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[Gnumed-devel] test results and therapeutic ranges (was Possible develop

From: J Busser
Subject: [Gnumed-devel] test results and therapeutic ranges (was Possible development opportunity)
Date: Mon, 13 Sep 2004 13:33:13 -0700

Before considering the target range for Patient X with an INR of 2.0-3.0, can we also consider the handling of a drug whose levels can be measured, and which has a therapeutic range which
- may depend on the indication and/or
- may be changed by the doctor who wants it narrower/higher/lower than "usual"

1) have we a suitable place to keep this patient-specific information, perhaps linkable to the test, so that when the test result is reviewed we can easily discern if we are satisfied?
2) table test_results has fields
- val_normal_min
- val_normal_max
- text field val_normal_range

all of the above are meant to hold values provided by the lab

when a lab supplies for example phenytoin/dilantin result of 56 and provides a numeric or text range of 40-80 do we place that in the _normal_ field(s) in which case they are no longer _normal_ but _reference_ ?

maybe it is better to have a separate set of fields in addition to _normal_ considering that when a biologic test like INR comes back at 1.5, this is abnormally elevated in some people, but it is subtherapeutic in someone on warfarin

we could therefore add a set of fields prefixed value_therapeutic etc (or value_rx etc)

could it be a good idea to write a patient's corresponding target values into the test-result row, either overwriting the lab's reference range or (if these must be preserved as original communication) into value_target_min and value_target_max?

I am wondering if this would make querying and reporting faster, separating patients who will need a change of dosage (needing quicker contact) from the others? Also, once having written the target info into the test_result row, the row would remain meaningful even after a doctor later raises or lowers Patient X's range. I realize that a within-patient history of changes to target ranges should be accessible via the audits, but would rather avoid people misjudging from the INRs that have been running 2.0 - 2.8 that a patient's target is 2.0 - 3.0 when it is in fact 2.5-3.5, not to mention the complexity of later trying to assess the quality of anticoagulation in one's clinic/practice/surgery.

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