Transcript dose-vs-product-20th-march-2013

Vive la différence?
Dose Vs Product
Dose instructions syntax
Dr Paul Miller
[email protected]
Prescribing Model
La différence…
Dose Based
Furosemide
Hospital / Secondary
80mg oral at
Care
8am
Product based
Furosemide
General40mg
Practice
tablets
/ Primary
, take Care
2 at 8am
Interface
Furosemide
80mg oral at
8am
Furosemide
40mg tablets,
take 2 at 8am
dm+d
Furosemide
Furosemide
80mg oral at
40mg tablets
8am
Virtual Product
Ingredient
VTM
Virtual
Atenolol
Therapeutic
Moiety
Actual Product
Excipient
Product
Availability
Virtual Product
Form
Virtual Product
Route
VMP
Atenolol
Virtual
50mg
Medicinal
tablets
Product
Atenolol
AMP
50mg
Actual
tablets
Medicinal
Product
(Cox)
Controlled Drug
Prescribing
Combination
Pack Content
Drug Tariff
Category
Supplier
Licensed Route
VMPP
Atenolol
Virtual
50mg
Medicinal
tablets x28
Product Pack
Atenolol
AMPP
50mg
Actual
tablets
Medicinal
Pack
Product
(Cox) x28
Reimbursement
Information
Furosemide
Furosemide
40mg
tablets
take 2 at 8am
Pack Price
Product
Prescribing
Appliance
Product
Information
Solve this with?
• Models of dose & directions – ‘dose syntax’
• Would allow calculation of e.g.
– Daily quantities
– Compliance
– Safety
– Dose comparison
• Translation of
– Dose to Product
– Product to Dose
Model of dose and frequency
• Dose
–
–
–
–
–
–
–
40mg
0.5mcg
5ml
2 tablets
Thinly
2 puffs qds
If Systolic >160 take
80mg
• Frequency
–
–
–
–
–
Daily
Three times a day
Once daily at 18:00
Every Wednesday
Reducing by 1 tab a
week to zero
Work to date…
2005
2008
Dose Syntax Project
• …all dosage instructions require human
reading and interpretation and transcription
between different systems, both of which
offer a variety of opportunity for patient
critical error to enter
Dose Syntax Project
• Therefore, having a representation of dosage
instructions in a format to support electronic
use is a key requirement to move forward in
such areas as automated data entry into
prescription
• Many systems have local vocabularies to
produce dosage instructions ; however these
are non -standard in both content and
structure
Vision ‘vocabulary’ example
Dose Syntax Project
• Core Components
– dose quantity
– timing of the dosage
– route, site and method of administration
– rate of administration
– “additional information”
• (e.g. swallow whole, on an empty stomach).
Dose Syntax Class Model
In HL7 V3 Pharmacy Model
Issues
• Dose / Quantity
– Reducing doses
– mg/kg
• Timing Issues
– ‘during waking hours’
– ‘except Mondays and Fridays’
• Modelling issues
– “0.5 initially. If no joy, take 1 next time. Again if
not successful take 2 next time”
NHS CFH Dose Syntax Abstract Model
• “The Dose Syntax Abstract Model is intended
to be independent of any technology standard
or software platform and has been developed
with the aim of specifying the necessary
clinical requirements precisely and
unambiguously”
NHS CFH Dose Syntax Abstract Model
•
•
•
•
•
•
•
Dose Comparison
Dose Conversion
Dose/Volume Calculations
Dose Range Checking
Ward Medicines Management
Usage within Primary Care
Dosage Presentation
Medication Administration
EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA
class Medication Administration Package
EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA
Described Medication
Medication Administration
EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA
Medication Administration Procedure
+medication
Medication
Additional Instructions
+additionalInstructionsTrial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA
EA 7.1 Unregistered Trial Version
EA 7.1 Unregistered
- route: Coded [ 0..1]
0..1
-
description: String
0..*
-
administrationSite: Coded [0..*]
- excludedAdministrationSite: Coded [0..*]
EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version
EA 7.1
- method: Coded
[0..*] Unregistered Trial Version EA 7.1 Unregistered Trial Version EA
+administrationProcedure
0..*
Dose Quantitie s
EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA
1.. 1
Medication Dose Quantity
+doseQuantity
EA 7.1 Unregistered
Trial Version EA 7.1 Unregistered
Trial Version EA 7.1 Unregistered Trial Version
EA 7.1 Unregistered Trial Version EA
Precondition
Goa l
-
preconditionType: Coded
offset: DurationInterval [0..1]
Medication Administration Instruction
-
goalType: Coded
0..*
0..1
-
administrationDetails: String [0..1]
EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version
EA 7.1 Unregistered Trial
Version EA 7.1 Unregistered Trial Version EA
1.. 1
0..*
1.. 1
0..*
1.. 1
EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial
Version EA 7.1 Unregistered Trial Version EA
+criterion
0..1
+objective
0..1
Medication Dose Rate
…contains the set of classes,
and their relationships and
constraints required to describe
the administration of a
medication
1.. *
+doseRat e
EA 7.1 Unregistered Trial Version
EA 7.1 Unregistered Trial Version EA 7.11..Unregistered
Trial Version EA0..1
7.1 Unregistered Trial Version EA
Event Criterion
1
+doseString
1.. 1
EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA
Dose String
+doseTiming
Medication Dose Timing
-/ doseString: String
EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version
EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA
1.. 1
EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA
Coded Ev ent Criterion
-
value: Coded
Ev ent Criterion Reference
-
EA 7.1 Unregistered Trial Version EAvalue:
7.1 Reference
Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA
EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA
EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA
EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA
Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Tr
Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Tr
Described Medication
Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Tr
Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Tr
Unregistered
Trial Medication
VersionPackage
EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Tr
class Described
Medication
Unregistered
Trial Version EA 7.1 Unregistered Described
Trial Version
EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Tr
Medication Administration
Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Tr
Medication
Medication Administration Instruction
+medication 0..1
-
medicationId: Coded
form: Coded [0..1]
brand: Coded [ 0..1]
Ingredient
+/ingredient
- ingredientSubstanceId:
CodedUnregistered Tr
Unregistered Trial Version EA 7.1 Unregistered
Trial Version EA 7.1 Unregistered
Trial
Version EA 7.1
0..*
1.. 1
0..*
Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Tr
Unregistered Trial Version
Unregistered Trial Version
Unregistered Trial Version
Unregistered Trial Version
Unregistered Trial Version
Unregistered Trial Version
Unregistered Trial Version
Unregistered Trial Version
…the set of classes, and their
EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Tr
relationships and constraints
EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Tr
that
aspects
of EAa 7.1 Unregistered Tr
EA 7.1 Unregistered
Trial represent
Version EA 7.1 Unregistered
Trial Version
EA 7.1 Unregistered
Trial Version EA 7.1item
Unregistered
Trial Version EA
medication
relevant
to7.1 Unregistered Tr
EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Tr
specifying a structured
EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Tr
Medication Administration
EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Tr
Instruction.
EA 7.1 Unregistered
Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Tr
1.. 1
1.. 1
+doseFormSize
0..1
+strengthNumerator
Dose Form Size
-
value: Real
unitOfMeasure: Coded [0..1]
1.. 1
1.. 1
+strengthDenominator
Ingredient Strength Component
-
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unitOfMeasure: Coded [0..1]
0..1
Dose Quantities
EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version E
class Dose Quantities Package
Dose Quantitie s
EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version E
Medication Unit Dose Quantity
EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered
Trial Version EA 7.1 Unregistered Trial Version E
-
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unitOfMeasure: Coded
unitOfMeasureType: Coded
EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version E
+numerator
Medication Dose Quantity
1.. 1
+denominator
1.. 1
EA 7.1 Unregistered Trial Version EA +doseQuantity
7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version E
0..1
0..1
0..1
EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version E
Medication Dose Quantity Ratio
Medication Administration
EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version E
Medication Dose Rate
Medication Administration Instruction
1.. 1
+doseRat
e
EA 7.1
Unregistered Trial Version
EA 7.1
Unregistered
Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version E
1.. 1
…represent the key physical
quantity attributes of dose
quantity, dose timing and, for
continuously administered
medications, dose duration and
dose rate…
0..1 -
value: RealInterval
unitOfRate: Coded
unitOfMeasureType: Coded
Medication Dose Trial
Occurrence
EA 7.1 Unregistered Trial Version
EA 7.1 Unregistered Trial Version EA 7.1 Unregistered
Version EA 7.1 Unregistered Trial Version E
1.. *
-
value: IntegerInterval
+numberOfDoses
EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version
1.. 1
EA
0..17.1Simple
Unregistered
Dose Frequenc yTrial Version E
EA 7.1 Unregistered Trial Version EA 7.1 Unregistered
Version EA 7.1 Unregistered
Version EA 7.1 Unregistered Trial Version E
MedicationTrial
Dose Timing
Medication DoseTrial
Frequency
+doseTiming
-
intention: String
1 - doseTime: Timestamp [0..*] {ordered}
EA 7.1 Unregistered Trial Version EA 7.11..Unregistered
Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version E
1.. 1
Complex Dose Frequency
-
Coded [0..1]
EA 7.1 Unregistered Trial Version EA 7.1 Unregistered
Trial Version
EA 7.1 Unregistered
Trial Version EA 7.1 alignment:
Unregistered
Trial Version E
1.. 1
1.. 1
Medication Dose Interv al
+doseDuration
0..*
+courseDuration
0..1
-
alignment: Coded [0..1]
EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version
EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version E
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Time Period
-
value: DurationInterval
1.. 1
1.. 1
1.. 1
EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version
EA 7.1 Unregistered Trial Version EA 7.1+innerTiming
Unregistered
Trial Version E
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Inner Timing
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Unregistered
Trial Version
EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version E
1.. 1
EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA
7.1 Unregistered Trial Version E
1.. 1
EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version E
Together…
class NHS Dose Syntax Model
EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version
7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Versi
DescribedEA
Medication
EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1
Unregistered Trial Version EA 7.1
Unregistered Trial Version EA 7.1 Unregistered Trial Versi
Medication
Ingredient
+medication
+/ingredient
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1.. 1 Version
0..*
EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version
EA 7.1 Unregistered Trial
EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Versi
Medication Administration
EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered
1.. 1
Trial Version 1.. 1EA 7.1 Unregistered
1.. 1 Trial Version EA 7.1 Unregistered Trial Versi
Additional Instructions
+additionalInstructions
+doseFormSize
0..1
+strengthNumerator
1.. 1
+strengthDenominator
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AdministrationEA
Procedure
EA 7.1 Unregistered Trial Version 0..*EA 7.1 UnregisteredMedication
Trial Version
7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Versi
Dose Form Size
Ingredient Strength Component
EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Versi
+administrationProcedure
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1.. 1
EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version
EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Versi
Precondition
Goa l
AdministrationEA
Instruction
EA 7.1 Unregistered Trial Version EA 7.1 UnregisteredMedication
Trial Version
7.1 Unregistered
Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Versi
0..*
Dose Quantitie s
1.. 1
0..* Trial Version
0..* EA 7.1 Unregistered
EA 7.1 Unregistered
Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Versi
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1.. 1
Medication Unit Dose Quantity
+criterion
0..1 Trial
+objective
0..1 EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Versi
EA 7.1 Unregistered
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1.. *
Event Criterion
1.. 1
+numerator
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1.. 1
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EA
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EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial VersionMedication
EA 7.1
Trial Version EA 7.1 Unregistered Trial Versi
DoseUnregistered
Quantity Ratio
Coded Ev ent Criterion
Ev ent Criterion Reference
EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version
+doseRat e EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Versi
Medication Dose Rate
0..1
EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Versi
Medication Dose Occurrence
+numberOfDoses
EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered
Trial Version EA 7.1 Unregistered Trial Versi
1.. 1
0..1
Simple Dose Frequenc y
EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Versi
+doseTiming
Medication Dose Timing
Medication Dose Frequency
EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Versi
1.. 1
Complex Dose Frequency
1
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Version
EA 7.1 Unregistered Trial Versi
1.. 1
1.. 1
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EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Versi
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1
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1
EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial1.. Version
EA 7.1 Unregistered Trial Versi
1
EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial1.. Version
EA 7.1 Unregistered Trial Versi
EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Versi
EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Version EA 7.1 Unregistered Trial Versi
Dosage Calculations
• Dose Syntax Model:
– dose conversion calculations;
– dose / volume calculations; and
– dose rate calculations
• …to be able to convert VTM or product-based
dose quantities … into equivalent product-based
quantities
• …handling medications and prescriptions
between primary and secondary care.
• Discharge medication instructions…converted
into product-based quantities.
Using this!
Example 45:
During an in-patient stay, a patient is given
Atenolol 75 mg daily basis. When the patient is
discharged, the discharge instructions to the GP
ask for the patient to remain on Atenolol 75 mg
daily until the GP is satisfied with the patient’s
condition. If the GP wants to prescribe
318434003|Atenolol 25mg tablets|, how many
tablets should be taken daily?
Example 45
doseInstruction
medication
medicationId
form
doseQuantity
87652004|Atenolol|
3319411000001109|tablet|
value
unitOfMeasure
unitOfMeasureType
administrationProcedure
75
258684004|mg|
IQU (ingredient qty unit)
route
26643006|oral|
Example 45
So.. why not?
• Still some issues
– 29 noted
• Basic problems to solve first
• Implementation challenges
– Complexity
– User interfaces
– Safety
– Terminologies
• But one day soon…
Summary
•
•
•
•
•
My ‘tds’ is not your 8:00; 14:00; 18:00
Patients swallow products
Prescribers advise doses
The interface needs a brain
Solvable problem
– But Complex!