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[Gnumed-devel] Vaccination brand/route presentation
From: |
Jim Busser |
Subject: |
[Gnumed-devel] Vaccination brand/route presentation |
Date: |
Sat, 17 Sep 2011 20:24:24 -0700 |
Presently GNUmed wants vaccines to be defined in the table
clin.vaccine
with a foreign key to the brand (or, in the case of a 'fake brand' generic
vaccine, to an is_fake record created in that same ref.branded_drug table).
All of that is fine, but it got complicated by the requirement that each
clin.vaccine
be also characterized (defined) by the route by which it is supposed to be
delivered. That broke the fact that a single product (e.g. pneumococcal
polysaccharide vaccine) can be delivered by either the IM or SC route as
described in http://www.immunize.org/catg.d/p3085.pdf
Presently in GNUmed, selecting the indication (like pneumo) evokes the product
as per the screenshot example. This includes duplicates on brand, on account of
some being able to be delivered by more than one route:
Pneumo 23 (pneumococcus)
Pneumo 23 (pneumococcus)
Pneumovax 23 (pneumococcus)
Pneumovax 23 (pneumococcus)
Prevnar (diptheria, pneumococcus)
Prevnar 13 (diptheria, pneumococcus)
The user cannot distinguish and therefore cannot correctly select *which* of
the above is (invisibly to the user) defined in the backend as IM vs SC.
Likewise, one cannot "see" whether the 'generic' vaccine is defined in the
backend as IM or SC.
We can solve this problem if we either
1) remove route from clin.vaccine
This is simplest. No-one who did not alter their v15 or earlier schema would
have been able to create unique brand products having more than one vaccination
route. AFAICT, the route type is not so far written as an fk into any other
clinical entry.
Dropping column 'route' from vaccine definitions would allow to go back to
vaccine being unique on [fake] brand. This is IMO best, because – in the
situation of a report from a previous doctor that a patient received pneumovax
on <date> – the absence of historical information on route (e.g. in a transfer
of care record) will not be resolvable. Presently, the user can select a
generic record but they do so without realizing they are committing / attesting
(invisibly) to a product route they did not know to be true.
If we would drop the route column, users would then see each brand (product)
uniquely:
Pneumo 23 (pneumococcus)
Pneumovax 23 (pneumococcus)
Prevnar (diptheria, pneumococcus)
Prevnar 13 (diptheria, pneumococcus)
Synflorix (diptheria, pneumococcus, tetanus)
pneumococcus - generic vaccine (pneumococcus)
2) keep id_route a property of clin.vaccine AND keep the ability to have
multiple vaccine records per unique brand ( where UNIQUE {fk_brand, id_route)
AND display this route in the phrasewheel AND in the display of the patient's
history of vaccinations already given AND allow route to be null AND update the
generic vaccines to make no assumptions about the route utilized, by doing
UPDATE clin.vaccine
SET id_route = NULL
WHERE EXISTS (
SELECT 1
FROM ref.branded_drug r_bd
WHERE r_bd.is_fake IS TRUE
AND clin.vaccine.fk_brand = r_bd.pk
LIMIT 1) ;
3) make id_route into a nullable array of type integer, which -- provided the
array values are translated in the ui -- could better allow to guide the
clinician to not administer the vaccine in an inappropriate route. This would
mean that we should incorporate – into the phrasewheel display – the route
short form, such as
Pneumo 23 [i.m, sc] (pneumococcus)
Pneumovax 23 [i.m, sc] (pneumococcus)
Prevnar [i.m.] (diptheria, pneumococcus)
Prevnar 13 [i.m.] (diptheria, pneumococcus)
Synflorix [i.m.] (diptheria, pneumococcus, tetanus)
pneumococcus - generic vaccine (pneumococcus)
Generic vaccine should be allowed to have a null route.
I think that in the short term, option 1 is the least work, then option 2, then
option 3 (which IMO would, in the longer term, be most ideal / appropriate).
PS all of this discussion sets aside that it is possible, as part of the
documentation of the giving of the vaccine, that it was given e.g. in the left
deltoid or right gluteus or left vastus medialis. So to the extent that in any
patient this both matters and is of interest, the route can be documented that
way.
-- Jim
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