Responses to Dan Johnson's Workflow Analysis

This is a response to Dan Johnson's WorkflowAnalysis, where we try to show how we took his descriptions and explanations into consideration in the design of the application. At this point, most suggestions have been considered in a general and may not be fleshed out in all detail yet, because until now we were heads down into too much basic stuff. I will echo his bullet points here and provide a short paragraph to say how we functionally responded to them:

What are we prescribing?

Medications, Enteral, Parenteral

• These are distinguished by the route field. In hospital care parenteral infusions are created by mixing together components. This is not yet quite supported, although the data model can do it.
• Dose rate (mL per time) is supported by the model but not shown yet in the user interface

Oxygen

• Not considered yet in any other way than as a medication
  • with dose and nasal or inhalation route
  • flow rate is supported by the model but not shown yet on the user interface

Durable medical equipment

For Medicare, this has very special requirements, and physicians do not usually have the requisite forms. Can we include in this software copies of the CMS DME equipment prescription forms, or must those originate with the supplier?

• This has not yet been considered. It is possible though without starting a big new project, needs to be drafted, prioritized and scheduled.
• It is a supply order for a thing without a "substance administration"
• The model supports it.
• Mostly a matter of loading an electronic catalog of these items.
• Printing a special form for those is possible (subject to priority)

Therapy: speech, occupational, physical, other

• This has not yet been considered. It is possible though without starting a big new project, needs to be drafted, prioritized and scheduled.
• It is an order for a general activity without a thing supplied.
• The model supports it.
• Mostly a matter of loading an electronic catalog of these items.
• Printing a special form for those is possible (subject to priority)

Stages of prescription maintenance

Pre-office : what are the sources of the patient's meds?

Other professionals (identity not always known), Patient initiative

• These are part of the history.
• We can (and should) create a separate list of medication history items, i.e., those that are not ordered by current provider.
• We can reuse all existing functions for that, except changing a few things (mood code, author, etc.) to make sure these are not prescriptions of the current provider.

Current provider

(provider is plural == anyone who shares the available record)

• Presently we only work with one author, who is the user authenticated to the system.
• But medications are all shown, regardless of provider.
• We can divide it up as needed in response to the previous point.

In-office pre-visit

Clerk ensures a current medication list is available

Clerk examines patient record to ensure that a current medication list is available in the record.

• This clerk would fill in on medication history items.
• This clerk might transcribe previously paper-based items into the system (as we start the implementation of the new system).
• All these items would appear in the medication history list.
• Items in the medication history list could be "adopted" by the current provider simply by dragging+dropping between the two lists.

Office assistant verifies list

Office assistant rooming the patient ensures that current list accurately depicts what the patient is currently taking, interviews the patient, consults care-facility records sent with patient, contacts the patients pharmacy(ies) to confirm usage, contacts other providers (rarely) to confirm Rx.

• The results of this research need to be somehow documented. Might do this by annotating the prescriptions and medication-history items.
• This could be just free text annotations, or better
• Records which represent (to the best of available knowledge) in structured form what the patient is taking.

Office visit

physician-equivalent reviews

Physician-equivalent reviews the medication list to confirm its accuracy and appropriateness. Physician may contact (usually via telephone) providers or pharmacies to discover what the patient may be actually taking

• This is another iteration of the previous task.

After evaluating the patient medically [small or huge pause] physician prescribes medication:

modifications

alters brand, dose, form, strength, route, schedule, directions, quantity authorized, duration of authorization or number of refills

• It is as easy as selecting an existing item from the prescription list and modifying it in the editor that comes up.
• As soon as you edit, it creates a new version of the old record and keep the old record along with a link back to it.
• The editing action also has a record describing who did it and when
• We can make a field visible which will allow you to document reasons and any other discussions you want.
• The change action can also be linked to other items, such as progress notes.
• See the discussion on change tracking elsewhere.

discontinues a medication

• It is a know deficiency that we do not have a mark, button, or the like to signal discontinuation of a medication.
• Would probably be built into the edit prescription view.
• In addition, a right-click context menu action over the item in the list (discontinue).
• Need to discuss if a discontinued item would be removed from the list.
  • Possibly we can show it on the list as discontinued for a fixed time range and then drop it from the view.
  • Could also drop it right away.
  • Could make it as easy as pressing the delete-key over it.
• Our model allows for multiple ways of discontinuation:
  • replacement with a new drug (the idea of treatment persists only the mode is changed)
  • abort the treatment (marked as a bad idea)
  • complete the treatment (marked as done, no longer neccesary)
  • These are nuances which may not be very useful to distinguish, but we also allow
  • suspend a treatment for the time being, while leaving it on the list to resume later.

prescribes a new medication

• Right-click on medication list and select "new medication"
• Select something from main menu bar (the main menu bar is somewhat sloppy, I hardly ever use such main menus if there is a shorter way to it.

prescribing steps

identifies the name of the medication

• Type into the name field, auto-complete should allow you to quickly cut down to it in about 5 keystrokes.

availability, cost

• Not implemented. What are the data sources? Formularies? Where do we get them from?
• Clearly something to do in the future.
• How important is this now?

confirms patient willingness to accept the medication

• Do you want any special mark in the record for this step?
• Does this need any other support by the system?

confirms insurance restrictions on brand, name, and quantity

• Again formularies and insurance stuff.
• First problem is: where do we get this data from?
• Then how do we represent it?
• Then how do we use it?
• This would seem important to be done in the future, not sure it can be done very soon though.

checks against patient allergy

• An allergy list can be broken out from the problem list (not yet there).
• This check would in the future be automated (core part of this project's second phase).

checks against medication interactions

• This check would in the future be automated (core part of this project's second phase).

checks against food interactions

• Where would one get the information about what patient is eating?
• Would this not be simply a reminder: you should not drink orange juice?
• We can list the interactions and show those against non-drugs so you could read them off.
• This would then be considered part of the second phase of this very project.

Record

written record of the prescription

For the health record

• The system is an electronic record.
• Printing is currently being implemented
• We can define forms in XSL-FO and generate PDF.

written prescription

• Printing is currently being implemented
• We can define forms in XSL-FO and generate PDF.
• We can send it to a printer.
• We can try to fax directly.
• But from your earlier description, the process was to (1) print the prescription, (2) throw it in the fax machine, (3) keep it for the record. That we can definitely do.

creates a written communication for the patient

creates a written communication for the patient regarding medication use (med list, individual directions, medication schedule)

• I have always loved this and been inspired by this point.
• Printing is currently being implemented, etc.

fills out pharmacy or insurance forms

• We can do that with printing,
• Although the question is how do we manage these many forms?
• We are currently going with XSL-FO, just because it's the new standard
• My bias would have been TeX but it is less portable
• Something by which the user (you) or delegate could make their form for themselves would be nice.
• But definitely not Microsoft Word mail-merge :)
• Hard to think of anything, except, crazy enough but not impossible:
  • use a word processor,
  • write up an example
  • use certain tags for the values to fill in (e.g., put "${PATIENT-FIRST-NAME}" instead of "John")
  • print to (generic) postscript
  • run the generic postscript to a translator to create XML print form definition
  • use this to print off your form
  • iterate to debug
• Any suggestions for user-created prints are appreciated.

transmit prescription to the pharmacy

Transmits prescription to the pharmacy (hands Rx to patient or caregiver, faxes Rx, telephones pharmacist or nurse)

• Fax manual
• Fax automated (possible but extra development)
• e-prescribing network, e.g. surescript possible
  • but extra development
  • and independent of printing

after office visit error correction

Error correction include:

• patient
  • notes error, omission, or typo
  • asks for renewal of a medication not on the list
  • asks that the prescriptions be transmitted to 2 or more pharmacies after it's been transmitted to one
  • patient remembers that he's on a different medication, dose, or schedule than is printed on the list
• pharmacy
  • notes an allergy that wasn't on clinic record
  • reports a medication interaction that wasn't caught or known
  • reports the current unavailability of a medication
  • reports lack of insurance coverage for one or more medications
  • reports insurance or regulatory requirements for a change in quantity, duration, for substitution
  • reports that patient has not filled a prescription

• Who would make those corrections?
• Remember, the way it is set up, any change to a committed record would create another version.
• Not sure what to do with all of those, not in one fell swoop.

interim events

hospitalization-based med changes

• From whose perspective?
• If the system is only in outpatient care, it would be oblivious to hospital matters
• If the system is in inpatient care also, then one would continue with this same system.
• It would seem that the possibility to suspend prescriptions to resume later would be important here.

other provider correspondence with medication changes

• Currently not electronically.
• If provider wants to change his mind, can always go in and modify the prescriptions, etc.

telephone refill authorizations or requests

1. Log in
2. Select patient
3. Click on drug
4. Add supply/dispense (click the little + mark in the supply/dispense group)

• In the future, I understand, we would like to select a group of prescription from the list and right-click "refill all"

patient contact reporting adverse reactions or changes in use (telephone, email, letter, sidewalk conversation)

• Similar to inpatient visit
• Log in, select patient, do work.