Stream: implementers
Topic: Immunization order
Jose Costa Teixeira (Apr 22 2020 at 06:58):
How can we link an immunization to an order e.g. from a physician ?
Craig Newman (Apr 22 2020 at 17:55):
Not seeing a way to do that now. I know we've discussed it in the past, but doesn't look like we ever added anything. Immunization is based on Event so we could look at adding .basedOn and suggesting that it be used to point to the MedicationRequest order resource. Would that work?
Jose Costa Teixeira (Apr 22 2020 at 18:05):
That would work, yes.
MedicationRequest or ImmunizationRecommendation?
Jose Costa Teixeira (Apr 22 2020 at 18:05):
(or both)?
Lloyd McKenzie (Apr 23 2020 at 00:08):
I expect the resource should allow both and perhaps CarePlan as well - 0..*. @Jose Costa Teixeira can you submit a change request?
Craig Newman (Apr 23 2020 at 13:02):
I agree that .basedOn could point to either MedicationRequest or ImmunizationRecommendation (and maybe CarePlan - I'd have to think about that a bit more). I would have sworn that we added text somewhere that MedicationRequest is the appropriate resource for the order (rather than ServiceRequest), but I don't think I see that anywhere now.
Arianne van de Wetering (Nov 30 2020 at 16:41):
Craig Newman said:
I agree that .basedOn could point to either MedicationRequest or ImmunizationRecommendation (and maybe CarePlan - I'd have to think about that a bit more). I would have sworn that we added text somewhere that MedicationRequest is the appropriate resource for the order (rather than ServiceRequest), but I don't think I see that anywhere now.
I do see that MedicationRequest.basedOn has a reference to ImmunizationRecommendation, maybe this was what you were looking for?
But when a physician wants to register a desired immunization for a patient I assume that should be registered as ImmunizationRecommendation? What is the purpose of the subsequent MedicationRequest? Only a logistic event to get the product dispensed?
Craig Newman (Nov 30 2020 at 16:47):
The ImmunizationRecommendation is just clinical decision support for the provider. It may come from the local IIS (think the v2 history and forecast query) or from the EHR itself. If the provider decides to follow the recommendation, I could see the MedicationRequest being created if there the workflow needs it to schedule or execute the immunization (maybe vaccine needs to be dispensed, maybe the "task" needs to get on someone's to-do list, etc). I suspect the MedicationRequest could also potentially be the authorization to vaccine (as opposed to the ImmunizationRecommendation's suggestion to vaccinate).
Arianne van de Wetering (Nov 30 2020 at 16:54):
@Craig Newman Aaah I see. That makes a bit more sense now. Thanks. However, it raises a new question in my head. If we use MedicationRequest for the actual physician's intention to go ahead and do stuff (i.e. perform an Immunizatin), why not use MedicationAdministration to register it has been done?
In other words: what has been the rationale for the separate resource Immunization?
Craig Newman (Nov 30 2020 at 17:00):
That decision (Immunization versus a profile of MedicationAdministration) was before my time, but I believe it had was decided that an immunization was distinct enough to warrant a separate resource. I'm not sure exactly why that was decided (we might make a different decision today if we were starting from scratch). It might have to do with the fact that an immunization is typically more simple than other types of medication administrations (it's typically a set quantity via a set route administered in a set body site at a more regimented point in someone's lifetime).
Arianne van de Wetering (Nov 30 2020 at 17:08):
I agree it is quite distinct from other medicationAdministrations, but more in a conceptual way. You need immunization overview reports for other use cases (in real life) than medication overview reports and typically don't want them mixed.
Also (at least in The Netherlands) the logistical processes are quite distinct. Pharmacy's are not typically involved for dispense of immunization products. Furthermore: a lot of immunizations are administered via specific institutions typically not involved in "normal" medication processes (well maybe there is an exception to this rule: malaria profylaxe prescriptions).
Lin Zhang (Dec 01 2020 at 00:09):
And it is also related to travelling across borders.
Jose Costa Teixeira (Dec 01 2020 at 20:04):
I don't see a strong functional difference
Jose Costa Teixeira (Dec 01 2020 at 20:06):
The fact that immunizations are many times administered per protocol (and do not have an order) is overlapping - some medications don't have an order, and some vaccines have a prescription.
Jean Duteau (Dec 01 2020 at 20:08):
the main reason that the two WGs agreed on a separate resource was that the existing systems captured them differently. A lot of it is exactly what Arianne said. We have had standing meetings between PH and Rx to ensure that the two resources were functionally compatible.
Jose Costa Teixeira (Dec 01 2020 at 20:09):
For immunization, we usually care about " did this person follow the protocol yet" more than "is this order fulfilled". But the concepts are not so different
Jose Costa Teixeira (Dec 01 2020 at 20:12):
@Arianne van de Wetering is your analysis based on the current ZIBs (dutch model)?
Jose Costa Teixeira (Dec 01 2020 at 20:15):
- ordering vs recommendation - IIRC ImmunizationRecommendation predates medicationOrder.intent (which, can be proposal/plan) - and I think there is overlap there
Jose Costa Teixeira (Dec 01 2020 at 20:17):
- MedAdministration vs Immunization - I understand the needs are different (medication is taken vs person has fulfilled one more step towards immunization). We should at least make sure that we have guidance for the gaps and overlaps.
Jose Costa Teixeira (Dec 01 2020 at 20:21):
Arianne van de Wetering said:
I do see that MedicationRequest.basedOn has a reference to ImmunizationRecommendation, maybe this was what you were looking for?
No, we want the Immunization event to point to the order taht caused it. The way it is is fine for this case.
But when a physician wants to register a desired immunization for a patient I assume that should be registered as ImmunizationRecommendation? What is the purpose of the subsequent MedicationRequest? Only a logistic event to get the product dispensed?
The physician does not enter a ImmunizationRecommendation (that is what I am learning, and I'm glad with this)
The MedRequest is a formal request. I think the Dutch model would consider it a logistics - it allows dispense, reimbursement, etc. It is the doctor's signed paper that this patient can have a vaccine.
Jose Costa Teixeira (Dec 01 2020 at 20:22):
There is a difference between "this person should be vaccinated" and "give this person a vaccine" - currently I think there are at least 7.8 billion cases of that difference... :)
Michele Mottini (Dec 01 2020 at 21:45):
(Our system uses the same underlying concept for both Immunization and MedicationAdministration so we had to split it to implement the FHIR resources)
Jose Costa Teixeira (Dec 01 2020 at 21:51):
I think that we could trim Immunization , leaving Immunization only for the immunization-specific things - those that do not overlap with medicationadministration
Lloyd McKenzie (Dec 01 2020 at 23:00):
There was in depth discussion with implementers about whether they wanted to use MedicationAdministration to capture immunizations and the strong response was "no" - systems treat them separately. Different databases, different user interfaces, different reports, different decision support logic, often completely separate modules. So while we could combine them on the basis of reasonable degree of functionality, the implementer community doesn't want us to.
Arianne van de Wetering (Dec 02 2020 at 06:59):
Jose Costa Teixeira said:
Arianne van de Wetering is your analysis based on the current ZIBs (dutch model)?
Amongst others. Looking at different current implementations and (real life) processes.
Arianne van de Wetering (Dec 02 2020 at 07:09):
It would help us to have a reference to Medication from Immunization(Recommendation) as - I believe - @Jose Costa Teixeira has argued before.
Jose Costa Teixeira (Dec 02 2020 at 07:22):
Yes. Vaccines are medicines. The role of Immunization seems be "get the important information about the person's vaccination event" - which is fair but it could well refer to other resources. For example, in FHIR, the lot number of a product is always in the "product" except in Immunization, where it is in the event. This has an impact on traceability.
Arianne van de Wetering (Dec 02 2020 at 07:38):
Jose Costa Teixeira said:
Yes. Vaccines are medicines. The role of Immunization seems be "get the important information about the person's vaccination event" - which is fair but it could well refer to other resources. For example, in FHIR, the lot number of a product is always in the "product" except in Immunization, where it is in the event. This has an impact on traceability.
Exactly!
Craig Newman (Dec 02 2020 at 13:44):
Do we want to have a joint Public Health and Pharmacy session at the January WGM to further discuss this, particularly linkages between Immunization and Medication? We've discussed this just within Public Health, but expanding to Pharmacy might be helpful. I know WGM isn't for a while, but it might be the best place to get the right people together to talk.
Melva Peters (Dec 02 2020 at 13:46):
@Craig Newman we can schedule a joint session. Pharmacy is meeting Monday to Thursday Q1-4 during the WGM.
Craig Newman (Dec 02 2020 at 13:51):
Public Health is meeting Monday through Friday Q1 and Q2 with a sprinkling of Q3 sessions as well. An early session might work better for the European folks interested. @Jose Costa Teixeira , @Arianne van de Wetering does this idea seem useful to you?
Nathan Bunker (Dec 02 2020 at 20:53):
I would agree with a conversation about the link between medication and immunizations at the HL7 WGM in January. I think there is a good case to be made that they remain separate concepts. You can reduce immunizations to simply another medication, but they have an odd status in how systems manage them and how they are recorded on a person's record. They tend to be couched in their own location and remain an important part of the patients record even years later, as it establishes their status in immunity to critical diseases. But it may be good to talk about what links can be made. In my own projects I'm wondering if it would be helpful to be able to link an immunization to a medication resource and then be able to represent that immunization resource as both an immunization and a medication so that it can be linked to other concepts.
Floyd Eisenberg (Dec 23 2020 at 15:39):
@Nathan Bunker Do we have a specific session in the January WGM to discuss immunization issues for such issues as the linkages you suggest? Perhaps a session with Pharmacy Committee and with Public Health (together or individually)?
Craig Newman (Dec 23 2020 at 21:36):
Our usual Immunization roundtable session (hosted by PHWG) is on the agenda for the WGM but a specific quarter hasn't been set yet. If there is a day and quarter that works best for you let us know and we can do our best to get it scheduled at that time. At the moment we don't have an official joint session with Pharmacy, but we can certainly let them know if there are topics they might be interested in.
Nathan Bunker (Dec 28 2020 at 14:26):
Agree with Craig that the roundtable would be a good place to bring this up and discuss, at least at the level of figuring out where this should go for future discussions. The roundtable is good for bringing up general questions and reporting on progress while trying to avoid going down into too much detail to find the final technical solution. This is an area I'm hoping we'll have more time in the new year to work on.
Jose Costa Teixeira (Dec 28 2020 at 15:58):
Nathan Bunker said:
In my own projects I'm wondering if it would be helpful to be able to link an immunization to a medication resource and then be able to represent that immunization resource as both an immunization and a medication so that it can be linked to other concepts.
you mean represent the Immunization concept as both Immunization resource and a MedicationAdministration resource?
Melva Peters (Jan 06 2021 at 14:27):
@Craig Newman do you have a quarter in mind for this discussion during the WGM?
Craig Newman (Jan 06 2021 at 15:57):
not yet. Would Thursday Q1 work for everyone? Alternatively, we could look at Thursday Q2 or Friday Q1.
@Melva Peters @Jose Costa Teixeira @Nathan Bunker @Floyd Eisenberg
Melva Peters (Jan 06 2021 at 16:06):
@Craig Newman Thursday Q1 or Q2 works - Pharmacy has a conflict for Friday Q1
Jose Costa Teixeira (Jan 06 2021 at 16:12):
Thursday Q1 is impossible due to OO / BRR discussion
Q2 is also difficult due to FHII-I.
Jose Costa Teixeira (Jan 06 2021 at 16:12):
are there any other slots?
Nathan Bunker (Jan 06 2021 at 16:52):
All the times Craig gives I can make work.
Craig Newman (Jan 06 2021 at 18:34):
Those are the only slots Public Health still has open where we were planning on holding a session. We hadn't planned on holding sessions on Monday or Friday Q3 or any day during Q4. We could add a session, but that starts to get pretty late in the day for Europe.
Jose Costa Teixeira (Jan 06 2021 at 18:41):
I appreciate not having to join a session in Q4 PT
Melva Peters (Jan 06 2021 at 18:41):
Pharmacy isn't meeting on Friday.
Jose Costa Teixeira (Jan 06 2021 at 18:42):
is Monday an option?
Floyd Eisenberg (Jan 06 2021 at 19:47):
Thursday Q1 would be optimal for me, Q2 is ok, Friday Q1 is not ok. Monday Q1 or Q4 works but I share Jose's concern about Q4 Pacific Time.
Floyd Eisenberg (Jan 06 2021 at 19:48):
Oh - Friday Q 2 or Q3 can work for me as well
Craig Newman (Jan 07 2021 at 13:35):
PH has Monday Q2 open but I don't think that @Nathan Bunker can make that time.
Melva Peters (Jan 07 2021 at 13:56):
Pharmacy has a conflict Monday Q2 so can't join.
Craig Newman (Jan 07 2021 at 17:16):
@Melva Peters what slots does Pharmacy have open. If Pharmacy can host the discussion, we might be able to split Public Health and get the right people there. I'm definitely not available Tuesday Q2 or Wednesday Q1
Melva Peters (Jan 07 2021 at 17:18):
@Craig Newman Pharmacy has availability Monday Q4, Tuesday Q3 or Q4, Wednesday Q2, Q3, Q4 or Thursday Q1, Q2, Q3 or Q4. We can host.
Melva Peters (Jan 12 2021 at 13:39):
@Craig Newman Has Public Health discussed which quarter works for a joint session?
Craig Newman (Jan 12 2021 at 15:13):
I didn't think there was a session that worked for everyone. @Melva Peters @Floyd Eisenberg @Nathan Bunker @Jose Costa Teixeira would Friday Q2 work for you?
Jose Costa Teixeira (Jan 12 2021 at 15:14):
What time is Q2?
Nathan Bunker (Jan 12 2021 at 15:15):
11 am PT, I think that's 8pm your time?
Nathan Bunker (Jan 12 2021 at 15:15):
This time works for me.
Jose Costa Teixeira (Jan 12 2021 at 15:43):
I think Friday Q2 works
Melva Peters (Jan 12 2021 at 15:47):
Pharmacy isn't meeting on Friday and I have a conflict at that time.
Craig Newman (Jan 12 2021 at 19:57):
Public Health can probably host
Melva Peters (Jan 12 2021 at 23:16):
Friday Q2 isn't possible for Pharmacy
Craig Newman (Jan 13 2021 at 16:34):
It's sounding like WGM may not be possible. Do we want to add this to the agenda for a PH or Pharmacy WG call instead? The late Thursday afternoon timeslot for the weekly PH WG call, may not be ideal for Jose.
Melva Peters (Jan 13 2021 at 20:10):
Pharmacy meets on Monday's at 4pm Eastern. Maybe that would work?
Craig Newman (Jan 20 2021 at 20:13):
It's been a while, but we finally wound up scheduling Friday Q2 of the Public Health WG program to be an immunizations session. If folks are available, we can discuss the topic of immunization orders and then bring any updates to Pharmacy on one of their weekly calls.
Melva Peters (Jan 20 2021 at 21:44):
Craig, I'll see if Pharmacy can send a rep to Friday Q2.
Jose Costa Teixeira (Jan 21 2021 at 17:37):
Question: Patient has taken vaccine for Disease D. Patient has taken Product X.
For Product X, it is known that the patient should take a next dose of the same product in 21 days.
What is that"should take Product X in 21 days"? ImmunizationRecommendation or MedicationRequest?
Jose Costa Teixeira (Jan 21 2021 at 17:37):
I'm thinking MedicationRequest
Melva Peters (Jan 21 2021 at 17:43):
@Craig Newman John Hatem will attend Friday Q2 if you can email him the information. Thanks
Jose Costa Teixeira (Jan 21 2021 at 17:52):
Jose Costa Teixeira said:
Question: Patient has taken vaccine for Disease D. Patient has taken Product X.
For Product X, it is known that the patient should take a next dose of the same product in 21 days.
What is that"should take Product X in 21 days"? ImmunizationRecommendation or MedicationRequest?
@Craig Newman ?
Craig Newman (Jan 21 2021 at 22:40):
I would say it depends on who is saying it and with what authority. If it's clinical decision support, then it would be ImmunizationRecommendation. But if it's a provider placing a future order to fulfilled in 21 days, then I'd say it's a MedicationRequest
Jose Costa Teixeira (Jan 21 2021 at 23:18):
It's the nurse, telling the patient they have to come back, because the product manufacturer says so
Jose Costa Teixeira (Jan 22 2021 at 09:01):
(and I don't think it depends on who is saying it - a decision support system or a person may provide the same type of information)
Craig Newman (Jan 22 2021 at 13:25):
If it's the nurse telling the patient something, is that a Communication?
Lloyd McKenzie (Jan 22 2021 at 14:19):
If you just want a record of "this information was disclosed", yes. If you're wanting to trigger action that you can then track execution against, then you need an Appointment or ServiceRequest or Task or something.
Jose Costa Teixeira (Jan 22 2021 at 18:23):
it's a record of "this patient needs to have another dose in 21 days".
Jose Costa Teixeira (Jan 22 2021 at 18:23):
sounds like MedicationRequest
Craig Newman (Jan 22 2021 at 18:42):
Is there any expectation that the patient will return to that same provider for the second dose? Is it basically a future order?
Melva Peters (Jan 22 2021 at 20:52):
it may have an intent or proposal and not order depending on who is recording the MedicationRequest
Jose Costa Teixeira (Apr 14 2021 at 00:19):
@Christof Gessner I think the above is saying that "The patient should take the second dose in 21 days" is done by a MedicationRequest, not a ImmunizationRecommendation. Do you agree?
Jose Costa Teixeira (Apr 14 2021 at 00:23):
and @Giorgio Cangioli
Christof Gessner (Apr 14 2021 at 00:54):
If I remember correctly, both are mapped to the workflow request pattern.
Jose Costa Teixeira (Apr 14 2021 at 06:14):
yes that is correct, but doesn't solve the issue. CarePlan is also a request but I hope we can agree it's not the request to use for due vaccination. MedicationRequest is IMO more appropriate (not that my opinion is a strong argument, but if there is ambiguity, should this be fixed?
Giorgio Cangioli (Apr 14 2021 at 08:32):
Hi @Jose Costa Teixeira I'd agree with you if I should represent the "The patient should take the second dose in 21 days" as atomic request to administer a medicinal product (in that case a vaccine).
But if I think that request as part of a vaccination protocol and linked to other vaccinations I'd prefer to have it represented into an ImmunizationRecommendation.
Jose Costa Teixeira (Apr 14 2021 at 08:35):
(that is why i mentioned the careplan - if the immunization protocol is a plandefinition, the patient's plan is a careplan.)
Giorgio Cangioli (Apr 14 2021 at 08:37):
To be more clear I'd map the element "next dose date" present in several data sets (WHO SVC; EU DGC; ISO TS 5384) into the ImmunizationRecommendation and not in the MedicationRequest
Jose Costa Teixeira (Apr 14 2021 at 08:43):
My concern is only of an overlap from a FHIR perspective. I think the ImmnunizationRecommendation resource does not have a large base for applicability.
Giorgio Cangioli (Apr 14 2021 at 08:44):
Jose Costa Teixeira said:
(that is why i mentioned the careplan - if the immunization protocol is a plandefinition, the patient's plan is a careplan.)
I believe this is a separate discussion :-)
I read this as should we rid off of some Immunization specialized resources and reuse instead other generic ones ?
.. but IMO this is not for R4...
Jose Costa Teixeira (Apr 14 2021 at 09:38):
Right. If there is confirmed overlap in R4, we can choose either MedRequest or ImmunizationRecommendation. And we can review for future versions if we need that overlap
Jose Costa Teixeira (Apr 14 2021 at 09:40):
For R4, my personal choice would be to use MedRequest as is stated above, but I don't know the reasons you may have to keep immunizationrecommendation.
Lloyd McKenzie (Apr 16 2021 at 17:06):
Not sure why CarePlan wouldn't be viable. Not saying it's the only option, but I don't think it would be wrong if what you're trying to say is a 'should' rather than a 'must'.
Jose Costa Teixeira (Apr 18 2021 at 12:17):
I understand CarePlan, in this context, as a "vaccination plan". So it could be used (given the overlap of medicationrequest and careplan when saying "this is planned". For one specific expected immunization, I'd still use MedRequest.
If we have 3 overlapping resources, we have to at least provide guidance; And I don't know if ImmunizationRecommendation has a strong base for existence TBH
Peter Jordan (Apr 18 2021 at 20:49):
@David Hay - any thoughts on this in the light of your recent blog posts on FHIR Enabling an Immunization Register?
Craig Newman (May 18 2021 at 15:36):
On Tuesday Q4 of next week's WGM, Pharmacy will be hosting Public Health to further discuss immunization orders and other related topics. Everyone is welcome to join.
@Jose Costa Teixeira @Giorgio Cangioli @Christof Gessner @Peter Jordan @David Hay
Giorgio Cangioli (May 18 2021 at 15:38):
Hi @Craig Newman this is good because we have some questions from the IPS track (@Rob Hausam ) we'd like to discuss with the team.
Rob Hausam (May 18 2021 at 15:41):
Yes, we definitely want to discuss this.
Jose Costa Teixeira (Nov 10 2021 at 09:37):
Are there any updates? I think that having a link to a protocol (which is formally defined elsewhere) is a common need. I can see only 2 non-working options:
- We use the protocolApplied - but there is no reference there to a PlanDefinition or any other resource that we could use. We'd need an extension
- We could have an element like "instantiates" but this is not there. and there is no standard extension we can use
Craig Newman (Nov 10 2021 at 13:41):
There is a PH WG Friday vaccination call every other week at 11AM Eastern (not great for all of the European crowd, sorry about that) that we can use for discussion if necessary. We are meeting this week (11/12). Let me know if you'll be attending and I can put it on the agenda.
Brendan Keeler (Dec 14 2021 at 15:47):
So if immunization orders become MedicationRequest, what's the right way to distinguish immunization MedicationRequests from regular medication order MedicationRequests?
Lloyd McKenzie (Dec 14 2021 at 16:18):
MedicationRequest.category
Brendan Keeler (Dec 14 2021 at 19:21):
Typically is used for inpatient / outpatient / etc, no?
Lloyd McKenzie (Dec 14 2021 at 21:08):
It can be used for a variety of things. If you need to distinguish and can't just figure it out by looking at the medication, that's where I'd stick it.
Jose Costa Teixeira (Dec 14 2021 at 21:22):
Agree. Vaccination is not that different from other prophylactic use of medication. Request.category can be used for many things but this is actually a good use of category
Eric Prud'hommeaux (Dec 14 2021 at 21:23):
and the max cardinality of MedicationRequest.categoryis * , so you don't have to sacrifice your original use
Brendan Keeler (Dec 16 2021 at 07:09):
I missed that cardinality was multiple response. Nice
Last updated: Apr 12 2022 at 19:14 UTC
