2014-09-29 Rx Conf Call

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Attendees

• Scott Robertson (Chair)

Draft Agenda

Recap from Chicago

• Highlights
• Draft minutes are posted
• Room Requests
  • have requested Monday to Thursday
    • meeting jointly with PHER - Tuesday Q4 - PHER hosting; Reps from SDWG Wednesday Q3 in Pharmacy Room; Meeting with FHIR Team - Tuesday Q2.
  • Request from EHR WG for a super joint meeting
    • This is a “Super Group” meeting with about 10 WGs that have tie-ins with the EHR WG, many developing a Functional Profile at the moment. During this part week’s HL7 WGM in Chicago on Wed Q2 we had 9 workgroups with overlapping interests do a quick report on their activities in a 10-minute (or so) timeline.
  • Any others

Content in Ballot (John)

• Medication Order - there is no link
  • John sent in a request to HL7 re: the missing links in the Pharmacy materials about two weeks ago - have heard back that they will update the page. This work has not been completed as of Monday, August 25, 2014.
  • 9/8/2014 update John has not heard anything -

Action: John will resend the email.

ISO eRx Requirements

• John/Melva

File:EN ISO 17523 (E) DIS submission 20140604 jh MP.docx

• 9/8/2014 update: Cristoff suggested that we have time to consider the comments. Christof to present document face-to-face in Chicago.
• Update from WGM - reviewed with Christoff to incorporate comments and then come back with any additional comments/question he may have

List Serve Discussion

Brett Marquard - Frequencies - September 4, 2014

File:Medication Frequencies in CDA.pdf

• CDA example task force are reviewing frequency and asked Rx WG to consider it. John reviewed it. Group discussed during this call. Group agrees that we should discuss this in our SD/Rx joint meeting in Chicago.
• Met during WGM - is there any additional action for this or can it be closed

ICH - dosing information question - July 10, 2014

• ICH continues its work to implement the ISO/HL7 ICSR 27953 specification and we need to revisit the appropriate answer for the following item in order to remain consistent with pharmacy best practices for electronic order/prescription and dispensing records. In the case of 30mg t.i.d, which data entry is preferable A, B or is there another option (based upon existing specifications/best practices) that ICH should consider?
  • A:
    • Dose (number): 30
    • Dose (unit): mg
    • Number of Units in the Interval : 0.33
    • Definition of the Time Interval Unit: day
  • B:
    • Dose (number): 30
    • Dose (unit): mg
    • Number of Units in the Interval: 8
    • Definition of the Time Interval Unit: hours
• this has not been answered - need A or B seem to be correct - 3 times per day is not the same as every 8 hours

Action Completed:  Scott drafted a response for review on the August 11th teleconference. Question answered with no acknowledgement person asking the question.  
Action:  Post Scott's response to the "hot topics" on At the request of the Patient Administration work group, MnM has decided to rename the "Schedule" data type to "Timing".  As a result of this change, we need to change the name of a few elements in existing resources to avoid having names that are ugly.

FHIR DSTU Updates and Resources

Review List of DSTU updates

File:Proposed DSTU Changes.xlsx

• PHER/Pharmacy Harmonization Changes will be included with these changes

Action:  Jean will include these changes in DSTU changes - still oustanding waiting for list from Jon. (action item below)
Action:  John to provide list to Jean - still needed as of 9/8/2014

• There was an entry about a question regarding "Days of supply"

Action: Jean to updated comments with "Days of Supply" item

New FHIR requests

Schedule Datatype

• Note from Lloyd: At the request of the Patient Administration work group, MnM has decided to rename the "Schedule" data type to "Timing". As a result of this change, we need to change the name of a few elements in existing resources to avoid having names that are ugly.
  • Specifically, we want to rename:
    • MedicationPrescription.dosageInstruction.timing[x], CarePlan.activity.simple.timing[x] and MedicationDispense.dispense.dosage.timing[x] to ....scheduled[x]
    • That way you end up with scheduledDateTime, scheduledPeriod and scheduledTiming instead of timingDateTime, timingPeriod and timingTiming.
    • As well, for consistency, you may want to rename MedicationStatement.dosage.timing to ...dosage.schedule
    • The reason for this change is to allow the "Schedule" name to be used for the Availability resource.
    • [1]
    • Please let me know if you have any objections to this proposed change. If not, I'll coordinate with your committers to apply the change.
  • Note from John Hatem 18/9/2014: Schedule does not work. Pharmacy will discuss and find a replacement name

MAR

• Note from James McLay: I was trying to decipher how to maintain a Medication Administration Record (MAR) from the contents of the medicationadministration.status element of the Medication Administration Resource. The value set for the status is fixed and doesn't include a start time.
  • The start time is captured in the "whenGiven" component of the spec but the resource does not keep a log of events that could be passed to a MAR. This is specifically of interest for ongoing infusions where there is a start and stop time, rate changes, new bags being hung, pauses, etc. The MAR keeps a log of these events.
  • I'm assuming our Pharmacy experts know how to do this. Any thoughts?
  • Note from Graeme Grieve 19/9/2014: The FHIR interface would allow a server to store a log of an administration, and return that to the client, but it seems like a very hard to problem to infer what should be presented in the MAR from the audit trail of the edits to the resource.
  • Note from Tom 22/9/2014: Focusing on the use case mentioned, the changes made to an ongoing infusion, I think it is important to note that each Medication Administration resource would deal with only one 'segment' of that.
    • My fellow pharmacites can correct me if I'm wrong, but I think it would work like this:
      • When an infusion starts, an administration resource is created with the appropriate start time and status. In the simplest case, its status would be updated and end time set once the infusion is completed. When the infusion fluid or even just the rate of flow is changed, that would be considered a new administration. So the earlier resource would be updated just like before AND a new one would be created.
      • That leaves me with two questions we should discuss on a Pharmacy conference call.
      • Would the same apply if there was only a bag change, but the fluid and rate would stay the same?
        • I would say it depends on how the system generates its administration IDs. It would work either way.
        • How would consecutive resource instances, expressing parts of an ongoing infusion be tied together?
      • This may require an extra data element, but it should be easy to support with a resource reference.
    • My 2 cents. I propose to add this topic to the agenda for an upcoming conference call, since it clearly needs some guidelines and descriptions in the publication.
  • Note from Graeme Grieve 22/9/2014: I don't mind if this is the answer, but it's certainly not what people would expect from reading the specification?
  • Note from Lisa Nelson 22/9/2014: As this gets clarified, I think it would be good for us to establish an approach that could work for CDA in a very analogous way. Even if CDA offers some additional approach, the one that is best for the industry is the one that is the most identical across FHIR and CDA. Have you considered if putting the sequence of substance administrations could go in an organizer (FHIR list) so that the serial progression of the substanceAdministrations could be sequenced components in the organizer's structure? Keep Structured Docs posted as the modeling progresses. I'm sure we would love to add a tapered dose example that aligns to our samples.
  • Note from Tom 22/9/2014: I agree that the sequence of resource instances could well be grouped this way. Good point that this is analogous to a tapered dose, which we have also agreed to handle with an <organizer> structure. We’ll definitely include this in the discussions on the upcoming Pharmacy conference call.

Clinical Connectathon comments

• In addition to the question that is already being discussed about MARs, there were some other questions raised in the clinical connectathon.
  • Medication Form
    • At present, the only place where the medication form is found is at Medication.product.form [2]. At least, that's the only place that I know where it is. Does this mean that pharmacy WG expects that form is always pre-coordinated with the medication code? (Strictly, the answer is, no, I guess, but the fact that form code is only found down there certainly implies that). I think this question get's much more pertinent given the proposed change to allow a medication code to be referred to directly - is this only appropriate for codes that pre-coordinate the form?
  • MedicationPrescription.dosageInstruction.asNeeded[x] - one of the types for this is "CodeableConcept", Concerning this, the documentation says: "If a CodeableConcept is present, it indicates the pre-condition for taking the Medication." There's no example codes or further documentation for this that I can find. What possible uses does this have? Is it really that common, given that none of the clinical users new of a use for this beyond prn?
  • Scheduling medications - one of the use cases that came up during the clinical connectathon was to say "Take this medication 3 hours before surgery". I couldn't see how the existing resources allow this to be expressed. Should they? Should it just be dosage instructions text? or something more?
  • Note from Tom 22/9/2014: The specification describes the resource and its data structure, but does not explain how changes DURING an ongoing infusion should be handled, whether it is as separate resource instances or otherwise. Hence my point that we should update the description (and examples) with guidelines for this use case. I wouldn’t say my response is the answer, it’s just a proposal for one way of handling this consistently. Pharmacy co-chairs have already confirmed that this will be further discussed on an upcoming conference call.

Pharmacy Template Project

• Mood Code Discussion - will be included
• John and Melva to continue the work