Medication Statement Use Cases (Med List User Stories)

Definitions:

• Clinical User: can mean Nurse, Clinical Officer, Physician's Assistant, Physician, Pharmacist, or Pharmacy Assistant/Tech (depending on facility policies; in extremely busy sites, even clerical staff may sometimes help with med list review). 
• Medication Lists: the list of medications is patient currently taking, vs historical / not-currently-taking, their dosage, and treatment indication. EMRs need to have this information, and indeed, the Medication List is a literal requirement for a FHIR IPS.
• Priority: For these stories, "High" means "should be included in immediate, first iteration"; "Medium" and "Low" mean "could wait until a second or subsequent version"
• Medication Reconciliation (aka "Med Rec"): This is
  •  the patient’s discharge medication(s) is compared with the medication(s) the patient was taking prior to hospitalization. This can avoid medication errors such as omissions, duplications, dosing errors or drug interactions, and should be done at every transition of care in which new medications are ordered or existing orders are rewritten.
  • Proof of 30 day medication reconciliations is increasingly required for health facilities to receive payment by Public or Private health insurance schemes. This is one reason why MedRec is a growing demand from EMRs. 
  • More info on Med Rec in FHIR here.

User Stories:

• Add Existing Medications: As a clinical user, I need to add medications to the list even if they were prescribed elsewhere, as the patient may be taking drugs ordered by a different site/clinician, and we still need those to be viewable in the patient's record.
  
  • Priority: High
  • (Current state: As of Feb 2024 in O3, Meds only show if they have been ordered by the user. Not all medications that a patient is being given are being prescribed in the clinic in which they might be treated, so it’s inappropriate to add an “order” for those medications.)
• Add Past Medications No Longer in Use: As a clinical user, I need to add medications to the list that were taken in the past but not anymore, as in some cases this is relevant to the patient's treatment plan (e.g. if the patient has previously been on ART Regimen 1, then switched to Regimen 2, but is now on Regimen 3 → It's often helpful to see that progression in the medical record.)
  • Priority: Medium
• Change Medications from Active/Taking to Inactive/Not Taking: As a clinical user, I need to be able to adjust a medication as to whether it is being taken or not taken, because I need to ensure the Med List is an accurate, up-to-date representation of what the patient is currently taking, since this may have changed since the last visit or even encounter. (E.g. maybe the Physician prescribed a medicine recently, but the patient has actually stopped taking it, because they experienced unpleasant side effects.) Just because a doctor prescribed a drug does not guarantee that a patient is actually taking that drug!
  • Priority: High
  • Sample Statuses: Note FHIR uses: active | completed | entered-in-error | intended | stopped | on-hold | unknown | not-taken (as seen in the IPS Medication Statement) 
• Record Reasons for Changes: Sometimes, it is important to record why the medication was changed (e.g. patient refused, stopped treatment, or reduced the dose), so that future clinicians can see relevant information that may influence their decisions for future treatment plans: e.g. if the patient experienced severe side effects (diarrhea, persistent nausea, etc), future clinicians would like to know this, so they know why that treatment was not helpful for that patient. 
  
  • Priority: Medium
• Change Doseage Information: Sometimes, as a clinical user, when I am talking to a patient I discover that they are taking a different dose of the drug than is currently on the list. This may be because they visited a different prescriber/site and were instructed to take a different dose, or, the patient independently decided to change their dosage either intentionally or by mistake: e.g. sometimes I discover a patient is only taking half the doseage we have on file. I need to be able to update this.
• Indicate that change was done based on patient conversation: 
• No Known Medications: As a clinical user, I need to be able to indicate that the patient is on "No Known Medications", since this is different than just leaving the system as "No medications recorded" since this implies that we may not have asked about Medication use for the patient (Unknown is different than "We did ask"!); and since, for many healthy people, they may be on no medications (such as a child coming in to an OPD for a mild burn who only requires a wound dressing), and it is important that we record this to show we did our due diligence medically.  
  • Priority: Low