This will be a multi-post series. The goal is to
Introduce people to medication orders (particularly non-clinicians).
Show some examples of how order entry has been tried in the past (post 2)
And then start working through some mockups on ways to improve this. (post 3+)
Consider all of these posts a first draft. They are primarily designed to help our group start working on demos of a cleaner order entry tool. All feedback is appreciated.
If you’d prefer to watch a video, see below, or search your podcast app for: Gregory Schmidt
Some Baseline Requirements vs1
The order entry module needs to work on mobile, tablet, and desktop.
It must work on devices that are 100% touch-screen only, and devices that are 100% keyboard entry only. And everything in-between.
It needs to handle ‘order sentences’ (eg. ‘Metoprolol 25mg PO BID), and also be able to handle fully custom orders where the clinician changes every component of the order script.
The ability to move from a pre-set order sentence, to changing order details must be smooth.
The order entry tool may be embedded within a workflow (eg. within a clinician driven questionnaire). Or, it may be accessed outside of a workflow - directly via an ‘order button’ elsewhere in the EHR.
Ultimately, the order entry tool has to compete against the ‘Gold Standard’ - which is a pen quickly scribbling on a prescription pad. The EHR will almost always lead in legibility, but traditionally greatly lags behind in speed.
The tool can’t make users frown, pull out their hair, or force them onto stress leave. As current EHRs do.
This general order framework needs to be able to work on orders other than medications - such as laboratory, imaging, consults, etc.
For now, this series will keep out of the discussion: Order Templates / Order Sets / Order Protocols.
Brief Overview of Medication Orders
Medication Prescriptions & Medication Orders
Typically a ‘prescription’ is thought of an an outpatient medication request, and a medication ‘order’ is considered an inpatient medication request. Traditionally a prescription is something you may give the patient to fill at a pharmacy, and an order is something a nurse may administer.
Overall, the idea of ‘ordering’ or ‘prescribing’ a medication is similar enough that FHIR has merged both medication prescriptions and medication orders into the single resource called: MedicationRequest. This makes sense to me.
For simplicity, I will refer to a ‘medication order’ to mean both ‘medication orders’ as well as ‘prescriptions.
Common Components of the MedicationRequest
A full MedicationRequest requires critical information. Some large categories are:
Identifying patient information - who is it for
Identifying ordering information - who ordered it? was it ordered on behalf of someone else? what state was the order placed into (active, held, etc)
The date the MedicationRequest was made
The medication order itself.
Common Components of the Medication Order
The common components of a medication script include:
Drug Name (Generic) vs (Non-Generic)
Drug Dosage (including numerical value and units)
Route for ingestion (eg. by mouth, intra-venous, per rectum, etc)
Frequency (how often to take the medication)
Duration (how long to take the medication for)
Without this information it is pretty difficult to dispense a medication properly. But additional information might be included in a medication order for further details.
Additional medication order details may include:
The medication form requested (powder, cream, ointment, etc)
Instructions to ‘take as needed” “PRN”. And if so, for what indication (eg. nausea)
Refill details (how many refills the patient may have)
Specific instruction for the patient (eg. do not take with alcohol)
Specific instructions for the nurse (eg. only give while patient awake)
The priority of the order (eg. Give STAT)
Specifics start date / time or specific end date / time
To only take the medication based on the result of another test or measurement (eg. a drug level or HgB result)
Details regarding order activation. Right away vs to be placed into a ‘pending list’ for activation later (eg. after coming out of the ER).
Can it be crushed or not?
If the drug can be substituted for generic, and if not why
How the medication should be prepared / mixed with other drugs
Each of the fields listed above have many options that can be selected from. Eg, there are actually dozens of different ‘routes’ that medications can be prescribed to enter the body (try to think of all the ways yourself, you’ll likely leave out a few… check your list against the SNOWMED CT Route Codes)
The components listed above can be mapped to the FHIR MedicationRequest resource as well as the attached medication concepts.
There are also ISO Standards around medication and electronic prescriptions. Unfortunately ISO keeps these behind paywalls. But critical documents appears
ISO 17523:2016 Health informatics -- Requirements for electronic prescriptions . View a full version of this as an early draft from 2014.
This links out to a number of other ISO standards around Medication, such as ISO 11615, 11616, 11238, 11239, 11240, 19844,
Users want to be able to place a medication order quickly. But there are a number of different variables that can be customized on any order.
How do we balance these competing interests?
The *next post* looks at how this has traditionally been handled in the EHR.