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

[J Busser]

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?