analysed.
Duration	Duration: Time how long it takes to complete the encounter or healthcare procedure analysed. Units: Hour Minute Second
Other contributors	Jose Andonegui, Complejo hospitalario de Navarra (CHN), jose.andonegui.navarro@cfnavarra.es; Luis Serrano, Universidad Pública de Navarra (UPNA), lserrano@unavarra.es; Jesús D. Trigo, Universidad Pública de Navarra (UPNA), jesusdaniel.trigo@unavarra.es