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Web session

Attendees

NameOrganization
Melva PetersJenaker Consulting
Peter SergentHL7 New Zealand
Danielle FriendEpic
John Hatem
Scott RobertsonKaiser Permanente
Daniel ZhangEpic
Jean DuteauDuteau Design
Tim McNeilSurescripts
Brett Marquard

Agenda Items and Notes

Outstanding Action Item List

Updates from Montreal WGM

  • Reviewed hot topics
    • Active Medication List
    • Formulary IG
    • FHIR Trackers - closed a number of them

PDeX Formulary Implementation Guide Progress

  • Pharmacy has taken ownership of this IG
  • Daniel is worried that this may not be in alignment with NCPDP
  • Jean reported there are NCPDP representatives on the PDeX calls
  • Initial work doesn't impact NCPDP
    • current work - patient/provider to payer - what is the drug cost
    • not pharmacy to payer
  • Tim reported that there is work going on at NCPDP to do the same work
  • CAIRN Alliance - APi - patient focused
  • Using MedicationKnowledge in daVinci
  • NCPDP is being developing V2 format and an XML format - not really based on formulary standard
  • Guidance that has been given to daVinci - use MedicationKnowledge
  • Status:
    • List resource - for returning CoveragePlan
    • MedicationKnowledge - for formulary drug
      • raised a concern that US Core uses Medication
        • 2 options - base on Medication with extensions or based on Medication
        • Scope of the resources is different - so should use MedicationKnowledge
    • Jean will forward the link out for review and asked for feedback
  • Tim indicated there is a regulation that requires NCPDP
  • Hope that it will be iterative and we will get feedback
  • Will be balloted STU in the early ballot
  • Link to current IG: https://formulary-ig.herokuapp.com

V2.9 Chapter 4A Vote

Active Medication List

Objective

  • Document guidance on how to retrieve the active medication list.

History

  • In US-Meds IG (STU3), the active medication list was retrieved by querying MedicationStatement exclusively where status = active.
  • In STU3, MedicationStatement had two elements for taken (Boolean) and status.
    • Taken was used to represent the medication usage (in the past)
    • Status was used to infer whether the medication should be on the “active meds list” (i.e. whether the patient should be taking the medication going forward)
  • In R4, MedicationStatement added not-taken into the status value set (and removed the taken Boolean). 
  • In R4, MedicationRequest was enhanced to add a new reported[x] element that indicates whether the MedicationRequest was reported (insert definition).

The Problem

  • Using MedicationStatement exclusively in R4 doesn’t work since we lost the ability to use MedicationStatement.status to convey whether a not-taken medication is active or not.  Some not-taken medications are associated with active orders/prescriptions while other not-taken statements are associated with old orders/prescriptions that have since been completed or stopped. 
  • Using MedicationRequest exclusively in R4 doesn’t work since it is still not scoped to handle patient statements about their over-the-counter (OTC) medication usage that don’t have an underlying prescription or request.
  • Using both MedicationStatement and MedicationRequest introduces patient safety risk if an application made a false assumption that all active medications were returned from a single resource.
  • Furthermore, the boundaries between MedicationStatement and a reported MedicationRequest present a challenge for systems that don’t make that fine distinction.  For example, the following use cases are often handled in the same way:
    • Patient conveys to provider A that another provider B prescribed a given medication (this is debatable whether it is a MedicationStatement or a recorded MedicationRequest)
    • Patient conveys they took an OTC medication (this is a MedicationStatement – since the patient isn’t requesting a new prescription)
    • The system programmatically learns of an existing medication and makes a non-authoritative copy (this is a recorded MedicationRequest)
  • Most systems CAN differentiate between:
    • What the patient said about their medication usage (taken vs not taken)
    • Whether the provider wants to keep the recorded MedicationRequest or MedicationStatement on the active medication list
  • In summary, we have a bit of a catch 22 where:
    • We can’t use MedicationStatement exclusively (when status = not-taken), nor can we use MedicationStatement to convey status of what was ordered (when usage differs from what was ordered).
    • We can’t use MedicationRequest exclusively (when scope excludes patient statements about OTC medications)
    • Systems often don’t differentiate between reported MedicationRequests vs MedicationStatements, so the boundaries are challenging to honor.

R4 Next Steps

  • Base specification allows the active med list to use MedicationRequest or MedicationStatement
  • Argonaut / US-Core IGs proposal to use MedicationRequest exclusively

R5 Next Steps

  • Clarify boundaries between reported MedicationRequest and MedicationUsage (and confirm that systems can honor those proposed boundaries)
  • Review MedicationUsage.status value set to ensure that the codes are limited to medication usage and not conveying an order status.

Discussion

  • Should pull requirements together and include the context on the medication lists and their use
  • New Zealand - strongly view that MedicationStatement - patient's lists of medications drawn from multiple sources - national repositories, pharmacies, prescribing systems
  • need to consider how to get this done in light of updates to US Core
  • Discussion/Collaboration page - Medication List
  • Melva Peters - create Confluence to use to collaborate on the discussion

FHIR

Medication Knowledge Resource (#160095)

Gforge Trackers - Link to Gforge Tracker

Triaged Trackers

  • #22272 - Medication Form Codes
  • #22148 - MedicationDispense.performer.actor
  • #22146 - MedicationRequest.performer
  • #20673 MedAdmin category CodeableConcept
  • #19913 - Valueset for Dosage.method

    • This issue is related to the Zulip chat related to "infusions".  Once we have improved the value set to support "IV Push" and "IV Bolus", it should be possible to query for all medications who have a route of Intravenous, and exclude in the query those medications who have a method of IV Push or IV Bolus.
    • See Pharmacy List Topic where this same issue is discussed.   
  • #19365 - Definition for Medication List 

  • #15509 - Example Scenarios for Pharmacy
  • #15136 - Conditional Dosages
    • Reach out to CDS to see if they have done any work in this space
    • Melva Peters Create examples from Oncology, NCPDP and GF19694

Waiting for Input

  • #20184 - binding for site in Dosage
  • #17222  this tracker is about the assessment of whether Medication Request resource could support anesthesia gas orders.  We did receive a document from Anesthesia and will follow up with them about their use cases.  

    • John Hatem will follow up with anesthesia regarding pharmacy feedback and to assess next steps

Catalogue Project

  • No report

Updates from Workflow

  • Workflow asked Pharmacy WG to discuss the use of eventHx on MedAdmin and MedDispense.  Do we need it, and if we do, then...
    • Suggest we also talk to PA about their use of a similar concept, that they modeled differently -  see Encounter.  Is it possible to harmonize? 
  • There is no Event pattern for representing eventHx, but they are exploring this.
  • Will review and discuss on an upcoming call

Pharmacy Templates

  • waiting for Kai to produce updated version
  • Have confirmed with Lynn that we can publish a consolidated version - will be published as Release 1 - includes order, statement, dispense and administration
  • Will bring publication request to next

Healthcare Product

  • Meeting held today - looking at structures
  • HealthCareProductDefinition - no plan to create a resource - it is a just a pattern
  • Substance, Specimen, BiologicDerivedProduct - will be looking at overlaps

CIMI 

  • no meeting this week - where do we go this agenda topic?

New Projects

  • Dennis Tribble's Project

Any Other Business

  • US Meds - Block Vote
    • Committers 
      • Floyd Eisenberg
      • Jenni Syed
      • Matthew Rahn
    • Line Items
      • 12551 Include examples for queries in Med dispense profile (Jenni Syed) Persuasive
      • 20644 Add  “real“ world work flows to PDMP Page (Matthew Rahn) Persuasive
      • 20645 Missing Clear Examples (Matthew Rahn) Persuasive
      • 20646 Improve the PDMP Security Guidance (Matthew Rahn) Persuasive
      • 20647 Consider the following updates to the PDMP Mappings (Matthew Rahn) Persuasive
      • 16300 Define  “deduplication“ of data more clearly (Floyd Eisenberg) Persuasive with Mod
    • Have started to apply Trackers
    • Motion:  Brett moved to approve the Block - seconded by Daniel - 8-0-0
    • Will need a subsequent publication request
    • No requests to pull anything from block vote
    • Some trackers marked "resolved-changed required" -  need to determine what to do
  • Brett and Melva will review and determine next steps for resolved-changed required
  • Melva Peters to reach out to Michelle to see if these changes are still relevant
  • Melva Peters to update tracker items

Next meeting

  • May 27, 2019 - 4pm Eastern