The (virtual) medication profile What is it? Why do we need it? How does it fit in with AORTA?

Overview Brief summary of AORTA infrastructure The essence of data The “Guideline for Medication Transfer” The ‘building blocks’ Ways to maintain and share the profile The virtual medication profile

3 NICTIZ, aims and activities Creation of the right conditions for nationwide and transparent access to real-time healthcare information about every patient: Nationwide infrastructure in the healthcare sector to ensure fast, secure and transparent information exchange  AORTA! Software interfaces to achieve seamless inter- operability, leading to a ‘virtual EHR’  HL7 v3 Initial focus on single, well-understood domain: national electronic medication record

4 Possible solutions for the network infrastructure Option 1: One big EHR database with healthcare info for 16 million people Option 2: Leave data at the source, but register a reference to it in a central repository (a so-called ‘Act Registry’) (Option 3: Somewhere in between; core data in the repository; details at the source)  AORTA!

5 The essence of AORTA: The Care Information Broker (ZIM in Dutch) Data itself it not copied in the registry Source systems upload a reference to their data –GPs and specialists upload prescription references –Pharmacies upload dispense references –Etc. All references are based on a (currently available) national patient ID and national care provider ID Interested parties use web service queries, instead of notification messages between systems

6 There are pros and cons to every solution Advantages –Always the most recent data from the ‘virtual’ DB –No risk of inconsistencies due to duplication –No exponential growth in # of interactions –Centralized access  easier to enforce standards Challenges –Performance is as yet a very uncertain factor –Centralized model requires a lot of coordination  making deadlines really becomes a challenge –The (national) ZIM has been built by an IT vendor (since the government has no intention to operate it)  this vendor achieves a monopoly position Jahrestagung HL7 Deutschland Berlin, October, 2010

7 Data retrieval with a Care Information Broker: Hospital Community Pharmacies General Practitioners Dispense and Prescription Queries E-Prescriptions Dispense References Care Information Broker (Act Registry) PRESC GP1 PAT1 PRESC GP1 PAT2 PRESC HOSP1 PAT1 … DISP PHARM1 PAT1 DISP PHARM2 PAT2 …

HL7 Models (Dispense Query) 8

Models (Dispense Query Reponse) 9

10 Secondary Care (hospitals) Medical Specialists Hospital Pharmacy Lab, Radiology, etc. Community Pharmacies Primary Care General Practitioners (‘home doctors’ in Dutch) Dentistsetc. Pharmacies in the Netherlands (3-layer model) inpatient Tertiary (long-term) Care Nursing homes, psychiatric clinics, etc. Local Pharmacy flow of prescriptions flow of patients

The essence of medical data Data is generated at the point of care Data can be maintained at point of care itself, or in centralized repository (regional, national) Data can be in ‘raw’ form (proprietary database), or contained in clinical documents (CDA format) Two (overlapping) reasons for data capture: –Controlling: triggers/responses in a workflow (e.g. prescription  validation  dispense) –Observing: capture the state of the real world (e.g. known conditions, actual med. usage) september ’1511 © Stichting HL7 Nederland

What’s the virtual EHR? 12 Virtual EHR = building block of overall virtual EHR (e.g. dispense of a certain medication) Regardless of: –Source of data –Format of data Dimensions of EHR: –Provider record (e.g. GP, specialist) –Activity database (e.g. pharmacy, lab) –Concern tracking (still in development)

The Dutch “Guideline for Medication Transfer” Every care provider has to do whatever it takes to make information relevant to medication safety available to others, further down the chain Every care provider has to do whatever it takes to have information relevant to medication safety available at the point (and time) of care The guideline describes both: –Behaviour (business rules for care providers) –Information (what is needed for assessment) The word ‘transfer’ is misleading, because it suggests a pre-determined architecture 13

Data set for assessment: the Medication Survey 14 Mandatory data elements: 1.A Prescribed medication, including strength and dosage B Dispensed medication (delivered to patient) C Administered medication (by care provider) D Actual medication usage, with time interval and optionally indication of early stop 2. Use of alcohol and other recreational drugs (nature and interval) 3. Reason for changing or stopping medication use, including initiator of the change 4. Initial prescriber and current prescriber 5. Pharmacists that dispensed the medication 6. Basic patient data: ID (BSN), name, date of birth, sex and address of patiënt 7. Derived or assessed contra-indications: conditions 8. Allergies/intolerances for medication and reported ‘adverse drug events’ Conditional data elements: 9. A set of relevant lab results (kidney/liver function, etc.) 10. Indication, for a number of relevant types of medication

Supporting the guideline Goal: every care provider has access to all relevant information at the point (and time) of care, especially at the time when medication therapy is assessed Requirement: every care provider assures that all relevant information that is generated at his/her point of care, becomes and remains available for others Instrument: the medication profile must always be up-to-date and accessible for every care provider (regardless of where the data is or what form it is in) 15

The ‘building blocks’ Medication data –Prescription Including therapy updates –Dispense Including OTC where relevant –Administration Including ‘Medication statements’ Recreational drug use (captured as ‘statements’) Certain lab results (based on authorization scheme) Potential contra-indications –Including hypersensitivities ‘Detected & managed issues’ 16

What are the blind spots? Most of the data that is generated (and sent) as part of a workflow is acccessible (prescriptions, dispenses). –15-year mandatory storage requirement for patient-related data –persistency is regardless of format (messages vs. documents) Usually captured, but rarely communicated: –Dosage changes in existing prescriptions –Stopped prescriptions (by another doctor) –Actual use (assessed by doctor or patient) Basically most information that is not part of a workflow. 17

Wider scope for ´prescriptions´ Traditionally, a prescription was a ´request to dispense´ But some medication orders don’t need a dispense: –Patient still has medication in stock –Dosage is lowered on prescription –Use of medication is being stopped New insight is that the last two are also prescriptions! Prescription update refers to prescription it updates/stops But even when there is no (known) prescription, “don’t use medication X anymore” is also a prescription! Essence is to describe the ‘pharmaceutical therapy plan’, while maintaining relationships (audit trail) where possible 18

Medication statements? Actual use can be different than prescriptions and dispense records suggest (compliance). A ‘medication statement’ is simply a ‘statement’ by a patient or his/her representative about actual use of medication (e.g. admission intake). Examples: –“I did pick up prescribed medication X at the pharmacy, but I never started using it.” –“I stopped after a week, because it made me dizzy.” –“I use medicine Y, which I bought while on vacation.” –“Last year I used a little blue pill for a while.” A medication statement is an ‘aggregated’ (sometimes vague) record of administration. 19

Ways to implement the medication profile Relay profile –Assumption: one responsible care provider at each point in time. Central profile –One central document (or other record), usually in a repository. Virtual profile –No assumptions about the responsibility for care or transfer of information. Data stays at the point of care and is managed there. 20

RELAY PROFILE 21 Outpatient visit GP visit Discharge medication Admission

CENTRAL PROFILE 22 Central repository Outpatient visit GP visit Discharge medication Admission Query/edit profile Query/open profile Query/edit profile

VIRTUAL PROFILE 23 Care information broker (ZIM) Outpatient visit GP visit Discharge medication Admissuon Query profile

Combining building blocks 24 Prescription Dispense Use / administration X

Medication ‘transfer’ based on virtual profile Uses a very universal and flexible mechanism. No dependence on strictly defined workflow At the point of care, there is only a record of what is done THERE (with references to activities elsewhere); there is no centrally managed document/database… Challenge: performance can be an issue. Challenge: presentation to user needs to be effective. Challenge: registration at the transfer between outpatient and inpatient (and vice versa) is still a source of debate. Challenge: persistence of identifiers is very important! 25