Phillip No, because prescriptions are outpatient and so are orders placed in clinic for direct administration of a drug or immunologic. Both may be part of an outpatient encounter- to respond to Russ's proposal.
I do believe it is possible however to separate the two types of orders in Epic, and I presume, in Cerner. Jim ________________________________ From: [email protected] [[email protected]] on behalf of Phillip Reeder [[email protected]] Sent: Thursday, September 29, 2016 10:13 AM To: Shelley Rusincovitch; Russ Waitman Cc: [email protected] Subject: Re: [Data.pcornet] Confirming medications sources for Antibiotic obesity study question Would the inpatient vs outpatient flag from med orders be good enough to determine if an order was for dispensing or administration? The documentation states that the outpatient flag would be used for things like take-home meds in during an inpatient encounter so I think it might. Thoughts? Phillip From: Shelley Rusincovitch <[email protected]<mailto:[email protected]>> Date: Wednesday, September 28, 2016 at 6:50 AM To: Phillip Reeder <[email protected]<mailto:[email protected]>>, Russ Waitman <[email protected]<mailto:[email protected]>> Cc: "[email protected]<mailto:[email protected]>" <[email protected]<mailto:[email protected]>> Subject: RE: [Data.pcornet] Confirming medications sources for Antibiotic obesity study question Hi Phillip, This was an area that the original CDM working group really wrestled with, especially given that there wasn’t a lot of precedence in modeling practices. I’m quite interested in what your experiences have been, and it’s helpful to hear that this isn’t clear. RX_BASIS was intended to connect the provider’s prescribing order with how the order was fulfilled. (The working group thought of this as the arrows connecting the domain boxes in the below diagram.) It was an area of consideration because the PRESCRIBING table can contain orders for many different activities. For example: · Order for an antibiotic to be delivered by a nurse in an outpatient clinic: RX_BASIS=Administration · Order for a painkiller to be delivered by a nurse in a hospital room: RX_BASIS=Administration · Order for a drug that will be dispensed at Walmart: RX_BASIS=Dispensing The RX_BASIS would be set depending on the context of your data – I know that’s a little tricky, but do the examples help? Inpatient orders would generally be expected to be administration basis. We expected that EHR systems including Epic’s Willow would support this distinction (although I don’t want to make too many assumptions about your specific instantiation of Epic!), but it may not be feasible in all legacy systems or data sources. Does this help? And just to mention that a feedback cycle for the new v3.1 draft specification will be opening on Monday, October 3 – I hope that you and your team might consider contributing, perhaps including your thoughts on this issue? Not everyone has been comfortable working directly in GitHub, but I’ve added this to our tracker and you’re welcome to add anything to the log: https://github.com/CDMFORUM/CDM-GUIDANCE/issues/22 Best wishes, Shelley From: Phillip Reeder [mailto:[email protected]] Sent: Tuesday, September 27, 2016 7:49 PM To: Russ Waitman <[email protected]<mailto:[email protected]>> Cc: Shelley Rusincovitch <[email protected]<mailto:[email protected]>>; [email protected]<mailto:[email protected]> Subject: Re: [Data.pcornet] Confirming medications sources for Antibiotic obesity study question Can you explain what the rx_basis means? Administration vs dispensing? And what should it be set to for the medication orders? Thanks, Phillip Sent from my iPhone On Sep 27, 2016, at 6:36 PM, Russ Waitman <[email protected]<mailto:[email protected]>> wrote: Thanks again Shelley, Phillip, JimC and DanC: to follow up on today’s gpc-dev call, I’d like sites to load physician orders broadly encompassing all encounter types and then investigators can filter to what the desire by linking on encounter type. That way the CDM would have utility for inpatient and emergency medicine (near and dear to Jim McClay). Russ From: Shelley Rusincovitch [mailto:[email protected]] Sent: Tuesday, September 27, 2016 1:33 PM To: Block, Jason Perry,M.D.; Russ Waitman Cc: Charles Bailey; Casie Horgan; [email protected]<mailto:[email protected]>; Jessica Sturtevant; [email protected]<mailto:[email protected]>; [email protected]<mailto:[email protected]>; Christopher Forrest ([email protected]<mailto:[email protected]>) Subject: RE: [Data.pcornet] Confirming medications sources for Antibiotic obesity study question Hi everyone, If it’s helpful from a general perspective, the CDM structures the PRESCRIBING table for any medication orders (regardless of whether it’s inpatient, outpatient, ED, etc). But this may be quite different than availability of these data. Best wishes, Shelley <image004.png> ___________________________________________ Shelley A. Rusincovitch Project Leader in Applied Informatics & Architecture Duke Clinical and Translational Science Institute (CTSI) [email protected]<mailto:[email protected]> / 919-668-5954 From: [email protected]<mailto:[email protected]> [mailto:[email protected]] On Behalf Of Block, Jason Perry,M.D. Sent: Tuesday, September 27, 2016 1:13 PM To: Russ Waitman <[email protected]<mailto:[email protected]>> Cc: Charles Bailey <[email protected]<mailto:[email protected]>>; Casie Horgan <[email protected]<mailto:[email protected]>>; [email protected]<mailto:[email protected]>; Jessica Sturtevant <[email protected]<mailto:[email protected]>>; [email protected]<mailto:[email protected]>; [email protected]<mailto:[email protected]>; Christopher Forrest ([email protected]<mailto:[email protected]>) <[email protected]<mailto:[email protected]>> Subject: Re: [Data.pcornet] Confirming medications sources for Antibiotic obesity study question Hi Russ. Thanks for emailing - no bother at all. I'm cc'ing a few others who have expertise in this issue (Charles Bailey at CHOP and Casie Horgan and Jessica Sturtevant on the DRNOC QF team). We are not including inpatient medications in our study. We made this decision for logistical reasons (we didn't think it would be available, or if available, it would be available in a highly variable way) and scientific (we are most focused on potentially modifiable antibiotic use, and inpatient use doesn't fit that categorization). The scientific point is a debatable one, and we have had some subtle disagreement on the team about this. But, ultimately, since it wasn't going to be available, we chose to pursue use of antibiotics prescribed in the outpatient setting. Casie and Jessica might be able to respond to how we excluded meds in ED and Inpatient settings, if they did that explicitly. Charlie has lots of experience with meds as well, so he might want to respond to this. I could see how studies would like to include ED and inpatient med prescribing (or dispensing), and I would support inclusion of that in the CDM. We just won't use for our study, as it's currently structured. jb ________________________________ From: Russ Waitman [[email protected]<mailto:[email protected]>] Sent: Tuesday, September 27, 2016 12:50 PM To: Block, Jason Perry,M.D. Cc: [email protected]<mailto:[email protected]>; [email protected]<mailto:[email protected]>; Christopher Forrest ([email protected]<mailto:[email protected]>) Subject: Confirming medications sources for Antibiotic obesity study question Dear Jason, I hate to bug you but we wanted to get your quick check on something as the GPC sites are doing their CDM work in support of your study. Apologies for not being as close to your study but wanted to confirm something about how the CDM is being loaded and potential implications for your study as it’s the first big thing using medications from the CDM. The CDM http://pcornet.org/wp-content/uploads/2014/07/2015-07-29-PCORnet-Common-Data-Model-v3dot0-RELEASE.pdf<https://urldefense.proofpoint.com/v2/url?u=http-3A__pcornet.org_wp-2Dcontent_uploads_2014_07_2015-2D07-2D29-2DPCORnet-2DCommon-2DData-2DModel-2Dv3dot0-2DRELEASE.pdf&d=CwMF-g&c=imBPVzF25OnBgGmVOlcsiEgHoG1i6YHLR0Sj_gZ4adc&r=Vu1yqij3sPINGhACFSh38ArhXkVAmgx-t4FJu5KXbYY&m=7IGVk2QoYKMlC9tHPJrSA9IKFgzn3D2U48glbgYDBl8&s=yGtovUGBuLMyDvbiumYOYlrfIsuGXaxHNIIEr6pMYNo&e=> on page 13 specifies that the prescribing tables and the dispensing tables should not contain - inpatient medication administrations - active medication lists resulting from medication reconciliation Prescribing should obviously have outpatient prescriptions but it’s unclear to some regarding physician inpatient orders. The table specification in written largely in language of outpatient prescriptions but the page 13 figure indicates that prescribing encompasses physician orders that spawn both dispenses and administrations. I would just be concerned that if sites are conservative in only loading ambulatory meds, we’re going to have limited CDM data to support studies that want to include inpatient and emergency room medication exposures. As you look at your early sites, what are you seeing? Does that match what exposures you wish you had? Bottom line: are you only looking at outpatient prescribing or dispensing exposure to antibioticsor does your study need inpatient and emergency room medication exposure? My personal bias is to exclude the admins and the med rec at this point but include both inpatient and outpatient medication orders written by the physician. 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