Summary of the discussion held on CKM.
We are checking the use of Medication Order instruction and Medication Management action for a potential implementation of this archetypes for internal hospital medication prescription.
Checking the Medication Management archetype transitions, we found that when the medication administration has been suspended and the conditions to continue with the medication administration are in place, the transition “Medication start date/condition set” leads from suspended state to scheduled state. The problem here is that there is no transition from suspended to scheduled in ISM.
Ian has provided one example where these transitions could have sense:
The use case for Suspended->Scheduled is something like a suspension of anticoagulants while the patient is undergoing surgery, with a restart date or condition set, and I do think Suspended->Scheduled->Active makes sense, and I suspect that was the basis for the documentation.
So, as this could be modeled with a direct transition from Suspended to Active, the recommendation is to leave the ISM as it is (I understand that it would be a major change) and change the archetype documentation to reflect that.
Do you have any comments on that?
The Scheduled state is normally used for interventions that can be scheduled - e.g. surgery, physio, dialysis etc. It could be medications, where the medication administration is managed, e.g. chemo, any other special medications.
But I don’t see how patient self-administered medications including oral anti-coagulants could be ‘scheduled’, or are we talking about hospital-administered warfarin or heparin? In the latter case, going from Suspended to Scheduled would imply to me:
- the administration of some in-patient managed drug is stopped (risk due to surgery)
- once the surgery & recovery is over, the patent should re-commence the medication (still as in-patient)
- the same original medication order is assumed, there is no new prescription
- the medication is set to recommence on a certain day, or number of days after surgery or similar
- the medication will (again) be administered by clinicians.
The reason for this is that Scheduled implies that there is a system containing a booking or similar, for which, when the date arrives, the intervention will move to the Active state.
If on the other hand this is about a patient self-administered drug and the doc wants to tell them to not take the medication in question for ‘10 days’ or whatever is thought to be safe, I don’t think the Scheduled state makes sense, unless that delay is going to be entered into some system that will generate a patient notification on some device, which he will then obey. (NB: this is however quite likely in the future, but it would be rare today).
In summary, the added transition Suspended → Scheduled could certainly make sense, and probably should be added to the Reference Model ISM, but we should be careful about when it should actually be used.
Yes, agree that the most common use-case will be a hospital-related administration suspension where suspension moves to re-scheduled on a particular date or criteria. I think we re getting closer to a single medication record scenario where the patient is asked/notified directly to stop and restart their meds.
My understanding is like yours: this only make sense for hospital related administration where you have a system to register actions and to control the schedule. In the case of self administered medication I think that actions will not be recorded, at least with the current technology were administered medication is not tracked (maybe in some specific cases with the support of a mobile app could be done).
Do you think it would make sense to have some way to define ISM in a similar way as tools like Jira do? In that way transitions and states could be verified depending on the specific clinical scenario.
Just adding link to the discussion in the international CKM where this topic were raised first: Clinical Knowledge Manager
The scenario mentioned above “suspended->scheduled->active”, or patient stops the medication due to some reason, and starts the medication again using the same prescriptions.
Clinically or technicly, we can argue that the suspended in this scenario may not be a true suspended. It is a pause. the actual instruction state for this medication is still Active. While the changes should be to the careflow_step, which can be archetyped including a careflow step, something like Pause.
I would suggest that if any clinician has recorded that medication X should be suspended (‘stopped’), we should regard it as ‘suspended’, since it acts as a direction to staff to act in a certain way. It might not be lifted for some time, depending on the patient situation, so it would presumably be dangerous if the representation of the order on the system was still ‘active’, implying administration should proceed as normal.
If on the other hand, a consultant judges that there is no need to formally change anything because in the inpatient situation, medication is totally controlled, pre-existing orders for long term medications could probably remain ‘active’ without harm.
I think in general we have to make no assumptions about continuity of particular staff being present, or knowing or remembering specifics that are not recorded, or for how long certain decisions may last for.
I understand your argument, but I do feel that this is better underpinned by a strong ‘suspended’ current_state , not just a flavour of ‘active’ as per Thomas’s post
Thanks @thomas.beale and @ian.mcnicoll for your response. I also did some research on prescription workflow management, and I do agree that suspended medicine is a valid status in the prescription workflow. When medicine is suspended, it sometimes comes with a suspension period, and it most likely has a suspension reason as well. I also find out that when the medicine is suspended, the suspension period shall be excluded in calculating the prescription period.
I believe the suspended medicine along with a suspension period is related to the original question of the post.
When there is a suspension period, conceptually I don’t think this period is the same as the period of a scheduled date. So I don’t think that the state for the prescription could be changed from suspended to scheduled. The prescription could be either resumed (active) or aborted (such as changed to a different medicine)
I’m still not sure I agree here.
Medication will be suspended for either a period, or until some other condition is reached, at which point I would have said the restart can be rescheduled on a specific date.
I agree that suspension duration is different from specific date, and possibly the suspension duration could be added as a new element, but equally it could be argued that if the period e.g. 14 days in known at the start of suspension, then it is sufficient to calculate the restart scheduled date, immediately after setting the suspended state.
In other circumstances the conditions to restart might be more nuanced e.g based on a lab test. On the basis of a particular lab test the restart scheduled date might be set in advance.
Hi Ian, thanks for your further thoughts.
In general, when a prescription is scheduled, it is part of a care plan. However, when a prescription is suspended with a suspension period, it is normally an action for unexpected events. I cannot think of a planned suspension clinically. Thoughts?
I agree that many suspensions will be planned e.g stop anticoagulants around time of surgery but even if that is expressed int he care plan, I’d still want that to be manifested in the prescribing/administration system to prevent the administration occurring.
An unplanned suspension might be as a result of an abnormal lab test but with a plan to recommence when the bloods are normal.
I’ll try to find out what Better do in their EPMA system.
Is there any update in this discussion? @ian.mcnicoll, did you find out what’s done it Better’s solution?
Sorry - that slipped - I have asked Better for their thoughts. There is also a related JIRA request to be able to ‘Restart’ a completed medication.
What are your own thoughts on the Suspended-> Scheduled issue @siljelb ?
Just a quick response to the top post - although adding Suspended->Scheduled as an allowed transition is a change to the RM, it is not a breaking change as such, so quite easy to be changed an implemented.
This is the response from Mitja Lapajne at Better Meds,
In Better Meds if a medication is suspended, users always need to manually reissue it. Automatically restarting medications after a period of time (or on some condition) without user intervention may be dangerous as patient conditions may have changed.
We use Prescription re-issued transition . This pushes the medication order instruction from state suspended to state active.
We don’t use Medication start date/condition set when reissuing.