Medication Documentation IHE Pharmacy / HL7 Pharmacy Editor: Jürgen Brandstätter

Medication Lists and Profiles Raw data collected of various data sources PrescriptionDispenseAdministration Medication Statement Medication Profile Allergies, Contraindications and other medication-related clinical information for medication management Reconciled Medication List Other non-clinical data related for Med. Management Unreconciled Medication List Reconciled Med. List Aggregated/processed medication list Higher complexity level with some kind of pre-processing of the data e.g. combining same medications, etc. Medication lists Processes Medication Reconciliation Medication Review Medication Aggregation/processing Collection of various data sources Medication Management Med. Management Profile

Medication Lists and Profiles Raw data collected of various data sources Processes PrescriptionDispenseAdministration Medication Statement Medication Reconciliation Medication Review Medication Profile Allergies, Contraindications and other relevant clinical information for medication management Reconciled Medication List Medication Management Unreconciled Medication List Reconciled Med. List Med. Management Profile Medication Aggregation Medication lists Processed Rec medication list Processed Unrec medication list

Raw data collected of various data sources PRE DIS PRE DIS MedStat ADM MedStat

Unreconciled Medication list PRE DIS PRE DIS Time MedStat ADM MayJunJul PRE DIS PRE DIS MedStat ADM MedStat

Act of reconciliation (e.g. at Hospital Admission) Query for Unreconciled Medication List Time Reconciled Medication List (at this point of time) Unreconciled Medication List (at this point of time) May serve as data source Pre 1Dis 1Pre 2RecMed List Dis 2Pre 3 Pre 1 Dis 1 Pre 2 Pre 1 Dis 1 Pre 2 RecMed List Dis 2 Pre 3 For dedicated use (e.g. during Hospital stay) For dedicated use (e.g. during Hospital stay)

Vienna Meeting Date: 12 February 2014 Medication management – Related concepts – Processes involved – Expected process outcomes Stephen Chu Slide 1

Collection – The action or process of collecting someone or something (Oxford English Dictionary) – To gather or keep objects of interest together (Macmillian Dictionary) – Note – “collection” does not imply/require compiling Compiling – Produce (e.g. a list or a book) by assembling data/information from the collection – Applying business rules E.g. Matching Prescriptions and Dispenses Slide 2

Normalization – The imposition of standards or regulation – To bring something into usual or expected state or condition (Merriam- Webster Dictionary) – The machine process of reorganizing data so that there is no redundancy of data – E.g. Removal of duplicates Annotation – The addition of note, coded note, comments, explanation to something (Merriam-Webster Dictionary; Oxford English Dictionary) – E.g. The adding of missing active ingredient information Grouping – The addition of overarching entities which bundle existing data together – E.g. Same medication given at several times is grouped together Slide 3

….. compilation Med 1 ( ) Med 2 ( ) Med 3 ( ) Med 1 ( ) Med 4( ) Med 2 ( ) Med 4 ( ) Unreconciled Med List Med 1 ( ) Med 1 ( ) + Active Ingredients Med 2 ( ) + Active Ingredients Med 3 ( ) + Active Ingredients Med 4( ) + Active Ingredients Med 4 ( ) + Active Ingredients Normalised, annotated Med List Normalization + Annotation + Grouping Slide 4

Medication Reconciliation – Definitions “Reconciliation” The act of causing two things, ideas, people or groups free from disagreement (Merriam- Webster Dictionary) The action of making two or more views, matters, items compatible with others (Oxford English Dictionary) The act of analysing two or more things, business accounts/records to identify discrepancies, find the causes and to make them consistent, aligned (Business Dictionary) – Medication reconciliation is a formal process of obtaining and 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 Slide 6

Med 1 ( ) 1000mg, oral Med 1 ( ) 500mg, oral Med 2 ( ) 25mg, oral Med 3 ( ) 10mg, sublingual Med 4 ( ) 10iu, SC Med 4 ( ) 5iu, SC Med 1 ( ) 1000mg, oral Med 2 ( ) 250mg, IV Med 3 ( ) 10mg, sublingual Med 2 ( ) 25mg, oral Med 4 ( ) 10iu, SC Med 1 ( ) 500mg, oral Med 4 ( ) 5iu, SC Unreconciled Med List Reconciled Med List Med 1 ( ) 1000mg, oral Med 1 ( ) 500mg, oral + Active Ingredient Med 2 ( ) 25mg, oral + Active Ingredient Med 3 ( ) 10mg, sublingual + Active Ingredient Med 4 ( ) 10iu, SC Med 4 ( ) 5iu, SC + Active Ingredient Reconciled, annotated Med List error ReconciliationAnnotation Slide 7

Aggregation – The act or process of forming a whole by combining several things together (Oxford English Dictionary) – In OO design, aggregation is a “containment” relationship which specifies that an object contains other objects – The combination of related categories to form a common branch of hierarchy, to provide information at a broader level (OECD statistical collation processing) – Aggregation denotes the compounding of data into an aggregate (Oxford Dictionary of Statistical Terms) – Aggregation is a process of gathering, collating, summarizing data into formats that achieve specific business objectives, e.g. to support data mining and analysis (data mining, business intelligence definition) Combing + Containment Combing + Summarization Slide 8

Medication Lists and Profiles Raw data collected of various data sources PrescriptionDispenseAdministration Medication Statement Medication Profile Allergies, Contraindications and other medication-related clinical information for medication management Reconciled Medication List Other non-clinical data related for Med. Management Reconciled Med. List Processes Medication Reconciliation Medication Review Normalization Collection of various data sources Medication Management Med. Management Profile Unreconciled Medication List Normalised, Annotated Medication List Reconciled, Annotated Medication List Reconciliation + Annotation Normalization + Annotation Annotation