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Re: [Gnumed-devel] Medication lists - Duration


From: Busser, Jim
Subject: Re: [Gnumed-devel] Medication lists - Duration
Date: Fri, 26 Jul 2013 00:26:58 +0000

On 2013-07-25, at 2:32 PM, Jim Busser <address@hidden> wrote:

> I am just realizing that
> 
>       Duration
> 
> ambiguates

My apologies, by the way, for all the "pressure" that I might seem to be 
creating to revise the current medication section. … I owe the flurry to my 
having tried really hard lately to use GNUmed, except finding it is still needs 
more work in order to work more clearly, more fully etc.

Coming back to Duration, the following are the potential 'time segments" of 
interest which fall between the ...

1) actual date start …  now

2) now … when to next review / reassess (while still on the medication)

3) now … when to discontinue the medication

Whether we are talking about an in-praxis visit, or whether we are talking 
about a chart review where we reach to a new insight or decision about a 
patient, it seems to me that the frame of reference in the clinical decision 
making is always "now".

In the case of hypertension, for example, I may

- in the case of a patient whose BP is not yet under control, I may wish to 
make a decision 2 weeks into the future whether I am satisfied with the current 
dosage
- in the case of a patient whose blood pressure *is* under good control, I may 
be satisfied to approve their use of some medications for 3 or 6 months into 
the future

despite that, in both cases, the same medications remain check-boxed "long 
term".

It is both possible, and common, to be able to make such decisions without 
always knowing when a medication started.

I very strongly think, therefore, that what we should be capturing is not

        "intended total duration"

but

        'duration into the future" = 'extension forward from now"

which, in the case where we are starting the drug today, is the same as the 
total duration anyway. ***But*** we need to unambiguously provide for all the 
cases where the start date was earlier than now, including when it was unknown 
and not realistically possible to identify.

I would point out that over in the Allergy section, the admitted possibility 
that patients do not know when (exactly) was their adverse reaction accounts 
for why the tooltip says:

        When did the patient note the onset of the reaction.
        If unknown, use the date when it was reported to you.

So ... can we please refactor what we will mean by "duration" so that, perhaps 
as part of the 1.4 upgrade, the interval value becomes replaced by

        value = original interval - (the time elapsed between started and now)

essentially making this the "time remaining" until next drug re-assessment, or 
change, or discontinuation?

The result will be the calculation of a "target date" and will require a 
decision whether this will be handled in a column dedicated for this purpose, 
and whether 'duration' remains a column in the schema, or simply a "field" in 
the middleware that is back-calculated and auto-populated from the "target 
date" when non-NULL.

-- Jim





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