From: Gunther Schadow [gunther@aurora.regenstrief.org]
Sent: Monday, February 10, 2003 11:38 AM
To: Woody Beeler
Cc: Lloyd McKenzie; Bob Dolin
Subject: RIM definition from me (Procedure)

Hi Woody, a little late, but anyway here is the definition of Procedure class:

OLD:

A planned alteration or manipulation of the structure of the body. This 
may require the disruption of some body surface, usually through an 
incision (i.e. "surgical procedure" or "operative procedure").

Examples: Appendectomy, Back massage, Dental filling



NEW:

An Act whose immediate and primary outcome (post-condition) is the 
alteration of the physical condition of the subject.

Examples: Procedures may involve the disruption of some body surface 
(e.g. an incision in a surgical procedure) conservative procedures such as reduction of a luxated join, including physiotherapy such as 
chiropractic treatment, massage, balneotherapy, accupuncture, shiatsu, 
etc. Outside of clinical medicine, procedures may be such things as 
alteration of environments (e.g. straightening rivers, draining swamps, 
building dams) or the repair or change of machinery etc.

Discussion: applied to clinical medicine, procedure is but one among 
several types of clinical activities such as observation, 
substance-administrations, and communicative interactions (e.g. 
teaching, advice, phsycho-therapy, repesented simply as Acts without 
special attributes.) Procedure does not subsume those other activities 
nor is procedure subsumed by them. Notably Procedure does not comprise 
all acts of whose intent is intervention or treatment. Whether the 
bodily alteration is appreciated or intended as beneficial to the 
subject is likewise irrelevant, what counts is that the act is 
essentially an alteration of the physical condition of the subject.

The choice between representations for a real activities is based on 
whether the specific properties of procedure are applicable and whether 
the activity or activity step's necessary post-condition is the physical 
alteration. For example, taking an x-ray image may sometimes be called 
"procedure", but it is not a Procedure in the RIM sense for an x-ray 
image is not done to alter the physical condition of the body.

Many clinical activities combine Acts of Observation and Procedure 
nature into one composite. For instance, interventional radiology (e.g., 
catheter directed thrombolysis) does both observing and treating, and 
most surgical procedures include conscious and documented Observation steps. These clinical activities therefore are best represented by multiple component acts each of the appropriate type.

END


After this:

We still don't completely resolve where radio-therapy sits. Is it
(a) an S.-Administration or is it (b) a Procedure or (c) neither? If 
(a), then the name must be changed from SubstanceAdministration to something else, I know we have talked about that. The definition of 
SubstanceAdministration already alludes specifically to some 
radio-therapies, particularly nuclear medicine. Is transdermal 
gamma-radiation included? Probably should be. In that case, substance 
administration is generally an administration of an agent that 
physically interacts with the body.

The question then is, why is this S.-Administration not a subtype of 
Procedure, since both are defined as alteration of the physical body 
condition (physical of course including molecular or cellular 
condition)? It would not be too hard to move S.Adm. under Procedure, 
would only have to rename routeCode back into approachSiteCode. I don't 
really like proposing this, but it seems kind of necessary ...



-- 
Gunther Schadow, M.D., Ph.D.                    gschadow@regenstrief.org
Medical Information Scientist      Regenstrief Institute for Health Care
Adjunct Assistant Professor        Indiana University School of Medicine
tel:1(317)630-7960                         http://aurora.regenstrief.org


