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  1. FHIR Specification Feedback
  2. FHIR-10066

Should route and site be inside dosage instruction line?

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    • Change Request
    • Status: Published (View Workflow)
    • Medium
    • Resolution: Not Persuasive with Modification
    • FHIR Core (FHIR)
    • DSTU2
    • Pharmacy
    • MedicationDispense
      MedicationRequest
      MedicationUsage (MedicationStatement)
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      July 11: Moved by John and seconded by to Scott to defer further discussion until after the STU3 Freeze - 6/0/0/ Carried

      Additional requirements were posted in Zulip Chat:

      Federica Lanzo: Hi there,
      We are currently working on the mapping from HL7 v2 medications to FHIR resources and we just realized that v2 allows multiple RXR segments, meaning multiple different routes (Oral, IV...), while the FHIR resource allows only one route that is a CodeableConcept, allowing therefore different codings for the same concept.
      What should we do to expose all routes available in HL7 v2?

      Erich Schulz: I dont have an answer but worth noting this only really applies to medication orders not administration (ie any single dose can only be given one route, even tho the order maybe PO/IV)

      *Federica Lanzo: *You are right with administration, but both orders (RDE and OMP message types) and dispense (RDS message type) medications allow repetition of the RXR.

      *Shanta Sankaran: *It is possible for a medication ordering provider to specify multiple routes for the same medication (and dosage) in order to give the medication administrator the ability to make a decision based on the patient's actual condition.
      When the actual administration happens, the nursing staff/administrator have made the route decision and at this point of time, the route is just one (the chosen one).

      Lloyd McKenzie: I expect the work group feels this should be handled by an extension. However, feel free to raise a change request to get clarity or to get such an extension defined

      Erich Schulz: it sounds like this is a regression on a core, everyday requirement...

      *Lloyd McKenzie: *Submit a change request and argue your case for it being in the 80% then

      Michelle Miller: Although MedicationOrder.dosageInstruction.route is 0..1, MedicationOrder.dosageInstruction is 0..*

      Why wouldn't multiple dosageInstructions, each with its own distinct route, work for this use case?

      Lee Suprenant: @Michelle (Moseman) Miller what does having multiple dosageInstructions mean? Based on the description I assumed it was for cases where the dosage changes over time (an implicit "followed by" relation). I'd be nervous about it sometimes meaning that and sometimes meaning it is a different option for administration.

      *Federica Lanzo: *Yes, there is that option, but it does not correspond exactly to what HL7 v2 allows you do achieve. In fact for the same dosage indication you could provide multiple routes.
      Our temporary solution makes use of the multiplicity of dosageInstruction where all the fields are populated in the same way with the exception of the route. This does not seem to match what a v2 message was trying to communicate, though.

      *Michelle Miller: *This was discussed during the Pharmacy work group conference call today: http://wiki.hl7.org/index.php?title=2016-06-13_Rx_Conf_Call

      An action item was noted to clarify the guidance around what multiple dosageInstructions mean. Specifically, clarify when there are multiples, is it an "and" where the med is given via one route followed by another route; is it an "or" listing alternative dosage instructions; could it be either one (depending on whether the timing dates are sequential or identical) etc. More discussion to follow to land the clarifications needed.

      The other comment was wanting a better understanding of the use case (i.e. saying v2 can do it was not a compelling reason for FHIR to do the same).

      Erich Schulz: @Michelle (Moseman) Miller 2 common drugs (paracetamol/acetaminophen and tramadol) are frequently charted as PO/IV - they have a high oral bioavailability so the dose is the same - and in both cases there is a strong case for wanting to track the total dose administered in a 24 period

      (I typically write O/IV on a med chart ~ 6 times every day)

      (just as way of background on the use case)

      Michelle Miller: Thanks, @Erich Schulz , I will pass along your use case example to the Pharmacy co-chairs for the continuation of this discussion, next Monday June 20.

      Oct 3, 2016:

      Add examples of medications with multiple possible routes/sites (will send some to list). John/Scott - noting that the PO/IV expample are two separate but linked orders. the issue becomes thhow do we coordinated ("or") multiple orders (we can look at activityGroup (or requestGroup?) may be a solution for this).

      add verbiage describing PO/IV situation as 2 orders, and (maybe) how ActivityGroup can be used

      motion: Not Persuasive with Mod , will assess ActivityGroup (Melva/Lee) 8-0-0

      Show
      July 11: Moved by John and seconded by to Scott to defer further discussion until after the STU3 Freeze - 6/0/0/ Carried Additional requirements were posted in Zulip Chat: Federica Lanzo: Hi there, We are currently working on the mapping from HL7 v2 medications to FHIR resources and we just realized that v2 allows multiple RXR segments, meaning multiple different routes (Oral, IV...), while the FHIR resource allows only one route that is a CodeableConcept, allowing therefore different codings for the same concept. What should we do to expose all routes available in HL7 v2? Erich Schulz : I dont have an answer but worth noting this only really applies to medication orders not administration (ie any single dose can only be given one route, even tho the order maybe PO/IV) *Federica Lanzo: *You are right with administration, but both orders (RDE and OMP message types) and dispense (RDS message type) medications allow repetition of the RXR. *Shanta Sankaran: *It is possible for a medication ordering provider to specify multiple routes for the same medication (and dosage) in order to give the medication administrator the ability to make a decision based on the patient's actual condition. When the actual administration happens, the nursing staff/administrator have made the route decision and at this point of time, the route is just one (the chosen one). Lloyd McKenzie: I expect the work group feels this should be handled by an extension. However, feel free to raise a change request to get clarity or to get such an extension defined Erich Schulz : it sounds like this is a regression on a core, everyday requirement... *Lloyd McKenzie: *Submit a change request and argue your case for it being in the 80% then Michelle Miller: Although MedicationOrder.dosageInstruction.route is 0..1, MedicationOrder.dosageInstruction is 0..* Why wouldn't multiple dosageInstructions, each with its own distinct route, work for this use case? Lee Suprenant: @Michelle (Moseman) Miller what does having multiple dosageInstructions mean? Based on the description I assumed it was for cases where the dosage changes over time (an implicit "followed by" relation). I'd be nervous about it sometimes meaning that and sometimes meaning it is a different option for administration. *Federica Lanzo: *Yes, there is that option, but it does not correspond exactly to what HL7 v2 allows you do achieve. In fact for the same dosage indication you could provide multiple routes. Our temporary solution makes use of the multiplicity of dosageInstruction where all the fields are populated in the same way with the exception of the route. This does not seem to match what a v2 message was trying to communicate, though. *Michelle Miller: *This was discussed during the Pharmacy work group conference call today: http://wiki.hl7.org/index.php?title=2016-06-13_Rx_Conf_Call An action item was noted to clarify the guidance around what multiple dosageInstructions mean. Specifically, clarify when there are multiples, is it an "and" where the med is given via one route followed by another route; is it an "or" listing alternative dosage instructions; could it be either one (depending on whether the timing dates are sequential or identical) etc. More discussion to follow to land the clarifications needed. The other comment was wanting a better understanding of the use case (i.e. saying v2 can do it was not a compelling reason for FHIR to do the same). Erich Schulz: @Michelle (Moseman) Miller 2 common drugs (paracetamol/acetaminophen and tramadol) are frequently charted as PO/IV - they have a high oral bioavailability so the dose is the same - and in both cases there is a strong case for wanting to track the total dose administered in a 24 period (I typically write O/IV on a med chart ~ 6 times every day) (just as way of background on the use case) Michelle Miller: Thanks, @Erich Schulz , I will pass along your use case example to the Pharmacy co-chairs for the continuation of this discussion, next Monday June 20. Oct 3, 2016: Add examples of medications with multiple possible routes/sites (will send some to list). John/Scott - noting that the PO/IV expample are two separate but linked orders. the issue becomes thhow do we coordinated ("or") multiple orders (we can look at activityGroup (or requestGroup?) may be a solution for this). add verbiage describing PO/IV situation as 2 orders, and (maybe) how ActivityGroup can be used motion: Not Persuasive with Mod , will assess ActivityGroup (Melva/Lee) 8-0-0
    • Melva/Lee: 8-0-0
    • Clarification
    • Non-substantive
    • DSTU2

    Description

      I've never heard of the same drug being administered by different routes within the same prescription, nor different body sites by dosage line. Is this in the 80%? Would it not be more appropriate to list these elements just once on the prescription rather than repeating for each dosage line?

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            lloyd Lloyd McKenzie
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