Stream: implementers
Topic: Dispense of several medications
Jose Costa Teixeira (Apr 19 2020 at 21:00):
How should we register the dispense of several products - with the explicit information that they were dispensed together?
In other words, how would we group MedicationDispenses?
Jose Costa Teixeira (Apr 19 2020 at 21:01):
I see partOf and I'd like to use that, but that is a reference to Procedure...
Jean Duteau (Apr 19 2020 at 21:01):
why do they need to be dispensed together? is there a groupId of some sort or is just a flag?
Jose Costa Teixeira (Apr 19 2020 at 21:01):
@Jean Duteau @Melva Peters could we consider adding something there?
Jean Duteau (Apr 19 2020 at 21:02):
i wouldn't. we haven't had that use case before now (and I'd want more details like I asked above). Just use an extension to add a groupID.
Jose Costa Teixeira (Apr 19 2020 at 21:02):
groupId - the administration instructions will apply to them both, the reimbursement rules as well, and they will be placed in the medication record together
Jean Duteau (Apr 19 2020 at 21:03):
well, all of those things occur today with multiple dispenses, but I've never seen any pharmacy treat the multiple dispenses as one
Jose Costa Teixeira (Apr 19 2020 at 21:07):
I'll challenge back the requirement, but to me it makes sense, the same as the prescription: items are ordered together and there is some responsibility in handling those as a group instead of separately.
Jean Duteau (Apr 19 2020 at 21:07):
sure, but it's certainly not in the 80% of implementations, so that is extension-space
Jose Costa Teixeira (Apr 19 2020 at 21:14):
I don't t doesn't seem part of the 80% but I personally haven't seen all the implementations.
Jose Costa Teixeira (Apr 19 2020 at 21:15):
I will check how this was done in v2
Jose Costa Teixeira (Apr 19 2020 at 21:18):
I'd be suprised if most systems did not support that a single dispense event contains several products.
The resources (rightfully) do not do that, but this seems tandard behaviour so perhaps a standard extension?
Jean Duteau (Apr 19 2020 at 21:57):
Jose Costa Teixeira said:
I'd be suprised if most systems did not support that a single dispense event contains several products.
The resources (rightfully) do not do that, but this seems tandard behaviour so perhaps a standard extension?
None of the Canadian pharmacy systems support that
Melva Peters (Apr 19 2020 at 22:10):
@Jose Costa Teixeira What is the specific use case? and do you have a specific implementation that is requesting this? I haven't heard of the use case up to now, but if you have an actual implementation that is asking for it, we could discuss. If it is just a nice to have, then I don't think we'd consider.
Jose Costa Teixeira (Apr 19 2020 at 22:22):
Thanks. This is for the national shared pharmaceutical dossier in Belgium.
Jose Costa Teixeira (Apr 19 2020 at 22:23):
I will challenge the requirement in the Belgium group
Jose Costa Teixeira (Apr 19 2020 at 22:23):
And depending on the feedback I will bring it up
Lloyd McKenzie (Apr 20 2020 at 01:46):
Typically when you're dealing with a "red pill in the morning, blue pill at night" sort of thing, the red and blue pills are dispensed in a single package and the dispense as at the combo-pack level. I've never heard of a combined administration instruction that involved multiple drugs that weren't dispensed in a combo pack
Jose Costa Teixeira (Apr 20 2020 at 09:50):
"take med blue pill 30 minutes after red pill". Red and blue are different dispenses
Jose Costa Teixeira (Apr 20 2020 at 09:54):
But I just checked - we are currently grouping on the transaction. So it's a technical grouping, not a functional one.
and TBH I see that we can functionally group dispenses per Procedure, but not by other events... whereas for prescriptions we do have a functional grouping
Jose Costa Teixeira (Apr 20 2020 at 09:56):
so @Melva Peters in my project scope this is currently not even a "Nice to have". I think it is a consistency aspect but I don't know how to handle that.
Melva Peters (Apr 20 2020 at 13:33):
Hi Jose, that sounds a condition on dosing - I'm not sure how grouping of the dispenses helps to solve the use case since it is the patient that needs to know this. We have an extension for conditional dosing, but I'm not sure it solves this use case at this point, but probably should. Why don't you add a JIRA issue with your use case?
Jean Duteau (Apr 20 2020 at 15:19):
Jose Costa Teixeira said:
"take med blue pill 30 minutes after red pill". Red and blue are different dispenses
This requirement isn't specific to dispenses. This is a dosage specification requirement so it applies anywhere that Dosage is used. We do have a Conditional Dosing extension and you can sort of do this with that extension:
<extension url="http://hl7.org/fhir/StructureDefinition/dosage-conditions">
<extension url="whenTrigger">
<extension url="offset">
<valueDuration value="30" unit="m"/>
</extension>
<extension url="trigger">
<valueReference>
<reference>
<display value="after the red bill is taken"/>
</reference>
</valueReference>
</extension>
</extension>
The only wrinkle is the representation of the MedAdmin, but I think using <display> is correct.
Jean Duteau (Apr 20 2020 at 15:34):
We probably want to update the extension (which is only draft at this point anyways) to have a choice of valueReference and valueString. Then this would be perfect for your requirement (which would probably needed on the Request as well).
Jean Duteau (Apr 20 2020 at 15:41):
J#26894 - is looking at the partOf element
J#26899 - is updating the dosage extension
Jose Costa Teixeira (Apr 20 2020 at 16:15):
+1 for #26894 b)
Jose Costa Teixeira (Apr 20 2020 at 16:16):
a) during a procedure (dental, surgery), products are dispensed and it is important to keep track of those
Jose Costa Teixeira (Apr 20 2020 at 16:19):
b) I think we can other events could be possible.
Jean Duteau (Apr 20 2020 at 16:19):
Jose Costa Teixeira said:
a) during a procedure (dental, surgery), products are dispensed and it is important to keep track of those
I question this - with our definition of dispense, I don't think that they are dispensed as part of the procedure. They might be dispensed due to an order that occurred as part of the procedure, but we already have a data element for that. Are we really saying that, while a procedure was occurring, the patient was dispensed medication? I don't think we are. If the dispense occurred in the same encounter as the procedure, then that is MedDispense.context. If it occurred later due to an order made during the procedure, than that is authorizationPrescription (and the MedRequest then points to the procedure or the encounter).
That's why I questioned the use of this attribute at all in MedDispense.
Jose Costa Teixeira (Apr 20 2020 at 16:20):
example: GP gives samples during an consult. Is that a thing we need to cover?
Jean Duteau (Apr 20 2020 at 16:21):
that's MedDispense.context or it might be the Procedure - in which case, we should provide that example in this attribute (like the JIRA ticket asks for)
Jose Costa Teixeira (Apr 20 2020 at 16:23):
Jean Duteau said:
Are we really saying that, while a procedure was occurring, the patient was dispensed medication? I don't think we are.
How else would you say that during this procedure (e.g. a surgery) the patient was given an injection or some anesthetic drug? Or is that not considered a dispense?
Melva Peters (Apr 20 2020 at 16:24):
How else would you say that during this procedure (e.g. a surgery) the patient was given an injection or some anesthetic drug? Or is that not considered a dispense?
@Jose Costa Teixeira that is a MedicationAdministration
Jean Duteau (Apr 20 2020 at 16:24):
Jose Costa Teixeira said:
Jean Duteau said:
Are we really saying that, while a procedure was occurring, the patient was dispensed medication? I don't think we are.
How else would you say that during this procedure the patient was given an injection or some anesthetic drug? Or is that not considered a dispense?
That's not a dispense - that's an Administration. A dispense is simply the supply of medication to a patient. I think your example of samples given during a consult is a more appropriate use of the Procedure link.
Jose Costa Teixeira (Apr 20 2020 at 16:26):
Drug being taken from the cart and made available to the patient during a surgery is a dispense and an administration.
Jose Costa Teixeira (Apr 20 2020 at 16:26):
You can take a full bottle of contrast and only administer 32 ml
Jose Costa Teixeira (Apr 20 2020 at 16:27):
The dispense will be used for inventory and billing purposes. The admin for clinical purposes
Jose Costa Teixeira (Apr 20 2020 at 16:27):
(I'm using the definition of Dispense in ISO and SKMT)
Jean Duteau (Apr 20 2020 at 16:28):
Jose Costa Teixeira said:
The dispense will be used for inventory and billing purposes. The admin for clinical purposes
My understanding of in-patient settings is that isn't a Dispense that would be recorded against the patient's record. It's more akin to "shop supplies" used when your car is being fixed. :)
Jose Costa Teixeira (Apr 20 2020 at 16:32):
We don't (and shouldn't) need know where it is being recorded (may be patient record, may be inventory, may be billing, may be traceability or falsified medicines check). The dispense data will likely be reused well beyond its primary purpose
Jose Costa Teixeira (Apr 20 2020 at 16:33):
taking the shopping analogy - it's the same as when we pick up a pastry from the shelf, or when we order it and someone puts it in a bag with our name. Both are dispenses.
Jose Costa Teixeira (Apr 20 2020 at 16:33):
(right?)
Jean Duteau (Apr 20 2020 at 16:43):
Jose Costa Teixeira said:
taking the shopping analogy - it's the same as when we pick up a pastry from the shelf, or when we order it and someone puts it in a bag with our name. Both are dispenses.
Again, I think in-patient settings are different. If you order an apple pie and the restaurant makes it from scratch, they don't record selling you "apples, flour, sugar, butter, etc.". Similarly, I'm not sure that in-patient apps record all of the materials used during a procedure as dispenses. I have limited exposure to in-patient pharmacy apps, but the in-patient care software didn't have those recorded as dispenses or supplies, only as administrations.
Lloyd McKenzie (Apr 20 2020 at 16:46):
I think the 'partOf' for the dispense would typically be the encounter associated with the procedure, not the procedure itself. And there's already an explicit element for the encounter
Jose Costa Teixeira (Apr 20 2020 at 16:49):
My initial perspective comes from in-patient settings, so the definition remains. They may not record the dispenses, but when they do, they are not administrations.
Jose Costa Teixeira (Apr 20 2020 at 16:50):
If they bake a cake for me, depends: Do they put my name in the flour bag? Then it's dispensed for me. If they just take it as they need, then they may or may not capture the dispense of 300 g of flour for me.
Jean Duteau (Apr 20 2020 at 16:50):
Jose Costa Teixeira said:
My initial perspective comes from in-patient settings, so the definition remains. They may not record the dispenses, but when they do, they are not administrations.
But your definition isn't the one we are using for the FHIR resource. You can't use ISO or SKMT's definition if it is different than our current scope. We would need to know from in-patient pharmacy application vendors if they actually do record those dispenses against the patient record or not.
Jean Duteau (Apr 20 2020 at 16:51):
So far, we've been having a theoretical discussion about this. My JIRA ticket was raised to go get actual implementer experience to see if the partOf attribute would be needed at all.
Jose Costa Teixeira (Apr 20 2020 at 16:51):
I would advise to take that definition of dispense. That one is clear and immutable across context and data purpose
Jose Costa Teixeira (Apr 20 2020 at 16:54):
And this is implementer feedback from a group of hospitals (where we started with people having a fuzzy definition of Dispense and then inventory does not match). This precise definition of Dispense was given by a pharmacist colleague in the UK, and it is the only one I've seen that is solid.
Jean Duteau (Apr 20 2020 at 16:54):
If you can get the vendor to step forward and show us how they record dispenses in the in-patient setting, that would be great!
Jose Costa Teixeira (Apr 20 2020 at 16:55):
??
Jean Duteau (Apr 20 2020 at 16:56):
Jose Costa Teixeira said:
??
You said that you had implementer feedback on how they record dispenses, so it would be great to have them demonstrate that to us so we can get a better understanding of in-patient setting dispenses.
Jose Costa Teixeira (Apr 20 2020 at 17:05):
This implementation was done several years ago. The results have been brought to IHE and ISO, but if HL7 prefers to keep its definition for medication dispense, that is fine.
Jean Duteau (Apr 20 2020 at 17:07):
Sorry, I'm not talking about the definition. I'm talking about how the system this group of hospitals you mentioned records dispenses against a patient's record in in-patient settings. We would definitely love to get more feedback from in-patient pharmacy systems.
Jose Costa Teixeira (Apr 20 2020 at 17:07):
My point is that a dispense is not an administration. They are different things. Maybe only 0,00020% of the hospitals support it, so I don't say FHIR must adopt that definition. For those that do, I'm sure they will find a way.
Jose Costa Teixeira (Apr 20 2020 at 17:08):
it's not against a patient record. It is in the pharmacy dispense sheet
Jose Costa Teixeira (Apr 20 2020 at 17:09):
if you need to cut tablets in half to give to a patient, you will consume 2 tablets, dispense 3, and perhaps administer 1.
Jose Costa Teixeira (Apr 20 2020 at 17:10):
if the FHIR dispense is only intended for patient records, that sounds like a strong limitation.
Jean Duteau (Apr 20 2020 at 17:10):
Jose Costa Teixeira said:
My point is that a dispense is not an administration. They are different things. Maybe only 0,00020% of the hospitals support it, so I don't say FHIR must adopt that definition. For those that do, I'm sure they will find a way.
No one is arguing that a dispense is an administration. Maybe you're missing my (and Melva's) point.
Use case: During a surgical procedure, a medication is administered to the patient (for anasthesia or contrast or some other reason).
Result:
a) A MedicationAdministration may be (should be?) recorded against the patient's record.
b) A Medication Dispense may be recorded against the patient's record.
We have evidence from our existing implementers that (a) occurs. We don't have evidence that (b) occurs. If we can get evidence of (b), that would really help us understand the in-patient setting better.
Jean Duteau (Apr 20 2020 at 17:12):
Jose Costa Teixeira said:
if the FHIR dispense is only intended for patient records, that sounds like a strong limitation.
Um, that "limitation" has been there from the beginning.
Description: Indicates that a medication product is to be or has been dispensed for a named person/patient.
Scope: This resource covers the supply of medications to a patient.
It's the same "limitation as the MedRequest, Administration, and Usage.
Jose Costa Teixeira (Apr 20 2020 at 17:15):
i don't read "for patient's record" there. Perhaps I was leading to confusion:
When I say "not in the patient's record" I don't mean a dispense is not for a patient. By its very definition, the dispense IS for a patient. I mean it goes into the billing records or supply records. It has the patient name, but it is not for clinical record purposes.
Jose Costa Teixeira (Apr 20 2020 at 17:15):
(named? does that exclude anonymized, pseudonimized patients?)
Trond André Aag (Apr 20 2020 at 21:31):
Jose Costa Teixeira said:
i don't read "for patient's record" there. Perhaps I was leading to confusion:
When I say "not in the patient's record" I don't mean a dispense is not for a patient. By its very definition, the dispense IS for a patient. I mean it goes into the billing records or supply records. It has the patient name, but it is not for clinical record purposes.
In Norway’s largest Health care region we have worked on an implementation of MedicationDispense that I suspect could have some similarity to your implementation @Jose Costa Teixeira. The purpose of the implementation is both Inventory update/Stock management and ordering from hospital pharmacy. We also aim to support dispense through Automatic dispensing machine using the same API. We have had initial discussion with Touchpoint for a POC based on the MedicationDispense.
All dispense are dose oriented, updating the dose status in the EMR. To complicate it even further we have a system that support ordering by generic medication (substance) where the product is selected either by nurse in a medicine room or at the pharmacy. The dispense for each dose is documented in the EMR, either as part of the nurse dispensing process or by pharmacy dispense (updating from the Pharamcy ERP). We have used the 2019 version of IPS Medication definition that have slice’s based on IDMP to support all variants of medication definitions.
Ordering from pharmacy would include standard medication and patient specific medication (typically cancer medication, infusion and pain relieve medication). Defining the complex medications is extremely complex :), but achievable within the standard resource. Production/dispensing in hospital pharmacy would be automated or semi-automated in our Health region, depending on facility infrastructure.
We have strictly limit the MedicationDispense to the process of supply medication and updating inventory. The process in the use case you mention where you administrating medication from a procedure tray, needs to be split in differnt processes. For a procedure tray, the medications are dispensed (by our definition) when the tray is ready/released for delivery at the pharmacy or is prepared in the medicine room. Administrating from a procedure tray is a separate process. There is no problem to include the procedure resourse in the dispense if you need to assosiate the dispense with a procedure. We evaluated a few use cases, but concluded to put it out of scoop.
Jose Costa Teixeira (Apr 21 2020 at 10:27):
That is very good input, @Trond André Aag
Thank you
Last updated: Apr 12 2022 at 19:14 UTC
