A case study showing the proposed adoption of FHIR to address needs of Bristol Connecting Care during medication reconcilliation. (Currently not implemented)

Client’s Context

Connecting Care is a local electronic patient record that allows health and social care professionals directly involved in your care, to share a summary of your medical record.

Case Overview

The pharmacists would like to retrieve medications history of the patient to prepare a list or reconciled medications. They want to know the patient’s medications journey. While the initial scenario seemed to be around medication reconciliation, what becomes clear is that it’s really around the creation of a consolidated view of medication.

The patient's medication journey demonstrating questions than are asked during medication reconciliation.



Problem Statement

The Pharmacist does not have a consolidated view of a patient’s medications because the information is distributed across a number of systems.

Business Process

High level business process diagram showing the requirement to display medication from either a specific system or all systems.



Use Case Diagram

Use Case Diagram showing the Pharamacists use cases being explored.



User Stories

While the scope is initially demonstrated in the use case diagram, it is possible to refine the scope further within user stories that originate from conversations with the user. For example, from the perspective of the current Care Connect specification, security is outside of the scope of profile definition and further discussions would be required within the trust to clarify where responsibility lies.

Feature User Story
In Scope
Medication List (View) As a Pharmacist (Hospital Services) I want to retrieve a patient's medications using their NHS Number so that I can find prescribed medications for a patient when I know the 'Traced' and 'Verfied' NHS Number.
Medication List (View) As a Pharmacist (Hospital Services) I want to retrieve a patient's medications using a local system number (e.g an MRN) so that I can find medications for a patient when I don't know the traced and verified NHS Number.
Medication List (View) As a Pharmacist (Hospital Services) I want retrieve all of a patient's medications from one or more specific system so I can build an accurate list of reconciled medications.
Medication List (View) As a Pharmacist (Hospital Services) I want to know the first issue of a prescription of medication for the patient so that I know how long the patient has been on a particular medication and I can see if this has changed over time.
Medication List (View) As a Pharmacist (Hospital Services) know the current issue of a prescription of medication for the patient so that I can include this in my reconciliation and I can identify how this have changed since the initial issue.
Medication List (View) As a Pharmacist (Hospital Services) I want to know know the last issue of a prescription of medication for the patient so that I know how long the patient was expected to be issued with that medication.
Medicationn List (View) As a Pharmacist (Hospital Services) I want to display patient medications from different sources in a single consolidated view so I can more easily reconcile them into a single list.
Medication List (View) As a Pharmacist (Hospital Services) I want to know if results have not been returned due to a error so that I can consider the impact of missing information on my reconciliation.



Dataset

Drug name (generic) Issue date
Drug name (Brand) if applicable Number of issues
Product form Number of authorised issues
Product strength Source system identity
Prescribed dose History of courses for same ingredient
Prescribed frequency Issue type (acute, repeat, repeat dispensing or automatic)
Prescription data Issue notes
Additional instructions Prescription delivery method
Status of medication Date of first issue
Cancellation reason Date of last issue
Person recorded Issue quantity
Role of person Issue status (either a date of issue or 'Not yet issued')
Date authorised until



FHIR Resources

Diagram showing that the resources MedicationOrder, MedicationStatement, Patient and Practitioner have been identified as necessary profiles to support a solution for Bristol Connecting Care.

Diagram showing the first proposal which didn't include the use of MedicationOrder

The first approach considered didn't include the MedicalStatement resource but simply proposed the use of MedicalOrder. Following clinical review it was highlighted that this would assume that all medications are prescribed which is not the case. Therefore, this was extended to include both MedicationStatement and MedicationOrder.



Resources

The resources used can be found by clicking on the links below:

Medication Individuals
MedicationOrder Patient
MedicationStatement Practitioner (Problem)

Entity Relationship Diagram showing the applied profiles.



API Signatures

As a Pharmacist (Hospital Services) I want to retrieve a patient’s medications using their NHS Number so that I can find prescribed medications for a patient when I know the ‘Traced’ and ‘Verified’ NHS Number.

GET [baseUrl]/MedicationStatement?patient.identifier=https://fhir.nhs.uk/Id/nhs-number|9876543210



As a Pharmacist (Hospital Services) I want to retrieve a patient’s medications using a local system number (e.g an Trust/Hospital Number or Master Patient ID (MPI)) so that I can find medications for a patient when I don’t know the traced and verified NHS Number.

GET [baseUrl]/MedicationStatement?patient.identifier=https://fhir.example.nhs.uk/PAS/Patient|123345



As a Pharmacist (Hospital Services) I want retrieve all of a patient’s medications from one or more specific system so I can build an accurate list of reconciled medications.

GET [baseUrl]
/MedicationStatement?patient.identifier=https://fhir.nhs.uk/Id/nhs-number|9876543210&identifier=https://theccg.systemsupplier.co.uk/Sys1|



As a Pharmacist (Hospital Services) I want to know the first issue of a prescription of medication for the patient so that I know how long the patient has been on a particular medication and I can see if this has changed over time.

GET [baseUrl]/MedicationOrder?patient.identifier=https://fhir.nhs.uk/Id/nhs-number|9876543210&code=http://snomed.info/sct|[SNOMED ConceptID of Drug]

The first issue of a prescription can be deduced from the results.



As a Pharmacist (Hospital Services) know the current issue of a prescription of medication for the patient so that I can include this in my reconciliation and I can identify how this have changed since the initial issue.

GET [baseUrl]/MedicationOrder?patient.identifier=https://fhir.nhs.uk/Id/nhs-number|9876543210&code=http://snomed.info/sct|[SNOMED ConceptID of Drug]

The current issue of a prescription can be deduced from the list if issues by identifying the most recent in the returned list.



As a Pharmacist (Hospital Services) I want to know know the last issue of a prescription of medication for the patient so that I know how long the patient was expected to be issued with that medication.

GET [baseUrl]/MedicationOrder?patient.identifier=https://fhir.nhs.uk/Id/nhs-number|9876543210&code=http://snomed.info/sct|[SNOMED ConceptID of Drug]

The last issue of a prescription can be deduced by ordering the returned medications



As a Pharmacist (Hospital Services) I want to display patient medications from different sources in a single consolidated view so I can more easily reconcile them into a single list. CC profiles - MedicationStatement and it’s containing profiles are structured and can be returned in Json, Xml or any other format.



As a Pharmacist (Hospital Services) I want to know if results have not been returned due to a error so that I can consider the impact of missing information on my reconciliation.

404- Resource not found
410- Resource deleted



Search Query Parameters

This can be found on the API page depending on which resource you are searching:

Medication Individuals
MedicationOrder Patient
MedicationStatement Practitioner (Problem)

API Sequence Diagrams

Sequence diagram showing the flow of information between actors



Technical Architecture

Diagram showing an overview of the solution's architecture.



Acceptance Criteria

While the acceptance criteria is not fully developed, below is an example of some possible criteria that could be defined.

Feature User Story
Medication List (View) As a Pharmacist (Hospital Services) I want to retrieve all prescriptions from all available systems for a specific patient so I can build a complete list of reconciled medications for the patient.
  • I am able to call an API with the URL: GET /MedicationOrder?patient.identifier=https://fhir/nhs.net/Id/nhs-number|9876543210.
  • I am able to pass NHS number as an input parameter
  • The API returns profile "MedicationOrder" with medications information about patient as a populated JSON object in the following format: <<Json Object>>
Tags: userstories