3.7.3 Manage Impact of Changes on EHR Applications

MODERATE

The new concept may not be available in some data entry contexts.

Although all new concepts will be available for ad-hoc searches, it may not be possible to enter a new concept in data entry fields with tightly defined value set bindings.

Risk is higher if the value set binding specifies members of a reference set or individual concepts. Value set bindings that use hierarchy-based constraints are more likely to include new concepts that are appropriate to the data entry context.

Review newly added concepts paying particular attention to concepts in areas of the hierarchies that are frequently used.

Consider if new concepts need be added to any reference sets, search constraints, user interface terminology bindings or queries.

HIGH

Risk is higher if the value set binding specifies members of a reference set or individual concepts. Value set bindings that use hierarchy-based constraints will automatically exclude inactive concepts.

Review inactivated concepts to determine whether they were previously subsumed by queries used for reporting or analytics. Use the reason for inactivation to inform decisions on an appropriate approach to resolution.

Choose an appropriate approach to resolve any potential reporting anomaly. Some possible resolutions are suggested here:

• Explicitly include the inactive concept in queries that formerly included it so historical data is still reported consistently.
• Create a reference set containing inactive concepts that were previously included in the result of a query and where appropriate include members of that reference set in query criteria.
  
• Use historical associations to extend normal subsumption so that inactive concepts are included whenever their active equivalent concepts are included. In the case of associations in the 900000000000523009 | POSSIBLY EQUIVALENT TO association reference set| this approach may need to be more carefully reviewed and selectively applied.
• Accept the exclusion of the now inactive concept from reports.
• Map the intended meaning of the original (now inactive) concept to an active concept and add that to the record in a way that allows it to be appropriately included in reports. For medicolegal reasons this should be an addition to and not a replacement of the record.

NONE

The only mutable concept data attribute in the release file is definitionStatusId. If the value changes this indicates a change in the definition. However, in itself a change to the definitionStatusId is not significant¹.

LOW

Description added to a new concept:

• By default the description used to display a new concept should be the preferred term in the selected language or dialect.
• Alternative descriptions may be displayed if they are more appropriate to the context or selected by a user.

Description added to an existing concept:

• Should have no impact on existing stored data.
• May be considered as an alternative display term in data entry template or reports.

LOW

Review data entry templates and reports that use a changed description as a display term:

• Update the display term to match any change to the term.
• Update the term if the use of upper and lower case does not conform to the options permitted by the caseSignificanceId.

In general, terms stored in existing patient records should not be updated based on terminology changes².

HIGH

Review any use of terms that are associated with:

• Descriptions that are inactive
• Descriptions that are no longer acceptable or preferred in a selected language reference set.

In these cases, replace the use of this term in data entry interfaces with a term for the same concept that is either preferred or acceptable in the selected language reference set. Similarly, if a term is stored with the selected concept, ensure that the term stored is also preferred or acceptable in the selected language.

In general, terms stored in existing patient records should not be updated based on terminology changes².

MODERATE

MODERATE

Relationships represent the inferred necessary normal form definition of a concept. OWL axiom reference set members represent the stated definitions of concepts.

Additions, changes or inactivations of either of these components, represent changes to the definition of a concept. A change in the definition of a concept also affects other concepts with a definitions that refer to that concept.

The impact of changes to concept definitions depends on the way these changes affect the results of expression constraints and queries used in data entry templates, reporting and analytics.

Review value set bindings, expression constraints and queries used in reports or analytics and identify the expression constraints on which these depend.

For each of these constraints that may have been affected by these changes apply the steps shown in Table 3.7.3-2. Where appropriate fake the actions outlined in Table 3.7.3-3 to address any unintended or unwanted effects arising from the update.

MODERATE

Check the content of the five sets of concepts generated by the last two steps using the notes in Table 3.7.3-3

New concepts in V2 release that were not present in V1.

• Inclusion of these concepts will not affect retrospective reports or analytics because the new concepts could not have been used previously³.
• Inclusion of these new concepts is appropriate as they conform to the stated constraint.

NONE

None

It is unusual for concepts to be reactivated so this set will usually be empty.

Concepts reactivated in V2 release after being inactive in V1 release. However, in theory this could alter the result of retrospective reports because reactivation of the concept causes these concepts to be included whereas previously they were excluded.

LOW

If this subset contains any concepts, be aware that this may affect result of rerunning an earlier reports or analytics on retrospective data. However, in most cases no action is required.

HIGH

HIGH

Concepts that only conform to the ECL in V1 that are inactive in V2. In this case, inactivation of the concept means that retrospective reports will exclude these concepts that were previously included in the report.

MODERATE

Concepts in this subset will be excluded from reports or analytics performed after upgrading to the new version but would have been included when using the current version.

In this case, the reason for exclusion is that the concept is inactive rather than being a direct consequence of the constraint. There are two ways to enable an inactive concept to be included to conform to a constraint. A direct reference to a concept identifier or a reference to the members or a reference set that includes that concept⁴.