EHR System Function and Information Model (EHR-S FIM is based on EHR-S FM R2.0) CP.1.3 Manage Medication List aka DC.1.4.2 in EHR-S FM Stephen.Hufnagel@tma.osd.mil , facilitator January 23, 2012 – Original February 24, 2012 – Last Updated Call for Participation This work is being done by the HL7 EHR Interoperability Work Group, meeting every Tuesday at 4PM ET, dial-in: 1-770-657-9270, Passcode: 510269#  The most current artifacts are at: http://wiki.hl7.org/index.php?title=EHR_Interoperability_WG 9/22/2018 DRAFT WORKING DOCUMENT

CP.1.3 Manage Medication List Statement: Create and maintain patient-specific medication lists. Description: Medication lists are managed over time, whether over the course of a visit or stay, or the lifetime of a patient. All pertinent dates, including medication start, modification, and end dates are stored. The entire medication history for any medication, including alternative supplements and herbal medications, is viewable. Medication lists are not limited to medication orders recorded by providers, but may include, for example, pharmacy dispense/supply records, patient-reported medications and additional information such as age specific dosage. Example: During an encounter, a health care professional might manage a patient’s Medication List and the system also manages the filling of prescriptions, according to scope of practice, organizational policy and/or jurisdictional law. RED: delete, Blue: insert DRAFT WORKING DOCUMENT 9/22/2018

CP.1.3 Manage Medication List Activities Mapped-to System-Components 9/22/2018 DRAFT WORKING DOCUMENT

DRAFT WORKING DOCUMENT CP.1.3 Manage Medication List Conceptual Information Model (CIM) Mapped to EHR-S Functions 9/22/2018 DRAFT WORKING DOCUMENT

CP.1.3 Manage Medication List Conceptual Data Model (CDM) 9/22/2018 DRAFT WORKING DOCUMENT

CP.1.3 Manage Medication List CDM Requirements-Traceability 9/22/2018 DRAFT WORKING DOCUMENT

CP.1.3 Manage Medication List CDM Requirements-Traceability 9/22/2018 DRAFT WORKING DOCUMENT

CP.1.3 Manage Medication List “See Also” Dependencies 9/22/2018 DRAFT WORKING DOCUMENT

Action Verb Hierarches Manage (Data) Capture Maintain Render Exchange Determine Manage- Data- Visibility Auto-Populate Enter Import Receive Store Update Remove Extract Present Transmit Export Analyze Decide De-Identify Hide Mask Re-Identify Unhide Unmask Archive Backup Decrypt Encrypt Recover Restore Save Annotate Attest Edit Harmonize Integrate Link Tag Delete Purge 9/22/2018 DRAFT WORKING DOCUMENT

DRAFT WORKING DOCUMENT Archive Older slides 9/22/2018 DRAFT WORKING DOCUMENT

CP.1.3 Manage Medication List Conformance Criteria 1. The system SHALL provide the ability to manage a patient-specific medication list based on current medication orders or prescriptions. The system SHALL provide the ability to manage the details of the medication information including prescriber, ordering date, dose, route, and SIG (description of the prescription, such as the quantity), formulation and instructions according to scope of practice, organizational policy and/or jurisdictional law. 3. The system SHALL provide the ability to manage, as discrete data, medication information including prescriber, ordering date, dose, route, and SIG (description of the prescription, such as the quantity) according to scope of practice, organizational policy and/or jurisdictional law. 4. The system SHALL provide the ability to capture other dates associated with medications such as start , end and discontinuation dates. 5. The system SHALL provide the ability to capture medications not reported on existing medication lists or medication histories. 6. The system SHALL provide the ability to capture non-prescription medications including over the counter and complementary medications such as vitamins, herbs and supplements. 8. The system SHALL provide the ability to render the medication history associated with a patient. 10. The system SHALL provide the ability to tag a medication as erroneously captured and excluded from the presentation of current medications. 11. The system SHALL provide the ability to render a current medication list for patient use. RED: delete, Blue: insert DRAFT WORKING DOCUMENT 9/22/2018

CP.1.3 Manage Medication List Conformance Criteria 12. The system SHOULD provide the ability to capture and render information regarding the filling of prescriptions. The system SHOULD provide the ability to capture and render information regarding the dispensing of prescriptions. The system SHALL provide the ability to receive from an external source (for example a plan, payer or pharmacy) a medication history. The system SHALL provide the ability to capture that a medication history is unavailable or incomplete. The system SHALL provide the ability to capture a description and reason for a medication when the medication name is unknown. The system SHALL provide the ability to render on the medication list active medications that the patient brings from home to take while hospitalized, which the Pharmacy may not dispense. The system SHOULD provide the ability to maintain the medication list with changes from pharmacist verification including pharmacist, date, and time. The system SHOULD provide the ability to manage the reason or indication for the medication when recording historical or medications from external sources (e.g. from home or other provider). The system SHOULD provide the ability to update a medication order directly from the medication list. The system SHALL conform to function CPS.4.2.1 (Support for Medication Interaction and Allergy Checking) to render any potential interactions when capturing or maintaining medications. The system SHOULD provide the ability to maintain a medication order directly from medication reconciliation. RED: delete, Blue: insert DRAFT WORKING DOCUMENT 9/22/2018

CP.1.3 Manage Medication List Conformance Criteria The system SHALL provide the ability to capture free text medications and render them in a manner that distinguishes them from coded medication entries. The system SHALL tag and render an indicator that interaction checking will not occur against free text medications. The system SHOULD provide the ability to render side effects of medications from the medication list that have been previously experienced by the patient. The system SHOULD provide the ability to render potential side effects of medications from the medication list. The system SHALL provide the ability to capture and render that the patient takes no medications. The system SHALL provide the ability to render only current active medications (i.e. exclude prescriptions whose duration has been exceeded or end date has passed). The system MAY provide the ability to render non-active medications or prescriptions for inclusion in current medication screening. The system MAY provide the ability to capture medication self-administration details including timestamps, observations, complications, and reason if medication dose was not taken. The system MAY capture Investigational Product Exposure information including Start Date/time, End Date/Time, Dose Amount, Dose Unit, Study Treatment Name, Route, Formulation as discrete elements. The system SHALL capture, maintain and present pre-admission medications. RED: delete, Blue: insert DRAFT WORKING DOCUMENT 9/22/2018

CP.1.3 Manage Medication List Conformance Criteria The system SHALL present pre-admission medications at the time of discharge. The system SHALL provide the ability to capture, maintain, and present all pertinent details of the medication administration including medication name, strength, dose, route, date and time of administration, exceptions to administration, and administrator of the medication. RED: delete, Blue: insert DRAFT WORKING DOCUMENT 9/22/2018

CP.1.3 Manage Medication List “See Also” Dependencies CPS.9.3 Health Record Output OVERARCHING: Trust Infrastructure Record Infrastructure 9/22/2018 DRAFT WORKING DOCUMENT