Stream: implementers
Topic: MedicationRequest, route and additionalInstruction
Arianne van de Wetering (Jul 02 2018 at 14:20):
MedicationRequest: why are route and additionalInstruction part of the 0..* dosageInstruction
A MedicationRequest has 1..1 medication and may have 0..* dosageInstructions.
route (oral, intramuscular) is defined as part of the dosageInstruction (0..1). That means each MedicationRequest may have 0..* routes (i.e. one for each dosageInstruction).
A route, however, seems to be more connected to the medication than anything else, in the vast majority of use cases?
In the details of dosageInstruction I read:
There are examples where a medication request may include the option of an oral dose or an Intravenous or Intramuscular dose. For example, "Ondansetron 8mg orally or IV twice a day as needed for nausea" or "Compazine® (prochlorperazine) 5-10mg PO or 25mg PR bid prn nausea or vomiting". In these cases, two medication requests would be created that could be grouped together.
In the medication datamodel in the Netherlands we have defined route as an element having a 0..1 cardinality in the MedicationRequest (i.e. outside of the dosageInstruction, which indeed needs a 0..* cardinality).
A similar argument is valid for the concept 'additionalInstruction' ('take with meals', 'take with water', et cetera). In FHIR MedicationRequest it is defined per dosageInstruction, where the Dutch datamodel defines it outside of dosageInstruction. The cardinality should still be 0..*, but should not need to be repeated (as exactly the same?) in each dosageInstruction. What is the use case where the additionalInstruction would differ depending on a dosageInstruction?
Lloyd McKenzie (Jul 02 2018 at 14:38):
It'd be uncommon, but you could have a mix of routes in sequential instructions. E.g. IV push to start, then IV bolus.
Lloyd McKenzie (Jul 02 2018 at 14:39):
The same would hold of "with meals". You could have something like "take 2 immediately, then take one each morning"
Arianne van de Wetering (Jul 02 2018 at 14:43):
The same would hold of "with meals". You could have something like "take 2 immediately, then take one each morning"
That is an example of timing differences, I am not disputing that.
It is a lot more uncommon to first have to take with water and then something completely diffent (with milk?) given that you are using the same medication. Some medication needs to be taken with food to protect your stomach, and that will always be true for a certain medicationRequest, right?
Arianne van de Wetering (Jul 02 2018 at 14:45):
It'd be uncommon, but you could have a mix of routes in sequential instructions. E.g. IV push to start, then IV bolus.
Since it is (very) uncommon, does it justify the fact that in 99% of the other cases, you need to repeat identical route information in all dosage instructions? Would it not be better to treat the edge use case, as an edge and in that case create separate MedicationRequests, as is also done should you need more then one route per dosageInstruction?
Lloyd McKenzie (Jul 02 2018 at 14:46):
That I'll punt to the work group :) @Melva Peters @John Hatem ?
Melva Peters (Jul 03 2018 at 03:28):
I would suggest that you add a Gforge tracker item and Pharmacy will have a look at it.
Arianne van de Wetering (Jul 03 2018 at 08:03):
Andrew Gledhill (Jul 05 2018 at 11:41):
Sorry to keep attaching 'updated' spreadsheets but this is a very complex issue and we all need to be moving in the same direction. I have analysed the medication order/request structure of 4,500 secondary care medication order sentences and am attempting to clarify the timing/frequency description for the most common medication requests. I have also tried to map these 'free text' frequency descriptions to the new FHIR timing tables. Excel spreadsheet attached.
HL7-Medication-Request-Dose-Timing-Frequencies-with-table-structure-20180704.xlsx
Varvara (Oct 18 2019 at 20:40):
Hi everyone, I also have a question about MedicationRequest.intent - it's not very clear which 'intent' should I use for pharmacy dispense prescription? Is it Order/ Fiiler-Order/ Original-Order?
Jose Costa Teixeira (Oct 18 2019 at 21:11):
Now that you mention it:
the binding for the intent is required and we have business-like concepts like reflex-order, original-order (I do not understand what these mean)..
Is this clear for everyone else?
Jose Costa Teixeira (Oct 18 2019 at 21:12):
thinkgs like instance-order and plan are qualifiers that are independent of any workflow. These new "intents" are puzzling
Jose Costa Teixeira (Oct 18 2019 at 21:16):
The answer to @Varvara 's question was simple: "order". Now I am not sure.
Either the intent values should be clear and universal, or the binding could perhaps be made flexible?
Varvara (Oct 18 2019 at 21:26):
@Jose Costa Teixeira thank you for the fast reply! I just have a feeling that maybe I could use this 'intent' for example, if original-order means the first dispense and filler-order means refill - this could be useful, but from the descriptions provided for intent codes I am so not sure if it's actually as I see it
Varvara (Oct 18 2019 at 21:27):
some use cases examples for each intent.code would be very helpful
Jose Costa Teixeira (Oct 18 2019 at 21:28):
filler order does not (imo should definitely not) mean refill. It would mean "the pharmacy has acknowledged the order and created an internal order for this to be processed - processed may mean dispense, or may mean validate, or...)
Jose Costa Teixeira (Oct 18 2019 at 21:30):
you say you want to differentiate the order that is used for "pharmacy dispense prescription",
what do you want to differentiate it from ? Can you give an example of an order that is not a "pharmacy dispense prescription"?
Varvara (Oct 18 2019 at 21:35):
As far as I see there are two prescriptions: the original one written by practitioner and fulfilled pharmacy dispense prescription (I am working with adjudicated pharmacy claims, so everything happened already), so I was searching for the correct intent.code for the latter
Jose Costa Teixeira (Oct 18 2019 at 21:39):
fulfilled pharmacy dispense prescription? You mean after dispensing?
Jose Costa Teixeira (Oct 18 2019 at 21:40):
if so, that would be a dispense, right?
Varvara (Oct 18 2019 at 21:41):
yes, sure
Varvara (Oct 18 2019 at 21:49):
but in pharmacy claims pharmacies also supply prescription info, for example they supply 'Date prescription was written as submitted by pharmacy ' or 'Estimated number of days the prescription will last as submitted by the pharmacy' so I have to map both prescription info and dispense info
Lloyd McKenzie (Oct 19 2019 at 11:20):
If the pharmacy created the original authorization (because the prescription was created by a pharmacist), then it would be 'original'. If it's the pharmacy's encoding of an order created by a physician or other clinician, then it would be 'filler'.
John Silva (Oct 19 2019 at 11:24):
@Lloyd McKenzie @Jose Costa Teixeira How does this align (or not) with the V2 concepts of Placer, Filler, Informer and Tracker? Maybe these are for workflow states not 'people involved' but anyone coming from V2 Pharmacy interfacing would be familiar with the V2 concepts and would want to know how (or if) they map to FHIR concepts/properties.
Lloyd McKenzie (Oct 19 2019 at 11:26):
original order = placer order. Filler order = filler order. Informer and tracker don't create orders, so they aren't reflected in intent.
Bill Lush (Apr 09 2020 at 15:03):
Sorry I can't help, but I would be like a better description of "original-order"; "reflex-order"; "filler-order"; "instance-order" as the description against is not clear. Could we have some examples to demonstrate how they should be used?
Melva Peters (Apr 09 2020 at 15:16):
@Bill Lush can you please add a FHIR change request in for this? Thanks
Lloyd McKenzie (Apr 09 2020 at 15:26):
We'd welcome suggestions for improving the language. Original-order is the one the authorization stems from. In the medication world, this is typically the "prescription". reflex-order is uncommon in pharmacy. It would be a medication (or possibly a lab test) automatically ordered by pharmacy on the basis of a prescription for another drug. (e.g. perhaps automatically putting something on an anti-nausea med by protocol when another med is ordered). Filler order would be the pharmacy-encoded version of the order - which typically picks a more specific medication, further refines administration instructions, etc. Instance-order would be the MAR entries created with a separate order for every single scheduled dose.
Last updated: Apr 12 2022 at 19:14 UTC
