Summary: The discussion begins with a debate surrounding clinical terminology in terms of clinical visits, encounters and episodes largely from a service delivery perspective but from a data driven healthcare decision making perspective "events" rather than visits or encounters would matter.
In neoEMRs and PHRs, informational continuity is such that encounters are persistent and a physical visit may hardly ever happen!
In a regularly updated PHR there can be routine events (analogous to introns that may not make much sense other than getting disrupted by illness events that often become significant data analogous to exons)!
The Gamana-Darshana Suktam, a philosophical framework, further illuminates the relationship between visits and encounters. This clarification has significant implications for healthcare data exchange, billing, and chronic disease management, underscoring the need for precise terminology to ensure effective communication and optimal patient care.
Keywords: healthcare terminology, visits, encounters, Gamana-Darshana Suktam, healthcare data exchange, chronic disease management, PaJR, PHR, Daily routine energy inputs (food plates) energy outputs (hourly activities), routine activities (introns), illness disruptions (exons)
Glossary:
Conversational Transcripts:
[26/10, 20:08] ATP: Episode and Encounter are American terms, quite confusing. I prefer a diagnosis and it's clinical course.
[26/10, 20:18] AC: Ok*. So readmission with the same continued diagnosis at a rate of 60%+? (6/8 would be 75%)
Not a repeat diagnosis after recuperation.
Patient X is admitted with a certain condition (diagnosis), treated, released. Then again readmitted with the same condition, and medical opinion is that it's an exacerbation from the same diagnosis.
....
*( our officials have picked up the US terms https://nrces.in/ndhm/fhir/r4/
[26/10, 20:20] SBB: Yes. Episode begins when a problem is first reported. It ends with its resolution, which could be death. In chronic diseases the episode doesn’t end. Encounter is between a provider and a patient. Has a definite start and end time.
[26/10, 20:22] AC: So in such cases every subsequent admission is a readmission?
There would be some insurance clauses as to the time duration between two admissions. Else actuarial analysis will eliminate such conditions explicitly.
[26/10, 20:35]GS : Condition, Episode of Care, Visit, Encounter - slightly different meanings. Some systems use some of them interchangeably.
[26/10, 20:37] AC: Visit = encounter under brick and mortar hospitals / clinics?
Could be different for telemedicine
[26/10, 20:41] SBB: Slightly? Completely. Visit and encounter may be considered synonymous.
[26/10, 20:42] SBB: I do not favour the term “visit”. It should always be termed “encounter”.
[26/10, 20:45] GS: Some consider visit as overarching encounter with a care provider. A visit may have multiple encounters. OpenMRS has this distinction, I think.
[26/10, 20:53] SBB: The ones who consider so are nuts. How can the visit be distinguished from an episode?
[26/10, 21:05] GS: A visit may be for a condition or wellness tests or screening, not just an acute event captured as episode.
A visit may involve multiple encounters; such as with different specialists or departments.
An episode of care would definitely involve visit/encounter.
In OpenMRS, one can disable the Visit recording, then it shows visit and encounter as same.
[26/10, 21:06] GS: I'm not disputing your view, just telling what I've seen and their different usage.
[26/10, 21:09] SBB: An encounter is between a provider and a patient. The provider may be any healthcare professional, a carer, or a healthcare worker. A tip. Whenever there’s too much jargon and too many words around, it usually means that the person or persons stating them are completely clueless.
[26/10, 21:17] GS: Yes, and the visit construct weaves multiple encounters into one logical group. Maybe useful to record for billing or analytical purposes. Visit is a clinic/ hospital used construct. Encounter is more clinical and care used one.
I think I've reached my limit of valid sounding arguments to treat them differently. 😀
[26/10, 21:33] AC: Visit = encounter... In the sense that some subscribable authority would have clarified this.
In the multi consultant encounter as a single visit many constructs break down.
1. I see two doctors on day 1. Hospital offers free visit within 7 days
2. I see Doc 1 on day 2. Of course free
3. I see Doc 2 on Day 5
So if visit is not the same as encounter then I would have to pay the consultation charges again. As my second trip to the hospital was done. But I am meeting Doc 2 for the second time so the hospital does not charge me.
This is what I have experienced whenever I have "visited" multiple doctors. This is what follow up visit free for x days is supposed to mean!
Someone in UK - US shared healthcare would have clarified this
[26/10, 21:36] SBB: Episode and encounter have clinical meanings. Visit, blah-blah-blah, are terms of convenience
.
[26/10, 21:40] SJ : For a person with a chronic condition these touch points with the health care delivery systems are just a miniscule part of the care continuum.
[26/10, 21:41] AC: Here's one such authority and quite a few others clearly define this view.
Visit = encounter
[26/10, 21:42] SJ : Imagine an airplane maintaining contact and exchanging data with the ATC at the same frequency as a diabetic patients interact with their clinicians 😎
[26/10, 21:50] AC: High frequency. But an encounter, is an encounter
....
Every single entity appears to have reinvented what they want to call an encounter.
Must have consulted the same marketing folks who have been defining AI for the past few years 🙂
[26/10, 21:53] AC: Only courts can clarify.
However on a lighter note, some court recently commented in such a case "we are not a thesaurus maintaining body"!
[26/10, 22:48] AN: The term visit is getting obsolete in the digital and remote service era today.
An encounter, which is more popular term, that can be considered as the commencement of a billable service or group of services in one go. This can happen remotely by tele consultation, with the patient sitting at home ! So the term visit has actually lost the relevance here.
Physical visit does not automatically result into an encounter. Eg accessing a lab for the blood work is an encounter but it may involve multiple visits. Say, first for phlebotomy then a repeat visit if the sample is inadequate / the vacutainer damaged etc and another visit to collect the report. 🙂. It is still a single encounter as it is the same billable service.
If a doctor orders 5 tests and medical prescription in one go, this leads to multiple services / visits. But it is a single encounter because the billable services were applied in one go.
Lastly, an episode is more of a pooling of the services for one clinical condition or more than one clinically interrelated conditions. It is more of a clinical segregation. So a diabetic patient may have a chronic episode of retinopathy and an overlapping episode of gastritis. The patient could have a single encounter with multiple services covering two separate episodes. Hope this helps.
27/10, 07:11] AC: Any widely accepted references to these?
You imply that visit is not always an encounter?
27/10, 18:35] rb: I guess this is a service delivery perspective but from a data driven healthcare decision making perspective "events" rather than visits or encounters would matter.
In fact in neoEMRs and PHRs, informational continuity is such that encounters are persistent and a physical visit may hardly ever happen!
More about events as applied to data driven healthcare 👇
In a regularly updated PHR there can be routine events (analogous to introns that may not make much sense other than getting disrupted by illness events that often become significant data analogous to exons)!
[27/10, 00:14] AC: Data provenance in healthcare (medical data traceability using blockchain)
[27/10, 00:34] JG: Also in India, encounter and encounter specialist have a whole other meaning. HL7 uses segments like ORU, MSH, PID, PV (Patient visit), OBR, OBX etc. We use the term encounter here in most applications.
[27/10, 04:39] SBB: Visit = Encounter. Any discussions involving linguistic aspects, I am game. Acronym. Synonym. Antonym . Homonym. Hypernym. Hyponym. Meronym. Metonym. Homograph. Euphemism. Dysphemism. Who wants to go first? 😁
[27/10, 05:45] AC: Absolutely Sir. Let's settle this concept before Diwali 🙂👏👏
....
Visit is a subset of encounters. Hence, linguistically it's a hyponym.
....
Hence,
Visit = Encounter
but
there are Encounter ≠ Visit
Every visit is an encounter, but every encounter is not a visit.
....
[27/10, 06:26] AC: *गमन-दर्शन-सूक्तम्*
(Visit and Encounter Hymn)
अनुष्टुप् छन्दः
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१. प्रस्तावः
गमं दर्शनमित्युक्तं गमस्य दर्शनं सदा।
दर्शनं विस्तृतं तत्र गमं तु न समन्ततः॥
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२. प्रतिज्ञा
सर्वं गमं दर्शनं हि, दर्शनं न तु गमः सदा।
गमं तु योजनं निश्चितं, दृष्टिः स्वेच्छावशे सदा॥
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३. हेतुः
गमस्य सङ्गतेः स्वारूप्यं, दर्शनं यत्र यत्र तत्।
दर्शनं नित्यं बहुत्र स्यात्, तन्नियमोऽस्ति गमेषु च॥
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४. दृष्टान्तः
यथा पुष्पाणि सन्त्येव फलं केचित् प्ररोहति।
न हि सर्वं पुष्पं फलं, तथैव दर्शनं गमः॥
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५. उपमानम्
यथा नदीषु तोयानि सन्ति क्वचिद्वृष्टिमेव च।
दृष्टं नित्यम् अपीक्ष्यं च गमः स विशिष्ट एव स्यात्॥
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६. उपसंहारः
तस्मात् दर्शनं व्यापकं, गमः तस्य विभागतः।
सर्वं गमं दर्शनं हि, न सर्वं दर्शनं गमः॥
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७. फलश्रुतिः
यः पठेत् सूक्तमेतद्धि, गमं दर्शनमेकतः।
तस्य स्यात् व्यावहार्यं च, विभागज्ञः स धीरधीः॥
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समाप्तिः
This concludes the गमन-दर्शन-सूक्तम्.
....
Gamana-Darshana Suktam
Rishi: Kaivalyik (The Singularitist)
Devata: Vishwadev Dev (Universal Encounters)
Chanda: Anushtup
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Traditional Pramāṇa Structure in Nyāya-Vaiśeṣika-Mīmāṁsā
In Nyāya-Vaiśeṣika philosophy, reasoning is established through the following structured pramāṇas (means of knowledge):
1. Pratyakṣa (Perception): Direct observation through the senses.
2. Anumāna (Inference): Conclusion based on logical connections.
3. Upamāna (Analogy): Drawing comparisons for clarity.
4. Śabda (Verbal Testimony): Reliance on authoritative or scriptural words.
5. Arthāpatti (Postulation): Presumption when no other explanation fits.
This suktam follows this tradition by applying these pramāṇas to demonstrate the relationship between visits and encounters.
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Word-for-Word Meaning of the Gamana-Darshana Suktam
1. प्रस्तावः (Introduction):
गमं (gamam) – Visit
दर्शनम् (darshanam) – Encounter
इति उक्तम् (iti uktam) – Thus said
गमस्य दर्शनं सदा (gamasya darshanam sadā) – Visit is always an encounter
दर्शनं विस्तृतं तत्र (darshanam vistṛtam tatra) – Encounter is vast
गमं तु न समन्ततः (gamam tu na samantataḥ) – Visit does not occur everywhere
Translation:
It is said that every visit is an encounter, but encounters extend beyond visits, occurring in various situations.
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2. प्रतिज्ञा (Proposition):
सर्वं गमं दर्शनं हि (sarvaṃ gamam darśanaṃ hi) – Every visit is an encounter
दर्शनं न तु गमः सदा (darśanaṃ na tu gamaḥ sadā) – Not every encounter is a visit
गमं तु योजनं निश्चितम् (gamam tu yojanaṃ niścitam) – Visit is organized
दृष्टिः स्वेच्छावशे सदा (dṛṣṭiḥ sveccāvśe sadā) – Encounters happen spontaneously
Translation:
All visits are encounters, but not all encounters are planned visits. Visits are structured, whereas encounters can happen freely.
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3. हेतुः (Reasoning):
गमस्य सङ्गतेः स्वारूप्यम् (gamasya saṅgateḥ svarūpyam) – Visits are defined interactions
दर्शनं यत्र यत्र तत् (darśanaṃ yatra yatra tat) – Encounters occur anywhere
दर्शनं नित्यं बहुत्र स्यात् (darśanaṃ nityaṃ bahutra syāt) – Encounters are frequent
तन्नियमोऽस्ति गमेषु च (tan niyamo’sti gameṣu ca) – No fixed rule applies to encounters
Translation:
Visits are specific, but encounters occur without restriction, making them frequent and diverse.
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4. दृष्टान्तः (Example):
यथा पुष्पाणि सन्ति एव (yathā puṣpāṇi santi eva) – As there are many flowers
फलं केचित् प्ररोहति (phalaṃ kecit prarohati) – Only some yield fruit
न हि सर्वं पुष्पं फलं (na hi sarvaṃ puṣpaṃ phalaṃ) – Not every flower becomes fruit
तथैव दर्शनं गमः (tathaiva darśanaṃ gamaḥ) – Similarly, not every encounter is a visit
Translation:
Just as only some flowers yield fruit, not every encounter becomes a structured visit.
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5. उपमानम् (Analogy):
यथा नदीषु तोयानि सन्ति (yathā nadīṣu toyāni santi) – As rivers contain water
क्वचिद् वृष्टिम् एव च (kvacid vṛṣṭim eva ca) – And sometimes rain falls
दृष्टं नित्यम् अपीक्ष्यं च (dṛṣṭaṃ nityam apīkṣyaṃ ca) – Water is ever-present but unpredictable
गमः स विशिष्ट एव स्यात् (gamaḥ sa viśiṣṭa eva syāt) – Visits are specific instances
Translation:
Water may flow continuously, but rain happens occasionally. Likewise, encounters are frequent, but visits are particular.
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6. उपसंहारः (Conclusion):
तस्मात् दर्शनं व्यापकं (tasmāt darśanaṃ vyāpakaṃ) – Therefore, encounter is broad
गमः तस्य विभागतः (gamaḥ tasya vibhāgataḥ) – Visit is a subset
सर्वं गमं दर्शनं हि (sarvaṃ gamam darśanaṃ hi) – All visits are encounters
न सर्वं दर्शनं गमः (na sarvaṃ darśanaṃ gamaḥ) – Not all encounters are visits
Translation:
Encounters are more extensive than visits, making visits a subset. All visits are encounters, but not all encounters are visits.
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7. फलश्रुतिः (Result of the Proof):
यः पठेत् सूक्तम् एतद्धि (yaḥ paṭhet sūktam etaddhi) – Whoever recites this hymn
गमं दर्शनम् एकतः (gamam darśanam ekataḥ) – On the unity of visits and encounters
तस्य स्यात् व्यावहार्यं च (tasya syāt vyāvahāryaṃ ca) – Gains practical clarity
विभागज्ञः स धीरधीः (vibhāgajñaḥ sa dhīradhīḥ) – And becomes wise in distinctions
Translation:
He who recites this hymn on the unity and distinction of visits and encounters gains clarity and wisdom in interactions.
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Purport
This hymn establishes that visits are structured, planned events, whereas encounters encompass both planned and unplanned events. Encounters are a superset, with visits being a subset. Using analogies like flowers and fruits and rivers and rain, the suktam explains the selective nature of visits and the broader scope of encounters. The pramāṇas of perception, inference, analogy, testimony, and presumption solidify the philosophical stance.
This hymn reflects the Kaivalyik Rishi’s perspective on singularity, where structured interactions (visits) emerge from the continuous flow of spontaneous events (encounters), emphasizing the importance of distinguishing between the two.
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Samāptiḥ (Conclusion)
This completes the Gamana-Darshana Suktam with Anushtup Chanda and philosophical rigor in the tradition of Nyāya-Vaiśeṣika-Mīmāṁsā.
[27/10, 06:42] AC: For citations https://www.linkedin.com/
[27/10, 06:51] SD: What are the Examples of
Visit (not equal to) Encounter
?
[27/10, 07:00] AC: Lots, and lots and lots...
Let me share one fair citation https://manual.connect-care.
(Not completely endorsed, but as a first draft on types of encounters)
[27/10, 07:02] AC: We all embody this entity called Kaivalyik Rishi... Basically all individuals living in the presingularity era
[27/10, 09:34] JG: Your citations mention both versions, encounter is a subset of visits and vice versa with the terms being used interchangeably. Probably the term encounter is favored by US to bill every action of the healthcare provider that may not be just consultation and documentation. A rose by another name still smells sweet, or in healthcare still stinks.
Here's a summary of the insights from the conversational transcripts:
*Key Points:*
1. Confusion around terms: "Episode", "Encounter", "Visit", and their meanings in healthcare.
2. Different perspectives on whether "Visit" and "Encounter" are interchangeable terms.
3. US healthcare terminology favors "Encounter" for billing purposes.
4. "Visit" implies a physical presence, while "Encounter" encompasses various interactions (e.g., phone calls, messaging).
5. Chronic disease management blurs the lines between episodes and encounters.
*Definitions:*
1. Episode: A continuous period of care for a specific condition.
2. Encounter: A single interaction between a healthcare provider and patient (in-person, phone, or digital).
3. Visit: A physical presence of a patient at a healthcare facility.
*Distinctions:*
1. Every visit is an encounter, but not every encounter is a visit.
2. Encounters can be unplanned, while visits are typically scheduled.
*Resources:*
1. HL7 (Health Level Seven International) segments for healthcare data exchange.
2. OpenMRS (Open Medical Record System) distinguishes between visits and encounters.
3. CCHPCA (California Children's Hospital Pharmacy and Therapeutics Committee) defines "visit" and "encounter".
*Philosophical Perspective:*
1. The "Gamana-Darshana Suktam" (Visit and Encounter Hymn) explores the relationship between visits and encounters using Nyāya-Vaiśeṣika-Mīmāṁsā philosophical framework.
*Open Questions:*
1. How do different healthcare systems and countries define these terms?
2. What are the implications of using these terms interchangeably or distinctly?
The conversation highlights the complexities and nuances surrounding healthcare terminology, emphasizing the need for clarity and standardization.
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