RE: Drug dispense entry class question

[Bakke, Silje Ljosland]

That’s probably a jurisdiction thing too. I’m not sure if it’s a legal 
requirement or just considered good clinical practice, but generally a dose 
change is a cessation/new order here. 

Regards,
Silje

From: openEHR-technical  On Behalf 
Of Sam Heard
Sent: Monday, August 13, 2018 2:46 PM
To: For openEHR technical discussions 
Subject: RE: Drug dispense entry class question


Hi All



There is the interesting situation as to what constitutes a stop/start and an 
amend for medication. Generally, if it is the same generic substance people 
will want to see it as an amend. This means they do not have to go through all 
the warnings and search again in the database. This is probably of no 
consequence from a data point of view, apart from the fact that you do not want 
to be warned that a patient has previously been on this medication (happens in 
our system).



Cheers, Sam



Sent from Mail for Windows 10




From: openEHR-technical 
mailto:openehr-technical-boun...@lists.openehr.org>>
 on behalf of Thomas Beale 
mailto:thomas.be...@openehr.org>>
Sent: Monday, August 13, 2018 9:07:18 PM
To: 
openehr-technical@lists.openehr.org
Subject: Re: Drug dispense entry class question



On 11/08/2018 20:50, Karsten Hilbert wrote:
> On Sat, Aug 11, 2018 at 04:24:47PM -0300, Pablo Pazos wrote:
>
> I meant to say that some treatments will not end until the
> patient dies meaning that the COMPLETED state will never be
> reached if we take into account

certainly true in theory, and maybe in reality. But drug treatments
change and different variants may be tried over time - true even for
basics like insulin - so at least for some chronic medication
situations, it probably will be the case that one treatment finishes and
another starts, based on a (?slightly) different order, with this
repeating over time.

- thomas


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Re: Drug dispense entry class question

[Ian McNicoll]

Hi Sam,

We modelled that as minor change (Active) / major change (Aborted) ,
without closely defining, what constiuted either...

Major change to order
Careflow step
A major change to the order was required, resulting in this order being
stopped and a replacement order being started.
Current state: aborted

Minor change to order
Careflow step
The medication order has been changed in a manner which does not require a
new instruction/order to be issued, according to local clinical rules.
Current state: active

Ian

Dr Ian McNicoll
mobile +44 (0)775 209 7859
office +44 (0)1536 414994
skype: ianmcnicoll
email: i...@freshehr.com
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Co-Chair, openEHR Foundation ian.mcnic...@openehr.org
Director, freshEHR Clinical Informatics Ltd.
Director, HANDIHealth CIC
Hon. Senior Research Associate, CHIME, UCL


On Mon, 13 Aug 2018 at 13:45, Sam Heard 
wrote:

> Hi All
>
>
>
> There is the interesting situation as to what constitutes a stop/start and
> an amend for medication. Generally, if it is the same generic substance
> people will want to see it as an amend. This means they do not have to go
> through all the warnings and search again in the database. This is probably
> of no consequence from a data point of view, apart from the fact that you
> do not want to be warned that a patient has previously been on this
> medication (happens in our system).
>
>
>
> Cheers, Sam
>
>
>
> Sent from Mail  for
> Windows 10
>
>
> --
> *From:* openEHR-technical 
> on behalf of Thomas Beale 
> *Sent:* Monday, August 13, 2018 9:07:18 PM
> *To:* openehr-technical@lists.openehr.org
> *Subject:* Re: Drug dispense entry class question
>
>
>
> On 11/08/2018 20:50, Karsten Hilbert wrote:
> > On Sat, Aug 11, 2018 at 04:24:47PM -0300, Pablo Pazos wrote:
> >
> > I meant to say that some treatments will not end until the
> > patient dies meaning that the COMPLETED state will never be
> > reached if we take into account
>
> certainly true in theory, and maybe in reality. But drug treatments
> change and different variants may be tried over time - true even for
> basics like insulin - so at least for some chronic medication
> situations, it probably will be the case that one treatment finishes and
> another starts, based on a (?slightly) different order, with this
> repeating over time.
>
> - thomas
>
>
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RE: Drug dispense entry class question

[Sam Heard]

Hi All



There is the interesting situation as to what constitutes a stop/start and an 
amend for medication. Generally, if it is the same generic substance people 
will want to see it as an amend. This means they do not have to go through all 
the warnings and search again in the database. This is probably of no 
consequence from a data point of view, apart from the fact that you do not want 
to be warned that a patient has previously been on this medication (happens in 
our system).



Cheers, Sam



Sent from Mail for Windows 10




From: openEHR-technical  on behalf 
of Thomas Beale 
Sent: Monday, August 13, 2018 9:07:18 PM
To: openehr-technical@lists.openehr.org
Subject: Re: Drug dispense entry class question



On 11/08/2018 20:50, Karsten Hilbert wrote:
> On Sat, Aug 11, 2018 at 04:24:47PM -0300, Pablo Pazos wrote:
>
> I meant to say that some treatments will not end until the
> patient dies meaning that the COMPLETED state will never be
> reached if we take into account

certainly true in theory, and maybe in reality. But drug treatments
change and different variants may be tried over time - true even for
basics like insulin - so at least for some chronic medication
situations, it probably will be the case that one treatment finishes and
another starts, based on a (?slightly) different order, with this
repeating over time.

- thomas


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Re: Drug dispense entry class question

[Thomas Beale]

There is nothing to prevent the creation of an ACTION /and /an 
ADMIN_ENTRY, possibly in the same COMPOSITION, and in at least some 
situations, this is probably the right thing to do.


- thomas


On 11/08/2018 20:51, Pablo Pazos wrote:

Thanks Ian,

I know this was modeled. Just wanted to understand the rationale 
behind choosing an ACTION vs an ADMIN_ENTRY, this is to help me create 
an exercise for my students. And for ACTION, if the dispense should be 
an active of final state, and from your message it seems I was on the 
right path, not thinking this as a final state since more actions can 
happen after the dispense, like the one I mentioned of the patient 
recording intake.


:)


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Re: Drug dispense entry class question

[Thomas Beale]

On 11/08/2018 20:21, Karsten Hilbert wrote:

On Sat, Aug 11, 2018 at 04:03:28PM -0300, Pablo Pazos wrote:


How would you map a "pharmacy drug dispense" task, where the patient comes
with a prescription and a clerk delivers the medication packages?

I was thinking this is clearly and ACTION, but also seems to be an
ADMIN_ENTRY, since it is just a delivery of some product.

I'm inclined to think it as an ACTION if this task alters the state of the
prescription INSTRUCTION ISM. On this case, as a parallel question, I'm not
sure if the dispense ACTION should be a final "COMPLETED" state, what
happens if we want to record the patient's intake of the drug? Where the
real "COMPLETED" is when the treatment is finished.

That might mean that some INSTRUCTIONs never get COMPLETED
until the patient dies.


The Instruction State Machine (ISM) is designed to accommodate this, by 
including 'timeout' transitions that enable software to 'expire' old 
orders. Of course, there needs to be some service or application that 
does this, but it is a perfectly legal change to the data that reflect 
reality, i.e. that the noone informed the system that a given order 
(typically medication) was completed or otherwise finished (e.g. aborted).




It might help to think of shifts in responsibility: who is
primarily responsible for completion of a given action ?

- write prescription -> doctor
- hand out drug based on prescription -> pharmacist
- take drug as instructed -> patient

Each change of responsibility: doctor -> pharmacist ->
patient might warrant a COMPLETED state.


This is not the way the current ISM works, but is closer to the Task 
level view of things, as opposed to order-level view (which doesn't care 
who the workers are). The state machine for Tasks is shown here 
, 
in the Task Planning spec. IN addition, there is the concept of a Task 
Plan (example here 
 
with multiple performers), which is per-performer (worker). Each Task 
Plan has a computed state, based on the states of the Tasks within that 
plan. The logic for computing this is described here 
.


In openEHR systems of the future, both types of state machines will 
operate, so that it will be possible to know the state of every order, 
as well as the 'state of the work' being done to perform the orders.


- thomas

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Re: Drug dispense entry class question

[Ian McNicoll]

Hi Pablo,

Yes. Sorry I misread your email but I think Karsten has helped you. We
regarded the dispense of a medication as part of the full medication
management cycle from initial order through to the patient being
administered the medication

It is possible to think of there being two parallel processes, as Gerard
has suggested.

1. The order -> administration of the medication to the patient
2. Physical Medication supply - prescription, authorisation, dispense,
refill

and we did consider using different archetypes for each but
after discussion and some practical experimentation decided to reflect
these as different pathway steps in the same archetype as in many health
systems, the separation is unclear.

Ian

Dr Ian McNicoll
mobile +44 (0)775 209 7859
office +44 (0)1536 414994
skype: ianmcnicoll
email: i...@freshehr.com
twitter: @ianmcnicoll


Co-Chair, openEHR Foundation ian.mcnic...@openehr.org
Director, freshEHR Clinical Informatics Ltd.
Director, HANDIHealth CIC
Hon. Senior Research Associate, CHIME, UCL


On Sat, 11 Aug 2018 at 20:52, Pablo Pazos  wrote:

>
>
> On Sat, Aug 11, 2018 at 4:50 PM, Karsten Hilbert 
> wrote:
>
>> On Sat, Aug 11, 2018 at 04:24:47PM -0300, Pablo Pazos wrote:
>>
>> > > > I'm inclined to think it as an ACTION if this task alters the state
>> of
>> > > the
>> > > > prescription INSTRUCTION ISM. On this case, as a parallel question,
>> I'm
>> > > not
>> > > > sure if the dispense ACTION should be a final "COMPLETED" state,
>> what
>> > > > happens if we want to record the patient's intake of the drug?
>> Where the
>> > > > real "COMPLETED" is when the treatment is finished.
>> > >
>> > > That might mean that some INSTRUCTIONs never get COMPLETED
>> > > until the patient dies.
>> > >
>> > >
>> > There is a state "EXPIRED", so that is covered IMO if an expiration
>> date is
>> > recorded, or even if the whole system has preconfigured expiration dates
>> > for drug treatments.
>>
>> I meant to say that some treatments will not end until the
>> patient dies meaning that the COMPLETED state will never be
>> reached if we take into account
>>
>
> Gotcha! Yes of course, chronic medication is never COMPLETED :)
>
>
>
>> >>> [...] the patient's intake of the drug [... where] the
>> >>> real "COMPLETED" is when the treatment is finished.
>>
>> Regards,
>> Karsten
>> --
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>>
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>
>
>
> --
> *Ing. Pablo Pazos Gutiérrez*
> pablo.pa...@cabolabs.com
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