Medication management is one of the most complex issues in health care computing, particularly in the distributed computing environment that openEHR aims to support. Illustrations of this complexity include:
Key groups include: (Note * indicates features that may differ from the instruction at the time of administration.)
Identifying the medication is a key requirement. This may include:
The approach has to deal with dispensing records (as these may use a different trade name and add instructions to the patient) as well as have non-clinical aspects such as deferred supply.
Information about an order may be specific to one prescription rather than to the order itself. Such information may include endorsements by the prescriber for a financial subsidy, altered supply conditions or may require authorisation of some kind to be recorded. Connecting the order with the dispensing process clearly reduces transcription errors but adds complexity as different brands and even substances may be dispensed at time. Dispensing may also be delayed or reversed.
It has taken many years of experiments and discussion to come up with the Instruction and Action classes to support workflow. These classes allow statements, using the action class, to be made when acting on an instruction that refer to the instruction but do not alter it. The state of the activity in the instruction is actually derived from the sum of action statements made with reference to that activity. The result is that a medication administration may leave the state of a medication order as 'active' or 'completed'. A decision not to administer a medication may leave the state of the medication order as 'cancelled' (if not started), 'suspended' or 'aborted' if not started. An action such as withheld may even leave the instruction as active.
The proposed actions that might be recorded against a medication order are:
|
Plan |
|
The medication is planned but no execution has taken place. |
Current state: initial |
|
Plan suspended |
|
The plan to order medication has been suspended. |
Current state: postponed |
|
Cancelled order |
|
The planned administration has been cancelled prior to any administration. |
Current state: cancelled |
|
Start time set |
|
The time to start this medication has been set. |
Current state: scheduled |
|
Issue item prescription |
|
The order has been transfered to the dispensary. |
Current state: active, initial |
|
Dispense medication item |
|
The medication has been dispensed. |
Current state: active, initial |
|
Commence medication item administration |
|
The medication has been taken by the patient for the first time. |
Current state: active |
|
Review medication item |
|
The medication has been reviewed. |
Current state: active |
|
Administer medication item |
|
A single administration of the medication has taken place. |
Current state: active |
|
Re-issue item prescription |
|
The medication has been re-prescribed for an existing order. |
Current state: active |
|
Medication item withheld |
|
The administration of a medication has been withheld and not given. |
Current state: active |
|
Medication item refused |
|
An administration of the medication was refused by the patient. |
Current state: active |
|
Reverse item dispense |
|
A dispensed medication is returned or not collected without use. |
Current state: active, initial |
|
Delayed supply |
|
The medication has not been dispensed as supply is not yet available. |
Current state: suspended |
|
Suspended administration |
|
The administration of the medication has been suspended. |
Current state: suspended |
|
Suspended re-order |
|
Reordering of this medication is not available. |
Current state: suspended |
|
Administration ceased |
|
The administration of this medication has been ceased before anticipated completion. |
Current state: aborted |
|
Reverse prescription |
|
The prescription has been cancelled but administration or dispensing may have occurred. |
Current state: aborted |
|
Completed |
|
The medication has been completed as prescribed. |
Current state: completed |
If we think about medication (and there is some detail of this in the openEHR specifications) there are a number of lists of medication a clinician would like to access. Such lists might include: