Re: [Gnumed-devel] Medication viewing

[Karsten Hilbert]

On Thu, Oct 22, 2009 at 06:14:28PM -0700, Jim Busser wrote:

Excellent thoughts, most of which should be captured in the
Wiki for reference. There's one design concept and one
design goal to be kept in mind for the time being:

        No mixing of clinical and administrative concerns.

        The goal for this iteration of medication handling is
        recording the last known status quo of patient substance
        intake. Anything beyond that is currently optional (but
        worth considering such as to stay compatible with extensions).

> The universe of what is relevant for a patient could include
> 
> a. what they had *ever* taken

There's a full audit trail which carries this information.

> b. what is currently available to the patient

This is an administrative concern.

> c. what the patient is *advised* to be taking

Regardless of what the patient is actually taking, right. We
support that by means of an intake_is_approved_of in
clin.substance_intake (btw, the schema docs are online now).

> d. what the patient *accepts* to be taking

This will be captured in a mixture of pre-maturely
discontinued medication (best accompanied by a clinical
note), allergies/and intolerances records, and clinical
narrative.

> The above is compounded by:
> - self-medication is possible, even without a prescription

And we cater for capturing that should the patient relate
appropriate information.

> - a patient may not continue to take a medication in the dosage
> originally prescribed or advised
> - a patient may refuse to try a therapy which may therefore not ever
> get prescribed

This would usually result in a clinical note documenting as much.

> Traditionally we do not capture a refusal of therapy in a medication
> list, except *after* the medication had been tried. After the
> medication had been tried with refusal of adherence, the medication
> may be considered Intolerated or maybe just ineffective and
> therefore never makes it into Allergy/Intolerance and only into an
> archive of what *had* been tried.
> 
> Leaves me wondering about pre-emptively entering (into the Allergies
> / Intolerances) drugs which the patient would refuse to take. if we
> might do it for beta-blockers in asthmatic patients there is no
> reason a clinical group might not choose to use this method.

Sounds reasonable to me.

> When making therapeutic choices, one might ideally be presented
> choices based on cost-effectiveness,

Surely so but purely administrative.

> a patient may agree to use a drug even despite that it gives side
> effects the patient can accept even while the information was
> entered in Intolerances. A display might set out (side by side)
>       Options History         Notes
> 
> Perfect-world would populate Options based on clinical decision
> support but even before that it should be possible to select drug
> categories (anti-depressant, anti-hypertensive, diuretic etc). The
> "Options" would list either generic single agents or maybe generic
> combos (trimethoprim-sulfa) -- not sure about that one -- or
> proprietary which may be combos.
> 
> The "History" would list whether there exists a current or past
> match for the drug.
> - In absence of any match, the History would be blank
> - in presence of a match, shown could be the date last started (+-
> stopped) plus the regimen
> - regardless of History, if it was a drug for which there was a
> drug-specific or class Allergy / Intolerance, that info would be
> displayed under the Notes column.
> 
> When Options are not having to be considered, the History listing
> would include what we know as the "Medication list (Current
> medication)" plus previous medication and could take into account
> whether the listed medications are intended to continue in
> perpetuity (as with chronic disease, maybe a duration symbol "+" and
> whether they have an anticipated ("soft") stop or supply
> reassessment date that may be understood distinctly from (hard) stop
> dates that denote an intentional discontinuation by patient
> (intolerance or ineffective or not needed) or doctor (intolerance or
> ineffective or not needed).
> 
> - provide unique listings, according to drug-strength-dosage, noting
> a single drug could appear in multiple active drug-strength-dosage
> listings (since not all daily/weekly regimens can be managed by
> fractions and multiples of tablets)
> 
> - filter / sort:
>       "Group A" = current (blue) = "soft_stop_date" is {NULL or future-
> dated} and hard_stop_date is NULL
>       "Group B" = undefined (orange) = "soft_stop_date" is today-or-past-
> dated} and hard_stop_date is NULL
>       "Group C" = stopped (grey) = hard_stop_date is not NULL (NULL not >
> today)
> 
> ... the idea of Group B allowing to identify patients whose
> medication may need special review whether for decision-making
> and/or adequacy of medication supply. You would only put in the
> hardstop date when you confirmed at the next visit that the patient
> actually stopped their medication as instructed at the prior visit,
> and when (if able to be determined). Red might be useful in relation
> to a supply calculated to be expired. It is not fully thought
> through, I can already see a conflict between "supply" and "clinical
> intention" but though I would at least share the general concepts.

This is something to be captured for later use.

Karsten
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