ehr system function and information model (ehr-s fim is based on ehr-s fm r2.0) cp.1.3 manage ...
DESCRIPTION
EHR System Function and Information Model (EHR-S FIM is based on EHR-S FM R2.0) CP.1.3 Manage Medication List aka DC.1.4.2 in EHR-S FM. [email protected] , facilitator January 23, 2012 – Original February 24, 2012 – Last Updated. Call for Participation - PowerPoint PPT PresentationTRANSCRIPT
EHR System Function and Information Model
(EHR-S FIM is based on EHR-S FM R2.0)
CP.1.3 Manage Medication Listaka DC.1.4.2 in EHR-S FM
[email protected] , facilitatorJanuary 23, 2012 – Original
February 24, 2012 – Last Updated
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Call for ParticipationThis work is being done by the HL7 EHR Interoperability Work Group,
meeting every Tuesday at 4PM ET, dial-in: 1-770-657-9270, Passcode: 510269# The most current artifacts are at: http://wiki.hl7.org/index.php?title=EHR_Interoperability_WG
CP.1.3 Manage Medication List
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Statement: Create and maintain patient-specific medication lists.
Description: Medication lists are managed over time, whether over the course of a visit or stay, or the lifetime of a patient. All pertinent dates, including medication start, modification, and end dates are stored. The entire medication history for any medication, including alternative supplements and herbal medications, is viewable. Medication lists are not limited to medication orders recorded by providers, but may include, for example, pharmacy dispense/supply records, patient-reported medications and additional information such as age specific dosage.
Example: During an encounter, a health care professional might manage a patient’s Medication List and the system also manages the filling of prescriptions, according to scope of practice, organizational policy and/or jurisdictional law.
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CP.1.3 Manage Medication ListActivities Mapped-to System-Components
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act CP.1.3 ACT Manage Medication List
CP.1.3 Manage Medication List
Manage Ev ents Manage Lists
Start END
Manage Records Manage Trusts Manage Business Rules
Medication List
Medication EventEHR
-S Components
ListEvent
Clinician
is-a
CP.1.3 Manage Medication ListConceptual Information Model (CIM) Mapped to EHR-S Functions
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class CP.1.3 CIM Manage Medication List
Event Medication List
Medication Event Medication History
CP.1.3 Manage Medication List
CPS.9.5 Ad Hoc Query and Rendering
CPS.9.3 Health Record Output
CP.3.3 Manage Clinical Documents and Notes
List
Record Infrastructure Trust Infrastructure
deoends on
depends on
depends on
is-ahas-a
0..*
CP.1.3 Manage Medication ListConceptual Data Model (CDM)
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class CP.1.3 LDM Manage Medication List
Ev ent
+ date (occurence)+ time (occurence)- change justification- circumstances- clinical information- date (entry)- date (review)- description- duration- information reviewed- information source- information validator- location- mechanism- metadata- person-role- status- trigger- type
+ deactivate()+ justify()+ manage()
Person-Role
- person identifier- role
Event Type Enumeration
- advanced directive- adverse reaction- al lergy- CDS Alerts- CDS reminders- CDS update- cl inical document or note- discharge- encounter- intolerance- medication (pharmacist change)- medication (prescription dispensing)- medication (prescription fil l ing)- medication history received (external source)- order- other- procedure- registry- reminders & alerts- report- surgical- transfer
Role Enumeration
- authenticator- author- fil ler- guardian- other- patient- prescriber- provider- relative- stakeholder- witness
Trigger Enumeration
- drug- environment- food- other
Medication List
Medication Ev ent
- date of discontinuation- date of end- date of review- date of start- dispensing information- dose- formulation- instructions- interaction checking done :boolean- interactions indicated- justi fication- medication administration information- name- order date- pharmacist change information- potential interaction- prescriber- route- SIG- source- type
«enumeration»Medication Type
Enumeration
Attributes- medication order- non-prescription- prescribed- previously unreported
«enumeration»Medication Source
Enumeration
Attributes- erroneously captured- patient- patient history
dispensing information
Medication History
- status
«enumeration»Medication History Status Enumeration
unavailable incomplete
Pharmacist's Change
Information
- date- time
Medication Potential
Interaction
Medication Administration
Information
- administrator- date- dose- exceptions- medication name- route- time
1..*
1..*
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req CP.1.3 RT Manage Medication List
CP.1.3#03 The system SHALL provide the ability to manage, as discrete data, medication information including prescriber, ordering date, dose, route, and SIG (description of the prescription, such as the quantity) ...
CP.1.3#04 The system SHALL provide the ability to capture other dates associated with medications such as start , end and discontinuation dates.
CP.1.3#08 The system SHALL provide the abil ity to tag a medication as erroneously captured and excluded from the presentation of current medications.
CP.1.3#10 The system SHOULD provide the abi lity to capture and render information regarding the fi l l ing of prescriptions.
CP.1.3#05 The system SHALL provide the abil ity to capture medications not reported on existing medication lists or medication histories.
CP.1.3#06 The system SHALL provide the ability to capture non-prescription medications including over the counter and complementary medications such as vitamins, herbs and supplements.
Ev ent
- change justification- circumstances- clinical information- date (entry)- date (occurence)- date (review)- description- duration- information reviewed- information source- information validator- location- mechanism- metadata- person-role- status- time- trigger- type
+ deactivate()+ justify()+ manage()
Medication Ev ent
- date of discontinuation- date of end- date of review- date of start- dispensing information- dose- formulation- instructions- interaction checking done :boolean- interactions indicated- justification- medication administration information- name- order date- pharmacist change information- potential interaction- prescriber- route- SIG- source- type
CP.1.3#22 The system SHALL tag and render an indicator that interaction checking will not occur against free text medications.
CP.1.3#11 The system SHOULD provide the ability to capture and render information regarding the dispensing of prescriptions.
CP.1.3#12 The system SHALL provide the abil ity to receive from an external source (for example a plan, payer or pharmacy) a medication history.
CP.1.3#14 The system SHALL provide the ability to capture a description and reason for a medication when the medication name is unknown.
CP.1.3#16 The system SHOULD provide the ability to maintain the medication list with changes from pharmacist verification including pharmacist, date, and time.
CP.1.3#17 The system SHOULD provide the ability to manage the reason or indication for the medication when recording historical or medications from external sources (e.g. from home or other provider).
CP.1.3#18 The system SHOULD provide the ability to update a medication order directly from the medication list.
CP.1.3#19 The system SHALL conform to function CPS.4.2.1 (Support for Medication Interaction and Allergy Checking) to render any potential interactions when capturing or maintaining medications.
CP.1.3#20 The system SHOULD provide the abil ity to maintain a medication order directly from medication reconci liation.
CP.1.3#21 The system SHALL provide the ability to capture free text medications and render them in a manner that distinguishes them from coded medication entries.
CP.1.3#13 The system SHALL provide the abil ity to capture that a medication history is unavailable or incomplete.
CP.1.3#15 The system SHALL provide the ability to render on the medication list active medications that the patient brings from home to take while hospitalized, which the Pharmacy may not dispense.
CP.1.3#24 The system SHOULD provide the ability to render potential side effects of medications from the medication list.
CP.1.3#25 The system SHALL provide the abil ity to capture and render that the patient takes no medications.
CP.1.3#28 The system MAY provide the abi li ty to capture medication self-administration details including timestamps, observations, complications, and reason i f medication dose was not taken.
CP.1.3#32 The system SHALL provide the abil ity to capture, maintain, and present all pertinent details of the medication administration including medication name, strength, dose, route, time of administration, exceptions to administration, and administrat
CP.1.3#29 The system MAY capture Investigational Product Exposure information including Start Date/time, End Date/Time, Dose Amount, Dose Unit, Study Treatment Name, Route, Formulation as discrete elements.
CP.1.3 Manage Medication ListCDM Requirements-Traceability
req CP.1.3 RT Manage Medication List
CP.1.3#01 The system SHALL provide the ability to manage a patient-specific medication list based on current medication orders or prescriptions.
CP.1.3#02 The system SHALL provide the ability to manage the details of the medication information including prescriber, ordering date, dose, route, and SIG (description of the prescription, such as the quantity) formulation and instructions ...
CP.1.3#30 The system SHALL capture, maintain and present pre-admission medications.
CP.1.3#31 The system SHALL present pre-admission medications at the time of discharge.
CP.1.3#07 The system SHALL provide the ability to render the medication history associated with a patient.
CP.1.3#09 The system SHALL provide the ability to render a current medication list for patient use.
Medication List
Medication History
- status
List
+ define sort restrictions()+ fil ter()+ link to problem-treatment()+ manage()+ manage reason for change ()+ sedine sort criteria()+ sort()
CP.1.3#23 The system SHOULD provide the abil ity to render side effects of medications from the medication list that have been previously experienced by the patient.
CP.1.3#26 The system SHALL provide the ability to render only current active medications (i.e. exclude prescriptions whose duration has been exceeded or end date has passed).
CP.1.3#27 The system MAY provide the abil ity to render non-active medications or prescriptions for inclusion in current medication screening.
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CP.1.3 Manage Medication ListCDM Requirements-Traceability
CP.1.3 Manage Medication List“See Also” Dependencies
class CP.1.3 DEP Manage Medication List
CP.1.3 Manage Medication List
CPS.9.5 Ad Hoc Query and Rendering
CPS.9.3 Health Record Output
CP.3.3 Manage Clinical Documents and Notes
Record Infrastructure
+ RI.1 Record Lifecycle and Lifespan+ RI.2 Record Synchronization
+ RI.3 Record Archive and Restore
Trust Infrastructure
+ TI.1 Security+ TI.2 Audit
+ TI.3 Registry and Directory Services+ TI.4 Standard Terminology and Terminology Services+ TI.5 Standards-Based Interoperability+ TI.6 Business Rules Management+ TI.7 Workflow Management
+ TI.8 Database Backup and Recovery+ TI.9 System Management Operations and Performance
CP, CPS & AS
depend on
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Action Verb Hierarches
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Manage (Data)Capture Maintain Render Exchange Determine
Manage-Data-
VisibilityAuto-PopulateEnterImportReceive
Store Update Remove Extract Present Transmit ExportImportReceiveTransmit
Analyze Decide De-IdentifyHideMaskRe-IdentifyUnhideUnmask
ArchiveBackupDecryptEncryptRecoverRestoreSave
AnnotateAttestEditHarmonizeIntegrateLinkTag
DeletePurge
Archive
• Older slides
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CP.1.3 Manage Medication ListConformance Criteria
1. 1. The system SHALL provide the ability to manage a patient-specific medication list based on current medication orders or prescriptions.
2. The system SHALL provide the ability to manage the details of the medication information including prescriber, ordering date, dose, route, and SIG (description of the prescription, such as the quantity), formulation and instructions according to scope of practice, organizational policy and/or jurisdictional law.
3. 3. The system SHALL provide the ability to manage, as discrete data, medication information including prescriber, ordering date, dose, route, and SIG (description of the prescription, such as the quantity) according to scope of practice, organizational policy and/or jurisdictional law.
4. 4. The system SHALL provide the ability to capture other dates associated with medications such as start , end and discontinuation dates.
5. 5. The system SHALL provide the ability to capture medications not reported on existing medication lists or medication histories.
6. 6. The system SHALL provide the ability to capture non-prescription medications including over the counter and complementary medications such as vitamins, herbs and supplements.
7. 8. The system SHALL provide the ability to render the medication history associated with a patient.8. 10. The system SHALL provide the ability to tag a medication as erroneously captured and excluded
from the presentation of current medications.9. 11. The system SHALL provide the ability to render a current medication list for patient use.
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CP.1.3 Manage Medication ListConformance Criteria
10. 12. The system SHOULD provide the ability to capture and render information regarding the filling of prescriptions.
11. The system SHOULD provide the ability to capture and render information regarding the dispensing of prescriptions.
12. The system SHALL provide the ability to receive from an external source (for example a plan, payer or pharmacy) a medication history.
13. The system SHALL provide the ability to capture that a medication history is unavailable or incomplete.14. The system SHALL provide the ability to capture a description and reason for a medication when the
medication name is unknown.15. The system SHALL provide the ability to render on the medication list active medications that the
patient brings from home to take while hospitalized, which the Pharmacy may not dispense.16. The system SHOULD provide the ability to maintain the medication list with changes from pharmacist
verification including pharmacist, date, and time.17. The system SHOULD provide the ability to manage the reason or indication for the medication when
recording historical or medications from external sources (e.g. from home or other provider).18. The system SHOULD provide the ability to update a medication order directly from the medication list.19. The system SHALL conform to function CPS.4.2.1 (Support for Medication Interaction and Allergy
Checking) to render any potential interactions when capturing or maintaining medications.20. The system SHOULD provide the ability to maintain a medication order directly from medication
reconciliation.
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CP.1.3 Manage Medication ListConformance Criteria
21. The system SHALL provide the ability to capture free text medications and render them in a manner that distinguishes them from coded medication entries.
22. The system SHALL tag and render an indicator that interaction checking will not occur against free text medications.
23. The system SHOULD provide the ability to render side effects of medications from the medication list that have been previously experienced by the patient.
24. The system SHOULD provide the ability to render potential side effects of medications from the medication list.
25. The system SHALL provide the ability to capture and render that the patient takes no medications.26. The system SHALL provide the ability to render only current active medications (i.e. exclude
prescriptions whose duration has been exceeded or end date has passed).27. The system MAY provide the ability to render non-active medications or prescriptions for inclusion in
current medication screening.28. The system MAY provide the ability to capture medication self-administration details including
timestamps, observations, complications, and reason if medication dose was not taken.29. The system MAY capture Investigational Product Exposure information including Start Date/time, End
Date/Time, Dose Amount, Dose Unit, Study Treatment Name, Route, Formulation as discrete elements.30. The system SHALL capture, maintain and present pre-admission medications.
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CP.1.3 Manage Medication ListConformance Criteria
31. The system SHALL present pre-admission medications at the time of discharge.32. The system SHALL provide the ability to capture, maintain, and present all pertinent details of the
medication administration including medication name, strength, dose, route, date and time of administration, exceptions to administration, and administrator of the medication.
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CP.1.3 Manage Medication List“See Also” Dependencies
• CPS.9.3 Health Record Output• OVERARCHING:
– Trust Infrastructure– Record Infrastructure
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