| Submitted By: Maureen Layden, MD, MPH / United States Department of Veterans Affairs | |
|---|---|
| Data Element Information | |
| Rationale for Separate Consideration | The related element is 'medication,' which refers to the identification of the medication substance. This request addresses the need to understand whether and how the patient is actually following the dosage instructions of an order, or whether the patient may be taking substances for which no order is known. |
| Use Case Description(s) | |
| Use Case Description | A clinician needs to know what a patient is taking in order to assess effectiveness with respect to a symptom or to assess whether other interventions may be advisable. A pharmacist needs to know whether a patient is taking a medication in order to assess whether other alternatives may be advisable. A CDS routine needs to know what a patient is taking in order to screen for drug interactions, allergic reactions, and other adverse events. A payor needs to determine whether an ineffective treatment may be due to adherence. A patient needs to confirm that the doctor understood and recorded his explanation of his medications. A caregiver needs to reconcile medication expectations with what the patient is doing. |
| Estimated number of stakeholders capturing, accessing using or exchanging | All clinicians who need to understand what a patient is taking All pharmacists who need to confirm suitability of an order All payors who need to assess compliance All patients who need to confirm their recorded data All caregivers who need to reconcile a patient's medications |
| Healthcare Aims |
|
| Maturity of Use and Technical Specifications for Data Element | |
| Applicable Standard(s) | FHIR Resource: HL7 FHIR R4 MedicationStatement, aka R5 MedicationUsage Data element: MedicationStatement.status; MedicationUsage.takenAsOrdered Values in http://hl7.org/fhir/CodeSystem/medication-statement-status: {active | completed | entered-in-error | intended | stopped | on-hold | unknown | not-taken} These are defined in terms of taking; i.e., “active” in MedicationRequest means that the prescription can be filled, but in MedicationStatement, means that the patient is taking it. FHIR R5 target is to remove “status” and create “use,” with values { Taking | Taking as directed | Taking not as directed | Not Taking | Unknown (unable to obtain)} AVS/PVS system uses “I am taking this med {As written | Differently | Not taking | Unsure}” http://hl7.org/fhir/R4/valueset-medication-statement-status.html |
| Additional Specifications | Pharmacy workgroup project on Medication List (work in process): https://confluence.hl7.org/display/PHAR/Patient+Medication+List+Guidance |
| Current Use | Extensively used in production environments |
| Supporting Artifacts |
The Joint Commission publishes National Patient Safety Goals NPSG.03.06.01: Maintain and communicate accurate medication information for the individual served. “Item 1: Obtain and/or update information on the medications the individual served is currently taking.” VA providers consistently capture this information in notes. This compliance with the Joint Commission is required by VHA Directives 1345 & 1164. The VA Pre Visit Summary & After Visit Summary (AVS & PVS) are in use at 95 VA facilities serving one million patients. The PVS form distinguishes among ‘as directed,’ ‘differently,’ ‘not taking,’ and ‘unsure.’ DoD has a similar capability in the OUTPATIENT MEDICATIONS REVIEW LIST (‘taking’ checkbox only). Some VA facilities implement this information in the Clinical Reminder capability. AllScripts’ DSTU2 FHIR API supports the wasNotTaken and reasonNotTaken values. Cerner’s DSTU2 FHIR API provides the wasNotTaken and reasonNotTaken values. The R4 API does not support the resource that includes this value. Epic’s DSTU2 and STU3 FHIR APIs provide the wasNotTaken (“taken” in STU3) and reasonNotTaken values. The R4 API does not support the resource that includes this value. These vendors’ decisions not to include this element in R4 may be attributable to the FHIR US Core Guide’s removal of the supporting resource. |
| Number of organizations/individuals with which this data element has been electronically exchanged | 5 or more. This data element has been tested at scale between multiple different production environments to support the majority of anticipated stakeholders. |
| Supporting Artifacts |
Medication use is captured in Notes for every visit, per Joint Commission mandate. These notes are accessible to providers in all VA and DoD facilities via the Joint Legacy Viewer integration point. They can be accessed by all Veterans in the MyHealtheVet application and by the Blue Button CDA download. The notes containing this information can be acquired by the 18 member organizations of the CommonWell health information exchange, supporting 95MM patients, and the members of the eHealth Exchange, supporting 120MM patients and 75% of US hospitals. The PVS form is sometimes exchanged in document form. This data is not exposed in a standard structured form because of the lack of a standard way to do so. https://www.jointcommission.org/-/media/tjc/documents/standards/national-patient-safety-goals/2020/npsg_chapter_ahc_jul2020.pdf https://www.myhealth.va.gov/mhv-portal-web/my-healthevet-va-notes-learn-more https://fhir.cerner.com/millennium/overview/ https://open.epic.com/Interface/FHIR https://developer.allscripts.com/Content/fhir/ |
| Potential Challenges | |
| Restrictions on Standardization (e.g. proprietary code) | None |
| Restrictions on Use (e.g. licensing, user fees) | None |
| Privacy and Security Concerns | Patient medication information is protected health information and should be kept as secure as the element naming the medication. |
| Estimate of Overall Burden | Systems currently support reconciliation and capture of adherence and OTC medications: new functionality will not be necessary. The primary burden will be in identifying the appropriate exchange form to which to map these existing capabilities. |
| Other Implementation Challenges | The primary challenge is coordination of design. The US Core DSTU3/R4 specification stipulates that all medication lists be constructed using order data only (MedicationRequest resources), and that reported usage (MedicationStatement) be converted into notional “requests.” The proposed data element seems best fit for the MedicationStatement resource; a requirement to support it in MedicationRequest may complicate the design unnecessarily. |
Pharmacologic agents used in the diagnosis, cure, mitigation, treatment, or prevention of disease.
Data Element |
Information from the submission form |
|---|---|
| Medication Usage |
|
Comment