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 the patient is 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 name for the process through which a healthcare provider compares the medication(s) the patient is currently taking, vs the ones they were previously taking. 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. For example, when a patient is admitted to a hospital, there are commonly 2 steps to Medication Reconciliation: (1) reviewing any information from the patient's EMR and from any notes that came in with the patient, about what medications they are normally on (since we want to ensure that treatment is continued while they are in hospital), and (2) verbally confirming with the patient (or caregiver) whether that list is still accurate - since the patient may not be taking what is recorded in the EMR or even in notes from their family doctor.
- Real Story Example: An elderly patient becomes more sick when in hospital. Staff discover that they were giving a much higher dose of blood pressure medicine than the patient was used to taking at home because at home they were taking just 1/4 the recorded/prescribed dose! Just because a doctor prescribed a drug does not guarantee that a patient is actually taking that drug or precisely that dose of that drug!
- Proof of 30-day medication reconciliations is increasingly required for health facilities to receive payment from Public or Private health insurance schemes. This is one reason why MedRec is a growing demand for EMRs.
- More info on Med Rec in FHIR here.
User Stories:
| Summary | User Story | Priority | Est. Lift? | Notes |
|---|---|---|---|---|
| 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. | 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.) | |
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.) | HIGH | Note FHIR uses: active | completed | entered-in-error | intended | stopped | on-hold | unknown | not-taken (as seen in the IPS Medication Statement) | |
| Handle Past Medication Dates | As a clinical user, I need to be able to record when a medication was started, and when it was stopped. In general, in OPD I need to record the date/month/year started/stopped. | HIGH | ||
| List Regimens/Multi-combo drugs. | Ability to document regimens, multi-combo drugs, including regimen number/etc. along with coded vs free text annotations about regimens (regimen notes?) | Note from Andy: I don’t think FHIR medications have the concept of regimen… perhaps others know better Regimen <> drug but Regimen -> Drug(s). Quite important for HIV, TB and Oncology Indicate if drug was sourced from elsewhrre | ||
| Add Past Medications No Longer in Use |
| MEDIUM | ||
Change Dosage 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 dosage we have on file. I need to be able to update this. | MEDIUM | ||
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. | MEDIUM | ||
| Add Medication that Patient is taking without a Rx | Ability to record a medication that the patient tells you about, that may or may not be coded within the local system (e.g. baby aspirin, or an obscure oncology med); indication of start/stop/etc. | Note from Andy: We should make sure that we are thinking about medications as concepts in a NHDD as well as prescribable / dispensable concepts in a formulary or drug dictionary. (OpenMRS has both concepts and drugs) Note: Need to ensure de-duplication process, so you don't see 8 listings for "aspirin" | ||
| Indicate MedRec done with Patient (or caregiver) | As a clinician, I need to indicate that a change was done based on direct patient (or caregiver) conversation, as this is often a requirement for my sites when a patient is admitted and/or discharged. Reason: This is seen in many sites as a higher quality of medication reconciliation than just comparing pre-hospital records alone (as those records may not indicate what the patient is actually taking!). (More of a priority for IPD.) | LOW | ||
| Handle Past Mediation Times for IPD | In IPD, I may need to also record the specific time, e.g. a sensitive drug infusion was started 1700h today, stopped 2300h today (with no plan to continue that medication). | LOW | ||
| Handle Vague Dates | My patients often do not remember the precise date when they started a medication, but they might remember the Month/Year or just the Year when they started taking it. I would like not to be blocked by being forced to invent a date for when it was started. | LOW | Priority: Low (since clinicians could use "Month 1st" to get unblocked) | |
| 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. | LOW |