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Re: [Gnumed-devel] clin_medication

From: Karsten Hilbert
Subject: Re: [Gnumed-devel] clin_medication
Date: Mon, 18 Oct 2004 13:30:15 +0200
User-agent: Mutt/

>>> What field  should carry the bid tid etc?
>> clin_medication.directions - free text
> This is ambiguous: the same data is being stored twice.
> The client should parse the directions string for bid tds etc. and
> then *remove* those words from the comment. The comment is
> for stuff that can't be broken down into the structure.
Agree. We then need some code in the script writer that can
produce the locally customary strings for patient use

>> dosage_form text
>>              not null, --check (form in ('spray', 'cap', 'tab', 'inh', 
>> 'neb', 'cream', 
>>              'syrup', 'lotion', 'drop', 'inj', 'oral liquid'))
> We should try to rationalise this list to forms [=Preparation] where the 
> distinction is clinically significant, viz.
Again, we need to ask ourselves what the purpose is going to
be. In a drug database, sure, it's going to be important to
make the form field fit for computation, eg. normalize it out.
OTOH, are we going to compute anything from the dosage_form in
our current medications list ? Likely not. What we do want to
do with it is to *remember* it so we can say "Ah, Mrs Smith,
you've been using the PCM supps with Jimmy. Good success there
or should we switch to syrup ?".

IOW, IMO it serves it's purpose quite well as an unconstrained
text field. For selection on the next script we'll draw from
"knowledgeable" sources anyways: either from the previous
script - where GnuMed does not *know* that the previous PCM
was supps but does *have* that information for me to select --
or from a drug database which even knows about the different
forms and will allow me to select either one - which is what
I'd want.

> >--   is_SR boolean   -- ???
> >
> Some drugs have both a slow-release and standard preparation available 
> under the same brandname, for some (tramadol, sertraline) distinction is 
> crucial.
Is there really really no other distinction ? All the drugs I
know of either have slightly different names or differ in form
(Voltaren Resinat vs. Voltaren dispers vs. Voltaren Dragees)
or have a name suffix (often SR, incidentally). Again, will we
ever want to *compute* anything from that value ? If there
really is no other way to tell the two preparations apart we
*will* need to carry that field in this table.

> Yes, but, IMHO we need enough information to find the preparation (or 
> clinically equivalent preparation)
> in any database, otherwise we are locked in by our own records.
However, the question is whether we need to be able to do this
programmatically or at all. The cases where it's ambigous are
AFAICT fairly rare and it seems justified to prompt the user.
I think I just want to hear evidence to the contrary of me
thinking that relevant clinical differences will always show
up in the name of a drug.

I may be wrong on the account of that we need this information
when checking for side effects, interactions, and stuff.

> >Am I thinking correctly that when we prescribe generics we
> >would do this:
> >
> >phenoxymethylpenicilline 1.5 Mio i.E.
> >clavulanic acid 3g
> >
> >which being TWO SEPARATE ROWS in clin_medication ?
> >Whereas when I would prescribe a particular drug by brand name
> >containing both of the above it would be just one row. This is
> >how I designed the table anyways
> >
> IMHO bad, as this means duplicates of all the other fields, poor 
> normalisation in other words.
Sure. But when I prescribe two different drugs I expect two
different rows. And a penicilline + clavulanic acid clearly
are two different drugs -- IF my mode of prescription is by
generic, eg active ingredient. If I then want to make sure the
patient isn't getting two pills I better note that down for
the pharmacist in directions as that is a detail of
formulation, not of ingredient. After all, my clinical
decision in this case is "this patient is getting that much
pen and that much clav and I don't care how". If I do care I
better write it down.

> Perhaps the generic text field can be upgraded to a parseable "generic 
> drug expression"
> such as "amoxycillin 875mg/clavulanic acid 125mg", effectively a 
> name-based substitute of PZN
If you think we need that we should use a dedicated field,

I think we need more input here.

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