Medication Documentation IHE Pharmacy / HL7 Pharmacy Editor: Jürgen Brandstätter.

Medication Documentation

IHE Pharmacy / HL7 PharmacyEditor: Jürgen Brandstätter

Medication Lists and Profiles

Raw data collected of various data sources

Prescription Dispense Administration Medication Statement

Med

icati

on P

rofil

eAllergies, Contraindications and other medication-related

clinical information for medication management

Reconciled Medication List

Other non-clinical data related for Med. Management

Unreconciled Medication List

Reconciled Med. List

Aggregated/processed medication list Higher complexity level with some kind of pre-processing of the data

e.g. combining same medications, etc.

Med

icatio

n list

s

Processes

MedicationReconciliation

MedicationReview

MedicationAggregation/processing

Collectionof various data sources

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Processes



MedicationReview

Med

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Allergies, Contraindications and other relevant clinical information for medication management


Medication Management



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MedicationAggregation

Med

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Processed Rec medication list

Processed Unrec medication list


PRE

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PRE PR

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PRE

DIS

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DIS

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Med

Stat

ADM

ADM

Med

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Med

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Unreconciled Medication listPR

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PRE

PRE

PRE

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Time

Med

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Med

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Med

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ADM

ADM

May Jun Jul

PRE

DIS

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PRE PR

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DIS

DIS

Med

Stat

ADM

ADM

Med

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Med

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Act of reconciliation(e.g. at Hospital Admission)

Query for Unreconciled Medication List

Time

Reconciled Medication List(at this point of time) Unreconciled

Medication List(at this point of time)

May serve as data source

Pre 1 Dis 1 Pre 2 RecMedList

Dis 2 Pre 3

Pre 1Dis 1Pre 2

Pre 1Dis 1Pre 2

RecMedList

Dis 2Pre 3

For dedicated use(e.g. during Hospital stay)

Pati

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Pharmacy Domain

Vienna Meeting

• Date: 12 February 2014

• Medication management– Related concepts– Processes involved– Expected process outcomes

Stephen ChuSlide 1

• Collection– The action or process of collecting someone or something (Oxford English

Dictionary)– To gather or keep objects of interest together (Macmillian Dictionary)– Note – “collection” does not imply/require compiling

• Compiling– Produce (e.g. a list or a book) by assembling data/information from other

sources

Slide 2

• Annotation– The addition of note, coded note, comments, explanation to something

(Merriam-Webster Dictionary; Oxford English Dictionary)

• Normalization– The imposition of standards or regulation– To bring something into usual or expected state or condition (Merriam-

Webster Dictionary)– The process of reorganizing data in a database so that it meets two basic

requirements: (1) There is no redundancy of data (all data is stored in only one place), and (2) data dependencies are logical (all related data items are stored together)

Slide 3

…..

compilation

Med 1 (2013-07-26)

Med 2 (2013-08-01)

Med 3 (2013-10-03)

Med 1 (2013-11-16)

Med 4(2014-01-06)

Med 2 (2013-08-01)

Med 4 (2014-02-12)

Unreconciled Med List

Med 1 (2013-07-26)Med 1 (2013-11-16)+ Active Ingredients

Med 2 (2013-08-01)+ Active Ingredients


Med 4(2014-01-06)+ Active Ingredients


Normalised, annotated Med List

Normalization+

AnnotationSlide 4

• Synchronization– to represent or arrange (events or items) to indicate coincidence or

coexistence (Merriam-Webster Dictionary)– Process of precisely matching or coordinating two or more items,

devices, activities, or processes (Business Dictionary)

• Reconciliation– The act of causing two things, ideas, people or groups free from

disagreement (Merriam-Webster Dictionary)– The action of making two or more views, matters, items compatible with

others (Oxford English Dictionary)– The act of analysing two or more things, business accounts/records to

identify discrepancies, find the causes and to make them consistent, aligned (Business Dictionary)Slide 5

• Medication Reconciliation– Medication reconciliation is a formal process of obtaining and verifying

a complete and accurate list of each patient’s current medicines. Matching the medicines the patient should be prescribed to those they are actually prescribed. Where there are discrepancies, these are discussed with the prescriber and reasons for changes to therapy are documented. When care is transferred (e.g. between wards, hospitals or home), a current and accurate list of medicines, including reasons for change is provided to the person taking over the patient’s care. Points of transition that require special attention are*1

Slide 6

Med 1 (2013-06-15)1000mg, oralMed 1 (2014-01-10)500mg, oral

Med 2 (2013-07-11)25mg, oral

Med 3 (2013-10-09)10mg, sublingual

Med 4 (2013-11-03)10iu, SC

Med 4 (2014-02-12)5iu, SC

Med 1 (2013-06-15)1000mg, oral

Med 2 (2013-07-11)250mg, IV

Med 3 (2013-10-09)10mg, sublingual

Med 2 (2013-07-11)25mg, oral

Med 4 (2013-11-03)10iu, SC

Med 1 (2014-01-10)500mg, oral

Med 4 (2014-02-12)5iu, SC

Unreconciled Med List Reconciled Med List

Med 1 (2013-06-15)1000mg, oralMed 1 (2014-01-10)500mg, oral+ Active Ingredient

Med 2 (2013-07-11)25mg, oral+ Active Ingredient

Med 3 (2013-10-09)10mg, sublingual+ Active Ingredient

Med 4 (2013-11-03)10iu, SC

Med 4 (2014-02-12)5iu, SC+ Active Ingredient

Reconciled, annotatedMed List

error

Reconciliation AnnotationSlide 7

• Aggregation– The act or process of forming a whole by combining several things

together (Oxford English Dictionary)– In OO design, aggregation is a “containment” relationship which

specifies that an object contains other objects– The combination of related categories to form a common branch of

hierarchy, to provide information at a broader level (OECD statistical collation processing)

– Aggregation denotes the compounding of data into an aggregate (Oxford Dictionary of Statistical Terms)

– Aggregation is a process of gathering, collating, summarizing data into formats that achieve specific business objectives, e.g. to support data mining and analysis (data mining, business intelligence definition)

Com

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Slide 8




Med

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rofil

eAllergies, Contraindications and other medication-related

clinical information for medication management


Other non-clinical data related for Med. Management


Processes


MedicationReviewNormalizationCollection

of various data sources

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Normalised, Annotated Medication List

Reconciled, Annotated Medication List

Reco

ncili

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n +

Anno

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Nor

mal

izatio

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Anno

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Annotation

Medication Documentation IHE Pharmacy / HL7 Pharmacy Editor: Jürgen Brandstätter.

Documents

Transcript of Medication Documentation IHE Pharmacy / HL7 Pharmacy Editor: Jürgen Brandstätter.