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[Gnumed-devel] Medication viewing

From: Jim Busser
Subject: [Gnumed-devel] Medication viewing
Date: Thu, 22 Oct 2009 18:14:28 -0700

Just wondering if some concepts may be future-compatible with current construction:

The universe of what is relevant for a patient could include

a. what they had *ever* taken
b. what is currently available to the patient
c. what the patient is *advised* to be taking
d. what the patient *accepts* to be taking

The above is compounded by:
- self-medication is possible, even without a prescription
- a patient may not continue to take a medication in the dosage originally prescribed or advised - a patient may refuse to try a therapy which may therefore not ever get prescribed

Traditionally we do not capture a refusal of therapy in a medication list, except *after* the medication had been tried. After the medication had been tried with refusal of adherence, the medication may be considered Intolerated or maybe just ineffective and therefore never makes it into Allergy/Intolerance and only into an archive of what *had* been tried.

Leaves me wondering about pre-emptively entering (into the Allergies / Intolerances) drugs which the patient would refuse to take. if we might do it for beta-blockers in asthmatic patients there is no reason a clinical group might not choose to use this method.

When making therapeutic choices, one might ideally be presented choices based on cost-effectiveness, and these could be listed against what a patient currently takes (or did previously take) and against whether there is a recorded allergy or intolerance. Notably a patient may agree to use a drug even despite that it gives side effects the patient can accept even while the information was entered in Intolerances. A display might set out (side by side)
        Options History         Notes

Perfect-world would populate Options based on clinical decision support but even before that it should be possible to select drug categories (anti-depressant, anti-hypertensive, diuretic etc). The "Options" would list either generic single agents or maybe generic combos (trimethoprim-sulfa) -- not sure about that one -- or proprietary which may be combos.

The "History" would list whether there exists a current or past match for the drug.
- In absence of any match, the History would be blank
- in presence of a match, shown could be the date last started (+- stopped) plus the regimen - regardless of History, if it was a drug for which there was a drug- specific or class Allergy / Intolerance, that info would be displayed under the Notes column.

When Options are not having to be considered, the History listing would include what we know as the "Medication list (Current medication)" plus previous medication and could take into account whether the listed medications are intended to continue in perpetuity (as with chronic disease, maybe a duration symbol "+" and whether they have an anticipated ("soft") stop or supply reassessment date that may be understood distinctly from (hard) stop dates that denote an intentional discontinuation by patient (intolerance or ineffective or not needed) or doctor (intolerance or ineffective or not needed).

- provide unique listings, according to drug-strength-dosage, noting a single drug could appear in multiple active drug-strength-dosage listings (since not all daily/weekly regimens can be managed by fractions and multiples of tablets)

- filter / sort:
"Group A" = current (blue) = "soft_stop_date" is {NULL or future- dated} and hard_stop_date is NULL "Group B" = undefined (orange) = "soft_stop_date" is today-or-past- dated} and hard_stop_date is NULL "Group C" = stopped (grey) = hard_stop_date is not NULL (NULL not > today)

... the idea of Group B allowing to identify patients whose medication may need special review whether for decision-making and/or adequacy of medication supply. You would only put in the hardstop date when you confirmed at the next visit that the patient actually stopped their medication as instructed at the prior visit, and when (if able to be determined). Red might be useful in relation to a supply calculated to be expired. It is not fully thought through, I can already see a conflict between "supply" and "clinical intention" but though I would at least share the general concepts.

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