Scenarios for good use of medication information

A system for keeping track of medication data would eventually see these scenarios:
(scenarios --> refer to available data, and what kind of static initial conditions can exist)

-    Patient’s medication is inside the same system and follows the basic scenario workflows – prescribed, and validated, dispensed and administered exactly as prescribed. CMPD.

-    (Chronic) patient is inside the hospital and all his medication activity is recorded inside the same system and follows the basic scenario workflows – prescribed, and validated, dispensed and administered exactly as prescribed

-    (Chronic) patient is inside the hospital and all his medication is inside the same system and follows the basic scenario workflows. In addition, patien has a contrasted exam and a surgery in the hospital.

-    (Chronic) patient is inside the hospital and all his medication is inside the same system and follows the basic scenario workflows, but medicaton is replaced in the Pharmacy by an equivalent

-    Patient is admitted to new hospital and reports known history to admitting physician

-    Patient is admitted to new hospital and history is fetched from community repository

-    Patient is admitted to new hospital and history is fetched from community repository, but from wrong patient

-    Patient is admitted to new hospital and history is fetched from community repository, patient reports additional medication to admitting physician

-    Patient is admitted to new hospital and history is fetched from community repository, patient reports verbal dose changes to admitting physician

-    Patient is admitted to a country but his medication history is available in another country

-    Patient is admitted to hospital for surgery. Search reveals that there is no current medication, but many years ago, patient took antidepressives that may still affect anesthesia. Complete history for the last X months (for vertain type of medication) is fetched from community repository in another country

-    Patient has a new treatment. In one of the therapies, there is a mismatch between the expected treatment start time and the real dispense time.

-    Patient has a continued treatment. In one of the therapies, there is a mismatch between the expected treatment start time and the real dispense time.

-    Patient is admitted to the hospital. Admitting physician builds the patient’s medication history from all sources and other consumers in the hospital reuse that information.

-    Patient is admitted to the hospital with infection. Patient refers previous antibiotic treatment followed correctly, and prescription and dispense data are according to patient’s statement. Antibiogram indicates treatment was not effective, and patient admits that 2 doses were skipped and taken after time.

-    Phychiatric patient reports adherence. Physician suspects the opposite.

-    Patient is admitted with complications, physician suspects the use of oral contraceptive but patient denies it for cultural reasons.


AND...
A system for keeping track of medication data would eventually be used in these cases:
(use cases --> refer to processing of the data, and what kind of dynamic behaviour can be expected)

- The health authorities decide to investigate the long-term effects of a counterfeit medication. Using unique medication item identification (see ePedigree), the patients that took the counterfeit medication are identified, and this is checked with the condition that was being treated with the medication. The patients are identified and called for a consultation.

- To eradicate H. Pylori, the physician wants to determine the ideal therapy. The physician consults the patient's previous treatments, which shows that a previous protocol was followed by the patient at home. The physician wants to investigate whether the treatment was properly followed, including administration times, to investigate whether there can be some resistance to the previous antibiotics.



I'll later post the features that are required by these use cases.



Real use cases also to follow.

Some existing boundaries in Healthcare management

Some boundaries still to be addressed in Healthcare - an outsider's perspective:


- The gap between "clinical products" and "physical/logistic items". 
When a physician wants clinical information for prescribing, he has the clinical attributes of a product (or product type). But for the pharmacist, this item has also logistic features, like location, price, packaging... And they are referring to the same thing.

- The difference between a catalog item (e.g. Renault 5 TL) and an instance of that (my first car, license plate FZ-09-62)
This very simple difference (or the lack of awareness) is breaking implementations of barcodes, RFIDs,


-The separation between Clinical domains and Healthcare Management. 
After seeing struggles between clinicians and business managers, the gaps between these 2 domains are obvious. The conflicting interests are usually taken (wrongly) as reasons for discussing who's better. To me, the most obvious is that multi-criteria decision making is common, and healthcare management (minimizing costs, maximizing benefit to patient and society) is a clear example where bridges are needed.

On Stock management in Pharmacy

Daily examples to describe some problems around the resupply of items in a Pharmacy:

The most usual approach to organized supply of items seems to be
Minimum Level Reordering

In this case, (which introduces the concept of reorder point), the reorder quantity can be fixed, but the frequency of refills depends on the consumption.
This is like we go shopping (for a predetermined number on units) immediately when we see we are short on some item.

In other cases, there may be a continuous (e.g. weekly) supply. In this case the frequency is fixed, but the refill amount depends on the quantity needed . This is when we go monthly or weekly to a big store - the amount we buy is usually variable.

Personally, like everyone, I think, I do not buy when the stock is below a given level. I note it in my list, and I consider the time between purchases and other factors to determine the quantity to buy.

More interesting for healthcare (but trivial to any person): when I go shopping, I take into account not only the current stock, and the usual stock, but also any additional factors that may influence e.g. the desired stock level - taking into account that I have one more person with me will increase the amount of food that I must buy.

This introduces the notions in Operations Research, where much advanced knowledge exists, and should be applicable to healthcare.

Healthcare logistics are still one step behind "normal" logistics, and the exploration of use cases should permit some innovation in healthcare.

User Interface guidance

Good design guidance from Microsoft about healthcare systems. 

http://www.mscui.net/

Nice move, addressing medication first.

Will keep it in the background. Or foreground, if needed.

Supply of Medical Devices

A nice video on supply of medical devices.

Optimizing the Supply Chain of Medical Devices: A Shared SaaS Platform for Suppliers and Providers
This reminded me of my field visits, where the sales Rep keeps a trunk stock, and a paper report or an application acts as a stock manager.

Some interesting concepts:
- Physician Preference Items (100 to 20000 US$ each, ca 40% of total hospital supply expenses)
- Consignment items
- Write-offs (I no longer find write-offs an issue, only the fact that they are not controlled/observed)
- Reverse logistics ARE important (Recalls, expired items)

Some concepts I keep present:
- 3 most important things seem to be traceability, traceability and traceability. Easy traceability, as in "show me your RFID/Barcode, I will know where you are". Ubiquitous traceability, as in "tell me often where you are".

- A rigid system would not work. Any system should not be limiting the marketing and distribution models

- Integration with other processes (charging, clinical) is a common requirement. For example tracking an item that has been implanted...

When it comes to inventory...
All you know is that you're wrong. But how wrong?

Going Agile

The team decided to implement Scrum.

Based on lessons learned with the best, we have a team that is willing to deliver working software and get frequent feedback.

The formula comes down to 3 things:
- Engage
- Always be ready to deliver frequently
- Evaluate your delivery frequently, and how to make a better delivery next time.

The product is an innovative one, so much benefit should come from this new approach.

New Zealand Pharmacy Community Pharmacy process and messages

Something from the other side: A business process description and a set of messaging standards.
HL7 v2 in community.

http://www.ithealthboard.health.nz/sites/all/files/10030.1%2BEPharmaceutical%2BBusiness%2BProcess%2BStandard%2Bv1.pdf


http://www.ithealthboard.health.nz/sites/all/files/10030.2%2BEPharmaceutical%2BMessaging%2BStandard%2Bv1.pdf

the Pharmacy Interoperability Model

Thanks, Simon Letellier