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Re: [Gnumed-devel] Drug browsing / Prescribing module


From: J Busser
Subject: Re: [Gnumed-devel] Drug browsing / Prescribing module
Date: Sat, 5 Feb 2005 14:31:27 -0800

At 9:47 AM +1100 2/6/05, catmat wrote:
it would be BAD to clone a previous prescription without realizing that the drug had been stopped or intended to run out (or, more often) the dosage had changed since the last prescription.

checking a prescription in oz is usually done verbally, before a previous prescription is re-printed. How would you see an application assisting in the checking? ( ? popup check list dose change dialog ,
each time re-prescribe was checked ?)
Not sure if this is what you are warning about.

Let us say a patient is prescribed enalapril (ACE inhibitor) 5mg daily and glyburide 5mg twice daily. It will always happen that *some* patients will require a change to their dosage before their current supply runs out. Either the dosage feels to the patient to be too strong or causing side effects (so they may reduce or stop on their own initiative, or after phoning the office), or may not be enough ("my blood sugar / blood pressure is still high"), or up-titration may have been part of the instruction, and all may have caused a change. Such changes need to be captured as part of the first/next encounter, as soon as they become known. These changes are not the same as prescriptions, because there may be no need for a new supply of drug. In Canada, when no new or additional supply is required, there is no requirement to write or communicate anywhere outside the office (even to a pharmacy) any change to what dosage a patient is taking (or what medications they are continuing to take, at all) after a prescription is dispensed.

I see consequences all the time, when doctors who temporarily care for patients (say, in hospital) write admission orders based on information available from the community pharmacies that gets treated incorrectly as a "profile":

- that list provides only what was prescribed, and filled, in community pharmacies
- infrequently-used prn medications (indomethacin) and courses of medication
   that were not completely used up (antibiotics, NSAIDs) often pre-date the
arbitrarily-chosen time interval over which the pharmacy database was searched
- free sample/starter medications from the doctor's office do not appear
- over-the-counter purchases (ASA, Iron, other) do not appear
- prescription medications dispensed by other systems (in my case the
provincial HIV Centre For Excellence - these include antibiotics for preventing
   and treating pneumocystis, mycobacteria and fungi) do not appear
- patients may no longer be supposed to be taking some of these medications,
   and/or dosage may have changed since a medication was last prescribed

Even when patients are out of hospital, our medication lists will be "blind" to changes made in walk-in-clinics or by specialists. That is why, before prescribing, it is so important (I cannot emphasize it enough) to have a tool independent of prescriptions, in order to manage, review & confirm with the patient any changes, relative to what they were last "known" to be taking. Only *then* proceed to prescribe, picking as you like from a list of prior prescriptions, and modifying as necessary.

If it is only within this encounter that a medication is being started, or restarted, or its dosage is being changed, the prescription could at the same time "update" the profile. There is no reason we cannot have a *link* between prescriptions and a "profile", it is just that they are not the same thing.

Is it useful to accept, and retain, the term "medication profile" to designate what a patient was documented or derived to be taking at any definable point in time (i.e. a snapshot)?

The thought occurs that there are substances (herbs etc) a doctor may like to catch within a "substance profile" and even more broadly there are treatments or routines (diet restrictions or supplements, activity restrictions or supplements) that could fit in a "treatments profile". Would we include at least the herbal and alternative substance usage in the medications framework?




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