The (virtual) medication profile

What is it? Why do we need it?How does it fit in with AORTA?

Overview

• Brief summary of AORTA infrastructure• The essence of data• The “Guideline for Medication Transfer”• The ‘building blocks’• Ways to maintain and share the profile• The virtual medication profile

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NICTIZ, aims and activities

Creation of the right conditions for nationwide and transparent access to real-time healthcare information about every patient:

•Nationwide infrastructure in the healthcare sector to ensure fast, secure and transparent information exchange AORTA!•Software interfaces to achieve seamless inter-operability, leading to a ‘virtual EHR’ HL7 v3•Initial focus on single, well-understood domain: national electronic medication record

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Possible solutions for the network infrastructure

• Option 1: One big EHR database with healthcare info for 16 million people

• Option 2: Leave data at the source, but register a reference to it in a central repository (a so-called ‘Act Registry’)

• (Option 3: Somewhere in between; core data in the repository; details at the source)

AORTA!

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The essence of AORTA:The Care Information Broker

(ZIM in Dutch)• Data itself it not copied in the registry• Source systems upload a reference to their data

– GPs and specialists upload prescription references– Pharmacies upload dispense references– Etc.

• All references are based on a (currently available) national patient ID and national care provider ID

• Interested parties use web service queries, instead of notification messages between systems

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There are pros and cons to every solution

• Advantages– Always the most recent data from the ‘virtual’ DB– No risk of inconsistencies due to duplication– No exponential growth in # of interactions– Centralized access easier to enforce standards

• Challenges– Performance is as yet a very uncertain factor– Centralized model requires a lot of coordination

making deadlines really becomes a challenge– The (national) ZIM has been built by an IT vendor

(since the government has no intention to operate it) this vendor achieves a monopoly position

Jahrestagung HL7 DeutschlandBerlin, October, 2010

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Data retrieval with a Care Information Broker:

Hospital Hospital

Community Pharmacies

General Practitioners

Dispense and Prescription Queries

E-Prescriptions

Dispense References

Care Information Broker (Act Registry)

PRESC GP1 PAT1PRESC GP1 PAT2

PRESC HOSP1 PAT1…

DISP PHARM1 PAT1DISP PHARM2 PAT2

…

HL7 Models(Dispense Query)

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AdministrationRequestEffectiveTimeInterval(ParameterItem)value*: SET<IVL<TS>> [1..*]semanticsText: ST [0..1] "Beoogde toedieningsperiode"

QueryByParameter(QueryByParameter)queryId: II [0..1]statusCode*: CS CNE [1..1] <= QueryEventStatusresponseElementGroupId: SET<II> [0..*]responseModalityCode: CS CNE [0..1] <= ResponseModalityresponsePriorityCode: CS CNE [0..1] <= QueryPriority "I"initialQuantity: INT [0..1]initialQuantityCode: CE CWE [0..1] <= QueryQuantityUnit

SortControl(SortControl)sequenceNumber: INT [0..1]elementName: SC CWE [0..1] <= ElementNamedirectionCode: CS CNE [0..1] <= Sequencing

0..*sortControl

0..1administrationRequestEffectiveTimeInterval

0..1medicationCombinedOrderID

0..1patientID

PatientID(ParameterItem)value*: II [1..1]semanticsText: ST [0..1] "Patiëntnummer"

MedicationCombinedOrderID(ParameterItem)value*: II [1..1]semanticsText: ST [0..1] "Voorschriftnummer"

DispensingPharmacistID(ParameterItem)value*: SET<CE> [1..*]semanticsText: ST [0..1] "Verstrekkende apotheker"

MedicationCode(ParameterItem)value*: SET<CE> [1..*]semanticsText: ST [0..1] "Medicatiecode"

0..1medicationCode

0..1dispensingPharmacistID

ControlActProcessclassCode*: <= CACTmoodCode*: <= ActMoodCompletionTrack

0..1queryByParameter

AvailabilityTimeInterval(ParameterItem)value*: IVL<TS> [1..1]semanticsText: ST [0..1] "Beschikbaarheidsperiode"

0..1availabilityTimeInterval

Medication Dispense Event Query(QURX_RM990011)

Description: This R-MIM defines the parameters usedto query for dispense events of prescribed medication.

0..1medicationDispenseEventID

MedicationDispenseEventID(ParameterItem)value*: II [1..1]semanticsText: ST [0..1] "Verstrekkingsnummer"

DispenseEventEffectiveTimeInterval(ParameterItem)value*: SET<IVL<TS>> [1..*]semanticsText: ST [0..1] "Verstrekkingsperiode"

0..1dispenseEventEffectiveTimeInterval

Models(Dispense Query Reponse)

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PrescriptionclassCode*: <= SBADMmoodCode*: <= RQOid*: II [1..1]text: ED [0..1]statusCode*: CS CNE [1..1] <= activeconfidentialityCode: CV CNE [0..1] <= N+R+V+ConfidentialityByInfoType

CMET: (PAT) R_Patient[universal]

(COCT_MT050000NL)

0..1 scopedRoleName 1..1 patient *

typeCode*: <= SBJsubject

CMET: (ASSIGNED) R_AssignedPerson

[identified](COCT_MT090101)

0..1 scopedRoleName

0..1 assignedPerson *

typeCode*: <= AUTtime*: TS [1..1]modeCode: CV CNE [0..1] <= ParticipationModesignatureCode: CV CNE [0..1] <= SsignatureText: ED [0..1]

author

MedicationAdministrationRequestclassCode*: <= SBADMmoodCode*: <= RQOid: II [0..1]text*: ST [0..1]statusCode*: CS CNE [1..1] <= activeeffectiveTime*: GTS [0..1]priorityCode: CV CNE [0..1] <= R+UR "R"routeCode*: CE CNE [0..1] <= G-Standaard_thesaurus_subtabel_0007 (+RouteOfAdministration)approachSiteCode: SET<CE> CWE [0..*] <= ActSitedoseQuantity*: IVL<PQ> [0..1]rateQuantity: IVL<PQ> [0..1]maxDoseQuantity: SET<RTO<QTY,QTY>> [0..*]

MedicationDispenseEventclassCode*: <= SPLYmoodCode*: <= EVNid*: II [1..1]code: CV CNE [0..1] <= ActPharmacySupplyType-FS-MStext*: ED [0..1]statusCode*: CS CNE [1..1] <= completedeffectiveTime*: IVL<TS> [1..1]repeatNumber*: IVL<INT> [0..1] "0"quantity*: PQ [1..1]expectedUseTime*: IVL<TS> [0..1]

1..1 prescription *typeCode*: <= DIRdirectTargetOf

1..1 distributedMedicationKind *

DispensedMedicationclassCode*: <= DST

0..* medicationAdministrationRequest *typeCode*: <= TPAtherapeuticAgentOf

0..1 diagnosisEvent

typeCode*: <= RSONreason

PatientCareProvisionclassCode*: <= PCPRmoodCode*: <= EVNid*: II [1..1]

0..* patientCareProvision

typeCode*: <= REFRreference

1..1 dispensedMedication *typeCode*: <= PRDsubstitutionConditionCode: CV CNE [0..1] <= SubstitutionCondition

product

DiagnosisEventclassCode*: <= OBSmoodCode*: <= EVNid: II [0..1]code: CV CNE [0..1] <= PRELIMDX+FINALDXtext: ST [0..1]value*: CE [1..1]

ObservationEventCriterionclassCode*: <= OBSmoodCode*: <= EVN.CRTcode*: CV CNE [1..1] <= tabel_25_bbbbb_component

0..* observationEventCriterion *

typeCode*: <= PRCNpauseQuantity: PQ [0..1]

precondition

CMET: (MMAT) E_MedicationKind

[universal](COCT_MT720000NL)

Medication Dispense Event(PORX_924000NL)

Medication Dispense Event

0..1 serviceDeliveryLocation

typeCode*: <= DSTdestination

0..1ServiceDeliveryLocationclassCode*: <= SDLOCcode*: CV CNE [1..1] <= DADDRaddr*: AD [1..1]

OrganizationclassCode*: <= ORGdeterminerCode*: <= INSTANCEid*: II [1..1] (URA of AGB-Z nr.)name: ON [0..1]addr: AD [0..1]

1..1 assignedPerson *

typeCode*: <= PRFperformer

1..1 assignedCareProvider *

typeCode*: <= RESPresponsibleParty

1..1 representedOrganization *AssignedPersonclassCode*: <= ASSIGNEDid*: II [1..1] (UZI of AGB-Z nr.)

0..1 representedOrganizationAssignedCareProviderclassCode*: <= ASSIGNEDid*: II [1..1] (UZI of AGB-Z nr.)code*: CE CNE [1..1] <=PractitionerRoleNL (17.000, 17.060 of 01.015)

MedicationAdministrationInstructionclassCode*: <= INFRMmoodCode*: <= RQOcode*: CV CNE [1..1] <= tabel_25_component_bbbbb

0..* medicationStorageInstruction *

typeCode*: <= SPRTsupport1

MedicationStorageInstructionclassCode*: <= INFRMmoodCode*: <= RQOcode*: CV CNE [1..1] <= tabel_25_component_bbbbb

0..* medicationAdministrationInstruction

typeCode*: <= SPRTsupport2

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Secondary Care(hospitals)

Medical SpecialistsHospital

Pharmacy

Lab, Radiology,

etc.

Community

Pharmacies

Primary Care

General Practitioners

(‘home doctors’ in Dutch)Dentists etc.

Pharmacies in the Netherlands (3-layer model)

inpatient

Tertiary(long-term)

Care

Nursing homes, psychiatric clinics, etc.Local

Pharmacy

flow of prescriptions

flow of patients

The essence of medical data

• Data is generated at the point of care• Data can be maintained at point of care itself,

or in centralized repository (regional, national)• Data can be in ‘raw’ form (proprietary database),

or contained in clinical documents (CDA format)• Two (overlapping) reasons for data capture:

– Controlling: triggers/responses in a workflow(e.g. prescription validation dispense)

– Observing: capture the state of the real world(e.g. known conditions, actual med. usage)

21 apr 2023 11© Stichting HL7 Nederland

What’s the virtual EHR?

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Virtual EHR

= building block of overall virtual EHR (e.g. dispense of a certain medication)

• Regardless of:– Source of data – Format of data

• Dimensions of EHR:– Provider record

(e.g. GP, specialist)– Activity database

(e.g. pharmacy, lab)– Concern tracking

(still in development)

The Dutch “Guideline for Medication Transfer”

• Every care provider has to do whatever it takes to make information relevant to medication safety available to others, further down the chain

• Every care provider has to do whatever it takes to have information relevant to medication safety available at the point (and time) of care

• The guideline describes both:– Behaviour (business rules for care providers)– Information (what is needed for assessment)

• The word ‘transfer’ is misleading, because it suggests a pre-determined architecture

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Data set for assessment: the Medication Survey

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Mandatory data elements:

1. A Prescribed medication, including strength and dosage

B Dispensed medication (delivered to patient)

C Administered medication (by care provider)

D Actual medication usage, with time interval and optionally indication of early stop

2. Use of alcohol and other recreational drugs (nature and interval)

3. Reason for changing or stopping medication use, including initiator of the change

4. Initial prescriber and current prescriber

5. Pharmacists that dispensed the medication

6. Basic patient data: ID (BSN), name, date of birth, sex and address of patiënt

7. Derived or assessed contra-indications: conditions

8. Allergies/intolerances for medication and reported ‘adverse drug events’

Conditional data elements:

9. A set of relevant lab results (kidney/liver function, etc.)

10. Indication, for a number of relevant types of medication

Supporting the guideline

• Goal: every care provider has access to all relevant information at the point (and time) of care, especially at the time when medication therapy is assessed

• Requirement: every care provider assures that all relevant information that is generated at his/her point of care, becomes and remains available for others

• Instrument: the medication profile must always be up-to-date and accessible for every care provider (regardless of where the data is or what form it is in)

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The ‘building blocks’

• Medication data– Prescription

• Including therapy updates– Dispense

• Including OTC where relevant– Administration

• Including ‘Medication statements’

• Recreational drug use (captured as ‘statements’)

• Certain lab results (based on authorization scheme)

• Potential contra-indications– Including hypersensitivities

• ‘Detected & managed issues’

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What are the blind spots?

• Most of the data that is generated (and sent) as part of a workflow is acccessible (prescriptions, dispenses).– 15-year mandatory storage requirement for patient-related data– persistency is regardless of format (messages vs. documents)

• Usually captured, but rarely communicated:– Dosage changes in existing prescriptions– Stopped prescriptions (by another doctor)– Actual use (assessed by doctor or patient)

Basically most information that is not part of a workflow.

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Wider scope for ´prescriptions´

• Traditionally, a prescription was a ´request to dispense´• But some medication orders don’t need a dispense:

– Patient still has medication in stock– Dosage is lowered on prescription– Use of medication is being stopped

• New insight is that the last two are also prescriptions!

• Prescription update refers to prescription it updates/stops• But even when there is no (known) prescription,

“don’t use medication X anymore” is also a prescription!• Essence is to describe the ‘pharmaceutical therapy plan’,

while maintaining relationships (audit trail) where possible

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Medication statements?

• Actual use can be different than prescriptions and dispense records suggest (compliance).

• A ‘medication statement’ is simply a ‘statement’ by a patient or his/her representative about actual use of medication (e.g. admission intake).

• Examples:– “I did pick up prescribed medication X at

the pharmacy, but I never started using it.”– “I stopped after a week, because it made me dizzy.”– “I use medicine Y, which I bought while on vacation.”– “Last year I used a little blue pill for a while.”

• A medication statement is an ‘aggregated’ (sometimes vague) record of administration.

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Ways to implement the medication profile

• Relay profile– Assumption: one responsible care provider at each point in time.

• Central profile– One central document (or other record), usually in a repository.

• Virtual profile– No assumptions about the responsibility for care or transfer of

information. Data stays at the point of care and is managed there.

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RELAY PROFILE

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Outpatient visit

GP

vis

it

Discharge medication

Adm

ission

CENTRAL PROFILE

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Central repository

Outpatient visit

GP

vis

it

Discharge medication

Adm

ission

Query/edit profile Query/open profile

Query/ed

it profile

Query/edit profile

VIRTUAL PROFILE

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Care information broker (ZIM)

Outpatient visit

GP

vis

it

Discharge medication

Adm

issuon

Query profile Query profile

Query profile

Query profile

Combining building blocks

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Prescription

Dispense

Use / administration

X

Medication ‘transfer’based on virtual profile

• Uses a very universal and flexible mechanism.• No dependence on strictly defined workflow • At the point of care, there is only a record of what is done

THERE (with references to activities elsewhere); there is no centrally managed document/database…

• Challenge: performance can be an issue.• Challenge: presentation to user needs to be effective.• Challenge: registration at the transfer between outpatient

and inpatient (and vice versa) is still a source of debate.• Challenge: persistence of identifiers is very important!

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