Electronic Medication Management ( eMM )

1. Electronic Medication Management (eMM) Dr Stephen Chu Chief Clinical Informatician & Terminologist Clinical Terminology & Information, NEHTA 2 November 2012 • Landscape, Concepts and Definitions • eMedication Management Stack • scope, concepts and definitions

2. eMM: Landscape • Electronic Medication Management • Three key components • Contents • Concepts and definitions • Infrastructures • Trigger events; messages; services • Registry; repository • Applications/User interface/viewer

3. eMM: Landscape • Electronic Medication Management • Key landscape components Applications Triggers Registry/ Directory eMM Repository SEHR/ PHR Services Messages Queries Contents Interfaces

4. The Interoperability Stack - XDS - AORTA - Web services Transport/Architecture - Message Structure - Document (CDA) Structure Packaging Contents - Data/Information Models - Terminologies Focus of contents of this slide deck Concepts - Terms - Definitions

5. eMM: Landscape • Electronic Medication Management • The recipes and ingredients analogy The production (cooking) processes The consumptions Executive/ Management Decisions Medication Management Reconciliation The receipts Medication Management Plan Reviews Medication Profile Clinical Decisions Queries Med Review Record* Reconciled Med History List * Unreconciled Medication History List Patient Medication Record Medication related Reporting The data (ingredients) Labs … & others… Pharm Advice Dispense Records Patient Conditions Allergies; Adv reactions Contra- Indicat -ions Meds Admin Prescrip-tions The sources hospitals Community pharmacies Community Labs/paths Community Imaging services others …

6. eMM Concepts and Definitions • Definitions • Patient Medication Record • Record = documentation in writing or other permanent form • Medication record = documentation of medication prescription, dispense and administration information (for a defined period of time • Patient medication record = a collection of records pertinent to a patient’s medication prescription, dispense and administration information for a defined period of time • This collection of records may be persisted within a patient’s EMR and shared EHR

7. eMM Concepts and Definitions • Definitions • Reporting • Process of extracting data from one or more sources and converting them into a report for a specific purpose • Medication Related Reporting • A set of medication related information extracted from one or more sources and converted into a report to meet statistical , quality and safety, epidemiological, government or regulatory requirements • Example: Adverse drug/medication reaction reporting

8. eMM Concepts and Definitions • Definitions • Adverse Drug Reaction • “a response to a drug that is noxious and unintended and occurs at doses normally used in man for the prophylaxis, diagnosis or therapy of disease, or for modification of physiological function” (source: WHO) • “An appreciably harmful or unpleasant reaction, resulting from an intervention related to the use of a medicinal product, which predicts hazard from future administration and warrants prevention or specific treatment, or alteration of the dosage regimen, or withdrawal of the product” (source: Edwards RI, Aronson JK. Adverse Drug reactions: definitions, diagnosis, and management. The Lancet 2000;356:1255-59)

9. eMM Concepts and Definitions • Definitions • Adverse Drug/Medication Reaction Reporting • The reporting of appreciably harmful or unpleasant reaction, resulting from the use of a medicinal product, which may be prescribed or non-prescribed (such as an OTC medicinal product)

10. eMM Concepts and Definitions • Current & Past Medications • Current Medication List • A list of all medications (prescribed and over-the-counter) that an individual should be/are known to be currentlytaking as identified at the time of review • Past Medication List • A list of all medications (prescribed and over-the-counter) that an individual were known to be previously but NOT currentlytaking as identified at the time of review • Medication History List • A record of previouslyprescribed and dispensed medications (may include over-the-counter medications) for an individual • Retrospective in nature, but can contain continuing/future meds

11. eMM Concepts and Definitions • Definitions • Medication Reconciliation • Medication reconciliation is a formal process of obtaining and [clinically] verifying a complete and accurate list of each patient’s current medicines. Matching the medicines the patient should be prescribed to those they are actually prescribed. Where there are discrepancies, these are discussed with the prescriber and reasons for changes to therapy are documented. When care is transferred (e.g. between wards, hospitals or home), a current and accurate list of medicines, including reasons for change is provided to the person taking over the patient’s care. Points of transition that require special attention are*1 • Admission to hospital • Transfers within hospital (e.g. ED to ward; ICU to ward, etc) • From the hospital to home, residential aged care facilities or to another hospital

12. eMM Concepts and Definitions • Definitions • Medication Reconciliation • The process of comparing various medications lists to avoid errors such as transcription, omission, duplication of therapy, drug-drug and drug-disease interactions*2 • Based on this definition, the medication reconciliation processes include comparing and rectifying discrepancies as well as review of medication management therapy • It refers to the process of [clinically] reviewing the patient’s complete medication regimen on admission, at transfer and discharge, comparing it with the regimen being considered for the new care setting. The process aims at avoiding inadvertent inconsistencies in medication regimen across transition in care*3

13. eMM Concepts and Definitions • Definitions • Unreconciled Medication History List • Synonymous term: Unreconciled medication list • A list of patient medication compiled from collection of known sources (paper and electronic) at a point in time. The contents of this list has not be subjected to the process of clinical verification to remove errors, inconsistencies, duplications and rectify omissions • This is a “raw list” likely to be machine generated and has not undergone [human] clinical review, validation and reconciliation processing

14. eMM Concepts and Definitions • Definitions • Reconciled Medication History List • Synonymous term: Reconciled medication list • A set of patient medication compiled from collection of known sources (paper and electronic) at a point in time. The contents of the list have been subjected to comprehensive clinical verification processes, which include comparison of data from various sources, validation with data origins such as prescribers and dispensers. Omissions, inconsistencies, e.g. duplicates, are identified and rectified to ensure accuracy, consistency, currency and as error free and omission free as possible • Medication reconciliation processes may be or are typically conducted on admission, transfer or discharge of patient

15. eMM Concepts and Definitions • Definitions • Medication Review • A process of systematic evaluation of a person’s complete medication regimen and management of the medications*4 • Includes • a comprehensive, accurate medication history of the patient • careful examination of the purposes and actual use of individual medications • issues identified (including indications, actions, uses, effects and side effects, max cumulated dose, contraindications), and • medication management recommendations

16. eMM Concepts and Definitions • Definitions • Medication Review Record • Comprehensive and authoritative reviewed list of all medications (prescribe and over-the-counter) that a patient is current taking • Outcome of the review • Includes recommendations regarding proposed changes and ongoing medication management where applicable/required

17. eMM Concepts and Definitions • Definitions • Profile • specific attributes (such as feature, skills, knowledge, quality, capability, reputation) of something, an object, a person, an organization, a society/population that provide evaluation of the characteristics or features and support generalisation about the structure and behaviours of the target object, person, organization, society/population • Medication Profile • A set of information about characteristics of a patient’s medication use • Medication Management Profile • A set of information about a patient’s characteristics, which are relevant to safe medication management for this patient

18. eMM Concepts and Definitions • Medication Profile: Scope • Medication Profile • Comprehensive list of medications taken by a patient with information on indications, actions, use patterns, and may include • precautions, side effects, contraindications, max cumulated dose, and known allergy, intolerance histories where applicable • Managed contraindications • Failed therapy • Patient preferences • May include diagnosis and pre-existing conditions to allow contra-indication (may include supporting clinical evidences such as diagnostic results) checks • (may include genetic profile in future)

19. eMM Concepts and Definitions • Definitions • Medication Management Plan • A structured, formally defined scheme of patient medication management strategies and actions, including: • Patient’s demographics, problems/diagnoses and pre-existing conditions (including allergies and intolerances) • List of medications • Indications, actions, contraindications, precautions and managed contraindications, max cumulated dose where applicable • Patient preferences; failed therapy • Medication [supply and administration] schedules where applicable/necessary • Ongoing medication management strategies/recommendations • Next review due • May be stand alone or part of comprehensive care plan • Shared with other authorised health care providers

20. eMM Concepts and Definitions • Definitions • Medication Statement (HL7 Concept) • Definition: an assertion or statementthat a patient is "on" a medication independent of the knowledge of specific events such as prescriptions, administrations and dispenses • used: • When we have knowledge that a patient is taking a particular med and don't have knowledge of the underlying events (or those events aren't relevant) • When we have knowledge that a patient is taking a particular med and we *do* know the details about the underlying events, but from a workflow perspective it would be inappropriate or unnecessary to capture the details, but it's still important to capture the patient/drug

21. eMM: Landscape The production (cooking) processes • Electronic Medication Management • Medication Administration Records Reconciliation The receipts Complexity Medication Management Plan (processing, … etc) Reviews Medication Profile Queries Med Review Record Reconciled Med History List Unreconciled Medication History List Data components Prescribed √ Dispensed √ Administered ??? How useful clinically is a comprehensive or complete list of patient medication admin record? Or would profile of patient’s medication administration/ conformance be more useful? Patient Medication Record Medication related Reporting Administration/conformance Profile: - Max cumulated dose - Omission frequency + reasons - Dose variation frequency + reasons - Frequency variation frequency + reasons - Intermittent + PRN frequency + reasons

22. eMM: Landscape • Electronic Medication Management • Medication List Views The production (cooking) processes The receipts Reconciliation Medication Management Plan Complexity Reviews Medication Profile (processing, … etc) Queries Med Review Record Reconciled Med History List Unreconciled Medication History List Data components Patient Medication Record Medication related Reporting Long term meds list Short term/episodic meds list Intermittent meds list PRN meds list Types of med list view

23. Medication data requirement analysis The production (cooking) processes The consumptions • Top down and bottom up approaches Top down analysis Executive/ Management Decisions Medication Management Reconciliation The receipts Complementary Cross-referencing Validating Adequacy, accuracy reusability and consistency checks Reviews Medication Management Plan Clinical Decisions Medication Profile Queries Med Review Record Reconciled Med History List Bottom Up Unreconciled Medication History List Patient Medication Record Medication related Reporting The data (ingredients) Labs … & others… Pharm Advice Dispense Records Patient Conditions Allergies; Adv reactions Contra- Indicat -ions Meds Admin Prescrip-tions The sources hospitals Community pharmacies Community Labs/paths Community Imaging services others …

24. eMM: Landscape • Electronic Medication Management • Three key components • Contents • Concepts and definitions • Infrastructures • Trigger events; messages; services • Registry; repository • Applications/User interface/viewer

25. Medication data – how they are used: through application/Interface design