Stream: Medication
Topic: batched inpatient medication dispense
Olivier Boux (Dec 07 2021 at 16:04):
I am interested in inpatient medication dispense.
How to express a dispensation which would be the accumulation of individual dispensations corresponding for example to such a drug for the patients of such a ward unit for the next 2 days?
I would expect to have a MedicationDispense resource that refers to the K individual MedicationDispense (K being the number of patients present in the ward unit). I can't find the MedicationDispense element that would carry the reference to K individual MedicationDispense.
Lloyd McKenzie (Dec 07 2021 at 16:08):
@Melva Peters @Jean Duteau
Jose Costa Teixeira (Dec 07 2021 at 17:25):
If you are dispensing drugs for many patients, that is not a Dispense, that is a SupplyDelivery
Olivier Boux (Dec 07 2021 at 18:01):
A SupplyDelivery cannot reference some authorizingPrescription and yet, this is the case. Shall I build a SupplyRequest from those MedicationRequest and dispensing rules to address this thread? Which is not possible either.
It is mentionned in 12.21.2 Boundaries and Relationships
- The SupplyRequest resource is used for inventory management. When requesting medication, substances and devices when there is a patient focus or instructions regarding their use, DeviceRequest or MedicationRequest should be used instead.
That's the reason why I'm investigating dispense instead of supply in the use case 'medication dispense with global delivery'
Lloyd McKenzie (Dec 07 2021 at 20:50):
If you've got a prescription for many patients, then handle that as a prescription for a Group, and you could have a single dispense for the group.
Jose Costa Teixeira (Dec 08 2021 at 21:05):
I don't agree with using a Dispense with a Group, because this is not the dispense. This is an activity prior to dispense
Jose Costa Teixeira (Dec 08 2021 at 21:07):
Ward stock preparations can be for
a) "patients A, B, C" or
b) "whoever is in ward B tomorrow" .
Jose Costa Teixeira (Dec 08 2021 at 21:07):
Concretely: If you prepare 45 tablets for 15 patients, this is not a dispense
Jose Costa Teixeira (Dec 08 2021 at 21:08):
The dispense is when the ward nurse takes 2 tablets and assigns it to Patient 1.
Jose Costa Teixeira (Dec 08 2021 at 21:12):
This definition of Dispense was provided by a colleague and is used in IHE and ISO 19293. Of course @Olivier Boux you can follow this definition or not but I wouldn't want to end up with two separate flows - one for "nominal dispenses", and one for "global distribution". I know it's what you have in SIPh, but not having a standard workflow complicates matters (traceability, inventory) quite a bit.
Olivier Boux (Feb 16 2022 at 17:31):
Thank you very much for ISO definition of Dispense. I missed it.
Jose Costa Teixeira said:
but not having a standard workflow complicates matters (traceability, inventory) quite a bit.
I agree with you. That's the reason why I'm looking at a FHIR solution to the french medication inpatient workflow.
Jose Costa Teixeira said:
Concretely: If you prepare 45 tablets for 15 patients, this is not a dispense
I agree too. But in order to prepare those 45 pills, I have to take care of those 15 patients and those 45 pills delivered-not-dispensed are indeed in relation to the 15 prescriptions.
So I do have
- a material flow of 45 tablets: what FHIR resource to track this material flow? and
- a stream of 15 pieces of information to tell what was actually delivered to meet those 15 requirements over a given period of time.
I don't care if I have a FHIR resource that wraps these two streams or two totally separate streams (but not really independent at the source level). This is the FHIR specifications. The French will deal with it.
Jose Costa Teixeira (Feb 16 2022 at 19:28):
Ravi de se retrouver, @Olivier Boux :)
ISO definition of Dispense
Courtesy of Ann Slee in 2010 :)
- a material flow of 45 tablets: what FHIR resource to track this material flow?
- a stream of 15 pieces of information to tell what was actually delivered to meet those 15 requirements over a given period of time.
We have SupplyRequest and SupplyDelivery. As you'll see, SupplyDelivery tracks the expected flow and/or delivery. With the appearance of the Transport resource, we may resolve any ambiguity.
Jose Costa Teixeira (Feb 16 2022 at 19:29):
One thing missing (until r5) was the notion of Consumption. We can handle that now with InventoryReport (with countType=differential)
Jose Costa Teixeira (Feb 16 2022 at 19:32):
I don't care if I have a FHIR resource that wraps these two streams or two totally separate streams (but not really independent at the source level). This is the FHIR specifications. The French will deal with it.
Why not the French with / within IHE?
We are going through that as we speak. I've seen your specifications, and as expected, I'm getting inspired by that. We can make sure that IHE's handling of workflow is of use, create robust international guidance and handle the French-specific considerations on the French layer.
Olivier Boux (Feb 22 2022 at 19:00):
OK, let's use SupplyDelivery for our delivery of 45 tablets.
I can't reference the initial 15 MedicationDispense because basedOn is forced to reference a SupplyRequest resource. I would like to reference all 15 MedicationDispense.
Assuming this is done, this is a split delivery. I need to reference the time period covered by this delivery occurrence. I guess I will use the element occurence[x]:occurencePeriod.
This seems like a good idea.
It just lacks the notions of whenPrepared and whenHandedOver.
Lloyd McKenzie (Feb 22 2022 at 20:47):
If you're conveying drugs that are specific to a patient, you need to use MedicationDispense, not SupplyDelivery. For meds, SupplyDelivery is only for managing transport of drugs that aren't patient-specific. E.g. replenishing ward stock.
Jose Costa Teixeira (Feb 23 2022 at 05:53):
the case is for a batch of medication for 15 patients
Jose Costa Teixeira (Feb 23 2022 at 05:55):
@Olivier Boux we could
a) add whenPrepared and whenHandedOver,
b) add an event code above occurrence[x] so that we can say 1. what happened and 2. when did it happen
Jose Costa Teixeira (Feb 23 2022 at 05:56):
i'd like b) more because I don't know if there's a clear-cut definition of whenPrepared (for example).
Jose Costa Teixeira (Feb 23 2022 at 05:57):
"preparing" can be breaking tablets or preparing the batch. perhaps others
Lloyd McKenzie (Feb 23 2022 at 14:29):
Is the medication targeted to specific patients to satisfy an order, or is it being supplied to an organization who cares for 15 patients, some of whom might need the medication at some point. In the first case, I'd expect that to be a MedicationDispense for the group or a set of MedicationDispenses for the individuals.
Jose Costa Teixeira (Feb 23 2022 at 15:33):
it is to satisfy 15 orders: the system knows that there are 15 orders with that drug, so anticipates the stock, referring to the 15 orders.
Jose Costa Teixeira (Feb 23 2022 at 15:45):
Perhaps the assumption "if it has the patient name on it, it is a Dispense" should be further clarified.
I'm relying on the fact that Dispense is when a drug is assigned to a Patient. Before and after that there is maybe transport, supply, but no dispense.
(we could still use a MedicationDispense resource to track everything after the Dispense act, but that is another question)
Lloyd McKenzie (Feb 23 2022 at 15:46):
From pharmacy to ward is still a dispense if it's for a specific patient. Dispense isn't only "to the patient's hands". Feel free to submit a change request if the current language isn't clear enough.
Jose Costa Teixeira (Feb 23 2022 at 16:33):
yes, I think the point here is that this one bulk sending is for 15 patients
Jose Costa Teixeira (Feb 23 2022 at 16:33):
or better, it is because of 15 patients
Jose Costa Teixeira (Feb 23 2022 at 16:37):
to clarify the above, dispense is indeed not only to the patient's hands. Dispense is first point of assignment to a specific patient - e.g. packing multidose in named bags (even it later it will be transported and given to patient caregiver), picking from ward stock to patient (even if before it was transported but it was bulk), setting aside ingredients to make a patient's compound medication (even if the ingredients will not be delivered as is).
Lloyd McKenzie (Feb 23 2022 at 16:39):
I'll let the pharmacy folks argue more :)
Jose Costa Teixeira (Feb 23 2022 at 16:47):
Right, I was expressing the underlying definition to the point above. It's the only solid definition of Dispense I've seen. If definition of Dispense is changing needed, then there's no technical solution possible.
Jose Costa Teixeira (Feb 23 2022 at 16:52):
@pharmacy folks, please consider this for input:
from IHE where we've exhausted lots of workflows until a proper definition arrived, from ISO where this was an issue as well, the definition of Dispense may cause issues - depends if Pharmacy looks at workflows and supply matters. If so, please consider capturing this or another single definition of a "dispense"
Melva Peters (Feb 23 2022 at 23:00):
I'm not sure I understand the use case. If I go back to Oliver's first question it sounds like you want to group a bunch of dispenses for 15 patients together. Is that true? You are doing 15 individuals dispenses for 15 patients and sending them to the ward and then you want to group them together somehow?
Melva Peters (Feb 23 2022 at 23:00):
Before we start discussing changes or other options, I want to make sure the use case is clear
Jose Costa Teixeira (Feb 24 2022 at 07:35):
There would be 2 cases.
- We make individual dispenses for 15 patients fir 2 days, in 15, 30 or 90 sachets, and we want to send that bunch of sachets to the ward
- We know that those 15 patients require 45 medications, so we send 45 tablets in a box and we send the box
Jose Costa Teixeira (Feb 24 2022 at 07:36):
I think Olivier's use case is #1
Jose Costa Teixeira (Feb 24 2022 at 07:39):
as for the link to the prescription: in an implementation we were blocked by that until we realized that prescription is not the same as dispense request. A prescription says "drugs for 2 weeks", a dispense request says "dispense only for 2 days".
Jose Costa Teixeira (Feb 24 2022 at 07:40):
I don't know if FHIR wants to address that or if we'd need to use SupplyRequest to cover the gap.
Olivier Boux (Feb 24 2022 at 08:47):
Melva Peters said:
it sounds like you want to group a bunch of dispenses for 15 patients together. Is that true? You are doing 15 individuals dispenses for 15 patients and sending them to the ward and then you want to group them together somehow?
That's exactly it.
The 15 prescriptions do not have the same dosages. It is not a grouped prescription for 15 people (the same prescription x 15).
Melva Peters (Feb 25 2022 at 02:05):
What is the reason you need to group the dispenses. They would be individual MedicationDispenses done against individual MedicationRequests. Each dispense would be labelled for a specific patient, correct?
Last updated: Apr 12 2022 at 19:14 UTC
