Designing the Clinical Data Model for Medication list

Clinical
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CONTEXT:
We use the openEHR-INSTRUCTION.medication_order.v3 that is packed inside the COMPOSITION.request.v1. The design came up during coaching sessions as well as how the current EHR handles such orders. After having written my assignment for IREB Requirements Modeling I concluded, that there might be better approaches how to handle the inpatient’s medication orders during a “normal” hospitalization.

Consequently, I am planning to remodel the whole thing to fulfill the following requirements summarized and heavily simplified in the following class diagram:

openEHR discourse Class Diagram Medication order design
openEHR discourse Class Diagram Medication order design1021×601 15.7 KB

3 QUESTIONS:

  1. Do you store medication orders redundantly in openEHR such that the same instance is listed in the medication list, the medication order request (use case description as in FHIR), in the prescription and so forth?
  2. Or do you manage any medication instruction (order, requests, prescriptions and so forth) in one composition, namely in COMPOSITION.medication_list.v1 (which I will do)?
  3. May a patient have several medication lists in openEHR?
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My approach woukd be to use a prescription composition for each order and realted action and display a list of ‘current medications’ dynamically via AQL. Ie there is no need for a medication list composition as such.

Imo the medication list composition only needs to be used when a ststic list of current medications need to be maintained in a system that does not support active prescribing.

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Thanks, Ian, for hinting me to this possibility.

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In the London Care planning UCP app, we do anticipate having multiple Medication lists but these are all contextual and ‘not primary records of prescribing’ e.g a Medicaiton ist as part of a Sickle cell disease treatment plan. You might also need separate Medicaiton lists to manage meds reconciliation or a pharmacy review.

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Hello Lucas,

It is quite common to forget that openEHR is not just a bucket where we just throw and retrieve data. It defines an EHR architecture, and every component has its reason to exist.

A COMPOSITION carries with it a lot of context information that is important to preserve: the clinical session dates and location, the participants, the author of the information… By storing multiple ENTRYs (originated in different events) inside a single COMPOSITION you will lose all that contextual information. That’s why the recommendation is to use a different COMPOSITION for each medication order to keep their own context, and use the lists just to summarize the current situation of the patient.

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Nice explanation but i dont think it is strictly necessary to store a copy of the medication orders in a separate medication list composition if the list of current medication can be generated by querying the original precription compositions.

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@damoca

There exist requirements I have to fulfill and therefore provided the UML class diagram as reference, which is analogous to the dossier pharmaceutique (external link) in France.

Ian provided a good design choice by relying on AQL, such that I may compartmentalize the defined use cases between prescriptions and medication orders. For medication orders you can use several compositions depending on the context, and my context is depicted in the class diagram.

Consequently, I would like to ask, how would you, David, design such a setting in openEHR in the solution domain, having the class diagram as reference from the problem domain?

As far as I understood your answer, you would store medication orders redundantly by keeping copies wherever the context changes, which would answer my first question - I have numbered my questions now.

@ian.mcnicoll

The idea is, that a patient has a central repository with all the current active medication treatments. This repository shall be available to all clinics, such that once the patient is admitted or changes department, the responsible team may curate a new medication list that is a separate instance of the repository.

Additionally, a medication plan shall be generated from such a curated medication list, as a medication plan is simply a medication list projected to the future. In other words, a medication plan considers all active medication treatments from now on until the future.

The class diagram simply presents the central repository. The endgoal is, that a patient possesses 1 medication list as central repository, to which 1 to many curated medication lists are linked. The last part is not depicted in the class diagram.

So far, I know, that openEHR does not solve governance, which relies on how to throw and retrieve data in a meaningful way.

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I’m a bit surprised by the suggestions above. But maybe the difference is due to different clinical practice .
What I’m used to, is the doctor prescribes medication, (as instruction) in an event composition. And may have a medication summary that will not be kept current, eg during intake, also as an event composition.
And the pharmacist keeps a continuously updated medication list that’s a persistent composition. Probably containing instructions.
But the semantics are different. The doctors is instructing the pharmacist to deliver the medication. The pharmacist is in turn instructing the patient / nurse (how) to use the medication.
Off course as always in healthcare, these semantics get mixed up due to emergencies, or hidden due to efficient digital systems etc.
But I do get a bit scared by the suggestion to get a list of active meds by aql, while I feel this should be curated by a pharmacist.

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This is absolutely true - not just clinical pracrtice but the way that the broader healthcare system operates/legislation etc.

@Lucas - we are probably not understanding the bigger picture. It might help, if you clarify…

  1. Obviously your prescribing solution is based on openEHR.
  2. Are the other ‘clinics’ running on openEHR?
  3. If so are they runnig on te same CDR?
  4. If they are not running on the same CDR or even openEHR , is the idea, that the ‘Medication list’ is a common repo of meds orders, to which each ‘clinic’ refers as their master copy before reconciling into their own system?

If (4) is the case, I might be inclined to just store copies of the orignal orders and related actions (or generate those from non-openEHR feeds. I think, roughly speaking, this is how the Danish Shared Medication Record works.

So not a Medication list, as such, more an aggregated extract of medication order prescriptions and supply events e.g dispensing or administration , from which 'current or recent medication can be queried.

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Hi @Lucas, can you define the classes in your diagram? For instance it’s not clear what’s the difference between prescription and medication order. That’s important to be able to understand why you mentioned having a copy of the order in many places.

It’s also important to define what the medication list is, and in which context it will be used. For instance, there could be a medication list associated with the current hospitalization episode, or a medication list managed by one specific doctor in a long in a long term treatment, which could be related with inpatient’s too, or just the list of current medications a patient is taking, for instance for chronic diseases that should be administered also while hospitalized. So even just in the context of an inpatient, there could be different medication lists used for different things.

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The class diagram applies to inpatients in a healthcare organization, which have our EHR on premise. Switzerland consists of 26 autonomous healthcare systems. Each healthcare system may have several healthcare organizations. We serve healthcare organizations with an EHR and plan to transition our database to openEHR, such that each healthcare organization will have their own openEHR instance in the foreseeable future. Our goal is to model relevant data in openEHR and if possible not to rely on solutions outside openEHR if possible (such as non-openEHR feeds).

Definitions:

  1. Patient
  • The inpatient who is under care. In Swiss hospitals, a patient has a unique identifier within the hospital system, and all medical orders, prescriptions, and treatments are associated with this patient. The Medication List and other medical instructions are managed in relation to the patient.
  1. Medication List
  • A summary of all medications ordered and administered to the patient during hospitalization, and prescription for discharge. In the Swiss context, this list represents the central repository to include active/inactive/expired medication orders, medication administrations without a sanctioning order and prescriptions which can be tracked using online services. It serves as a core reference for both clinicians and pharmacists and is analogous to dossier pharmaceutique (external link) .
  1. Prescription
  • A formal request by a physician to provide medication to the patient. In Swiss healthcare, prescriptions are provided to the patient. A prescription is managed by the patient and is currently a document with plans to transition to messages. A pharmacist might receive such a prescription by the patient but physicians are also allowed to distribute medications.
  1. Physician
  • The clinician responsible for the care of the patient. In the context of the medication list, the physician orders, approves, and adjusts medication as part of the patient’s treatment plan. Physicians are key decision-makers in prescribing and modifying medication orders and consequently managing the medication list. Pharamcists usually intervene, if the medication is not available or there is an explicit request by the physician for assessment.
  1. Medication Order
  • An official instruction to administer medication to a patient to be carried out by the nurses. This order can also be initiated by the nurses, as several hospitals allow nurses to order medications. In order to keep the labels unique, I decided to label the relationship “initiates” to distinguish between “orders” by physicians. The nurses manage a stock of medications at the respective ward. If medications are missing, the pharmacists are informed to provide new stock or solutions to the problem. But pharmacists do a lot more than that, but are expliclitly excluded from the class diagram, because they rarely order or administer medications in the healthcare organization - but since last year they are also allowed to order a subset of medications.
  1. Medication Administration
  • The process by which a nurse or other healthcare professional administers medication to the patient according to the Medication Order or in an emergency without a sanctioning medication order. In Swiss hospitals, this process is tracked to ensure accurate dosing and adherence to the an ordered schedule. This data is typically logged electronically.
  1. Nurse
  • A healthcare professional responsible for managing the medication administration of a sanctioning order as well as the medication stock at the ward. In the Swiss healthcare system, nurses document when and how medications are administered. They also monitor the patient for any adverse reactions and report back to the physician if adjustments to the medication regimen are needed. Nurses can also order medications depending on internal guidelines.
  1. Medication
  • The actual drugs or treatment substances given to the patient. These medications can be categorized as core (the main therapeutic agents) or carrier solutions (such as saline in intravenous treatments). Each medication entry is tied to a specific order or prescription within the Swiss system. The database for all available medications in the Switzerland is populated using a service by a private company.
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There are differences. Currently, a medication order archetype is modeled in a Request for service composition, as a “Medication order” as the order is directed from a physician to the nurses also representing healthcare professionals fulfilling a request.

The composition prescription will not be used for inpatients, except if they need a document representing the internationally known “prescription”/“Rx”/“Recipe”, only then is it applied also using the medication order archetype. Furthermore, openEHR is just suitable for a subset of jobs the pharmacists performs. They are often responsible for stock management in a healthcare organization, and better frameworks and solutions other than openEHR exist for this purpose.

The pharmacist is not mentioned in the class diagram, does not curate the medication list, and they do not manage the medication list.

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I am honestly surprised by most of your responses, especially as the class names represent concepts available in the clinical knowledge manager. The class diagram has been specified having these descriptions in mind. Semantics are not so different, but I have the impression, most don’t read the descriptions of the archetypes in the international clinical knowledge manager - and I can understand because it is not very exhilarating and time-consuming - or simply apply what they know, without going into the context of this thread.

The pharmacist is not in the class diagram because the management of the medication list is in the domain of the physician - different countries, different rules.

What I will do:
As I am responsible for the development of the data model and the creation of the implementation guides for the developers, I will simply model the class diagram that represents actual requirements onto openEHR. Thanks to Ian, I was able to elaborate a suitable solution that conforms to openEHR. Nevertheless, for “Medication list” I will use the composition “Medication list” - what a surprise -which, based on its description, shall encompass the “Medication order” archetype. Currently, I have modeled the “Medication order” archetypes in “Request for service” compositions, why the redundancy came up, as the same instance (populated Medication order archetype) will be in a “Medication list” anyway. Consequently, I will remodel it such that all "Medication order"s are simply in the “Medication list” composition and with some logic magic be available to the nurses for the management of medication administrations without resorting to the “Request for service” archetype. This “Medication list” will act as a central repository similar to the dossier pharmaceutique in France - already mentioned in this thread. The management of this medication list will be performed in the logic layer, as openEHR does not support governance. That is why I asked my third question, for which I will create a generic model - also conforming to openEHR.

Currently, I have the same problem with Problem and diagnosis list, where almost all healthcare organizations expressed their wish to have a central repository of diagnoses for each patient. For this purpose, we will have a discussion in the upcoming weeks with several stakeholders on how to approach this issue in Switzerland. The main problem here is also governance.

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Very many thanks for this detailed information Lukas, It does make your situation and requirements much easier to understand. I’m taking a few days off so apologies for just a brief response for now.

I’m not surprised that you are surprised at the discussion (and what might seem to be some pushback ) . One of the most important things that I have learned in my openEHR journey, is just how much local clinical practice, national legislation and healthcare culture have an impact on the design of digital health systems. Many years ago Heather Leslie and I spent an entire morning in a Dutch coffee shop (no ,that kind of ‘coffee shop’!) about how do to 'do ’ medication authorisation. Only after a pretty difficult conversation did to become apparent that we were making assumptions based on how things work in the UK vs how they work in Australia.

The other factor is that there might be a significant difference between what is ideal vs. what is actually achievable locally, because of constraints of legacy systems or indeed legacy clinical thinking.

I’ll come back with some more practical suggestions ASAP.

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Thanks, Ian. I’m aware of the differences, as I’ve practiced in several countries, each with its own unique healthcare system. I assumed that, in an international community, the diversity of healthcare systems would be a given. However, navigating these differences does require a lot of patience on my part.

No rush—take your time. I also often find it challenging to respond to posts promptly.

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Hey there,
fellow swiss modeler here, following the discussion with great interest. I had the same confusion about the prescription composition after reading its intended use, since the role of the pharmacist in Switzerland and Germany usually is taken by a doctor or ideally a doctor from an Antibiotic Stewardship team.

The suggestion of using the request for service composition makes sense to me but again after daring to read the description and intended use it again seems to be unfitting because the interaction is between healthcare providers (organizations) not healthcare personnel (individuals).

I would be happy to hear more about those practical suggestions of yours, Ian :slight_smile:

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It depends on how you apply the term healthcare organization. The nursing staff may be treated as an organization, which receives the medication order. The organization decides then who performs the order, such that the organization aka nursing staff tasks a nurse to fulfill the order.

Many Swiss hospitals apply the term healthcare organizations at the level of the medical specialty such as surgery or internal medicine in order to artificially create a market where some economic rules might apply - but usually doesn’t. The idea is to create a dynamic such as encountered in the free market. A few also applied this term to different roles such as lab, physicians and nurses. But you will encounter this definition in the executive staff, if you dare to ask :wink:

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Hi,

The Prescription composition archetype is pretty old and has never been published, so I would not be guided too strongly by the exact wording. And indeed there are often differences between national jurisdictions, even within jurisdictions, in the way that, and by whom ‘medication orders’ are handled.

I agree that what we re talking about here is a kind of request for service but I think I would want to defend a prescription as being a very special case, usually bounded by legislation.

Perhaps this is a good opportunity to get this archetype reviewed, and word smithed to make usage clearer.

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