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  1. FHIR Specification Feedback
  2. FHIR-35196

Issue with Presenting Drug Alternatives description

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    • Change Request
    • Status: Published (View Workflow)
    • Highest
    • Resolution: Persuasive with Modification
    • US Da Vinci Drug Formulary (FHIR)
    • 1.2.0
    • Pharmacy
    • STU
    • Use Cases and Overview
    • 3.5.1
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      Change the wording to include an acknowledgement that such capability does exist, but requires detailed clinical data regarding the member as well as a clinical understanding about the therapeutic purpose that is not generally within the competency of the average member for which this IG is meant to assist  than is readily available for consumers.

      Make the following changes (underlined)

      Finding appropriate alternatives of a prescribed medication is complex and often depends on additional clinical information about the patient well as the condition or set of conditions for which the medication is meant to address. The means to identify therapeutic alternatives to drugs does exist in the industry, but such capability is complex, requires clinical information about the patient that is not within in scope of this guide, and a clinical understanding of the intended therapeutic use of the medication which is not generally within the competency of most members.  The information and business rules necessary to identify possible therapeutic alternatives, and therefore the ability to search for such alternatives, currently lies outside of the scope of this guide.

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      Change the wording to include an acknowledgement that such capability does exist, but requires detailed clinical data regarding the member as well as a clinical understanding about the therapeutic purpose that is not generally within the competency of the average member for which this IG is meant to assist  than is readily available for consumers. Make the following changes (underlined) Finding appropriate alternatives of a prescribed medication is complex and often depends on additional clinical information about the patient well as the condition or set of conditions for which the medication is meant to address.  The means to identify therapeutic alternatives to drugs does exist in the industry, but such capability is complex, requires clinical information about the patient that is not within in scope of this guide, and a clinical understanding of the intended therapeutic use of the medication which is not generally within the competency of most members.   The information and business rules necessary to identify possible therapeutic alternatives, and therefore the ability to search for such alternatives, currently lies outside of the scope of this guide.
    • Corey Spears / Dave Hill: 12-0-1
    • Clarification
    • Non-substantive

    Description

      Language at issue: "Finding appropriate alternatives of a prescribed medication is complex and often depends on additional clinical information about the patient well as the condition or set of conditions for which the medication is meant to address. The information and business rules necessary to identify possible therapeutic alternatives, and therefore the ability to search for such alternatives, lies outside of the scope of this guide."

      The language here stands out. It's describing finding alternatives to basically be impossible, and while that might be the case using Formulary info alone, I feel it would be worthwhile to reference the role that other transactions (like RTPB) can play when it comes to finding really granular coverage information, including alternatives. It would be helpful to at least allude to the fact that there are other processes that can handle this. Otherwise, any reader of this guide would safely assume that getting this information just isn't possible today. Identifying clinically appropriate alternative medications can be complex and dependent on patient-specific factors, it is unclear if the guide is saying that presenting alternatives is completely out of scope for the guide (meaning that the patient won't see any suggested alternatives) or if the guide is just not providing any guidance on how to determine alternatives. This should be clarified. Also suggest mentioning that other transactions, such as NCPDP RTPB. Is there a reason why this is out of scope for the guide? Clinical judgment will always be necessary in drug selection, but this FHIR guide should be able to offer basic alternatives for drugs in the same therapeutic class with a preferred formulary status (e.g., another statin, another angiotensin receptor blocker, etc.). PBMs are suggesting formulary alternatives in other standards (e.g., RTPB) so it's not clear why that would not be happening in this guide.

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              celine_lefebvre Celine Lefebvre
              Tyler Scheid
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