Medication List | ITK3 Mental Health eDischarge

Constructing a medication list

Important: The resources referenced in this section are the FHIR base resources which will be constrained by the profiles used by eDischarge, the profiles should be referred to for the actual allowable structure and content.

Overview

This section details the design approach using FHIR Resources to support the PRSB heading model for medication and devices.

Medication Snapshot

The medication list is a “Snapshot” of the medication at a point in time (for example on discharge from hospital). It is not a master list of the patient’s medications. Other lists of medications for the patient may exist on other systems. For Transfer of Care Documents there will a potentially be two lists one for active medication and one for discontinued medication. There are two entries in the FHIR Composition.section.text element:

medication item entries which map to the Medication Statements in the active list
Medication discontinued entries which map to the Medication Statements in the discontinued list

Resources Used for Profile Design

The FHIR Resources are profiled to create the medication list as below:

CareConnect-ITK-Medication-List-1 - An NHS Digital Profile for recording a snapshot of the list of Medications for the patient.
CareConnect-ITK-MedicationStatement-1 - An NHS Digital Profile for medication statements. The MedicationStatement Resource is a record of a medication that is being consumed by a patient.
CareConnect-ITK-Medication-1 - An NHS Digital Profile for medication. The Medication Resource is primarily used for the identification and definition of a medication.
CareConnect-ITK-MedicationDispense-1 - An NHS Digital Profile derived from the CareConnect MedicationDispense Profile. Indicates that a medication product is to be or has been dispensed for a named person/patient. This includes a description of the medication product (supply) provided and the instructions for administering the medication.

List

This Resource acts as a container for the medication items. The following is an example of the elements which can be used:

identifier - uniquely identifies this list of medication (UUID)
code - the type of list (SNOMED CT concept for “active medication” or “discontinued medication”)
status - should only be “current”
mode - should only be “snapshot”
title - descriptive name for the list
subject - a reference to the patient whose medication list this is
encounter - a reference to the context in which the list was created (the inpatient stay)
date - when the list was prepared
source - who or what defined the list
entry - a reference to the MedicationStatement Resource entry or entries
flag - MUST NOT be used for Transfer of Care
emptyReason - MUST NOT be used for Transfer of Care if list is empty do not send a List.

MedicationStatement

A record of a medication that is being consumed or has been consumed by a patient. The following is an example of the elements that can be used:

identifier - uniquely identifies this medication statement (UUID)
clinicalStatus - should always be active
category - should be inpatient
partOf - A reference to the MedicationDispense Resource used to carry the quantity that was dispensed (for example TTO after a hospital provider spell)
medication - the medication coded (a SNOMED CT Concept that identifies this medication), this is done by reference to the Medication Resource which details the medication.
effective - the date/time or interval when the medication was taken
dateAsserted - When the statement was asserted defaults to composition date
informationSource - Person or organization that provided the information about the taking of this medication, assumed to be composition author
reasonCode - Reason for why the medication is being/was taken
subject - The Patient
reasonReference - a reference to the Condition Resource that supports why the medication is being/was taken
medicationReference - a reference to the Medication Resource
taken - default to “unknown” or “na” if the taken element is not applicable for the medication or device
reasonNotTaken - MUST NOT be used for Transfer of Care
dosage - Details of how medication is/was taken or should be taken

Medication

The Medication Resource allows for medications to be characterized by the form of the drug and the ingredient (or ingredients), as well as how it is packaged. The medication will include the ingredient(s) and their strength(s) and the package can include the amount (for example, number of tablets, volume, etc.) that is contained in a particular container (for example, 100 capsules of Amoxicillin 500mg per bottle). The following is an example of the elements that can be used:

code - a SNOMED CT Concept that identifies this medication
form - powder, tablets, capsule etc SNOMED CT form concepts

MedicationDispense

The main purpose of the MedicationDispense resource is for Medication that is to record the amount of medication which has supplied to the patient. For example TTOs(to take outs). The following is an example of the elements can be used:

identifier - uniquely identifies this medication dispense (UUID)
status - for ToC should always be completed
category - inpatient or outpatient
medication - a reference to the medication which was dispensed
subject - a reference to the patient
performer - who / what dispensed the medication
quantity - How much was dispensed

How the Medication List is Constructed

The medication record is constructed as two lists. The diagram below shows the Resources used and the relationship between the Resources.

MedicationStatement Resource

This section gives guidance of the use of the MedicationStatement Resource. Sending Systems should send as much details as they can.

MedicationStatement.partOf

This uses a reference to the MedicationDispense.quantity to indicate the amount of medication that was dispensed, for example TTO after a hospital provider spell.

MedicationStatement.dosage.route

Constraint: NHS e-Prescribing route of administration subset refset 999000051000001100. The route can be any route, and not constrained to a dm+d route for the medication. Separate products are different MedicationStatements in Primary Care if the same product have multiple route options then the routes go in the FHIR element MedicationStatement.dosage.text. When using routes outside the stated ValueSet, then use FHIR element MedicationStatement.dosage.text.

MedicationStatement.dosage.site

Constraint: As per the FHIR ValueSet approach-site-codes. Site may have similar content as Route - There may be some overlap with Route (e.g. intra ocular left eye). If no code, then use the FHIR element MedicationStatement.dosage.text

MedicationStatement.dosage.method

This MUST NOT be used in Transfer of Care, carry in the FHIR element Composition.section.text use the FHIR MedicationStatement.dosage.text Short term this should be deprecated to a text string & concatenated with the dose direction (above).

MedicationStatement.dosage.timing

MUST NOT be used in Transfer of Care, but is captured as part of the FHIR element MedicationStatement.dosage.additionalInstruction string.

MedicationStatement.dosage.text

A single plain text phrase describing the entire medication dosage and administration directions, including dose quantity and medication frequency. e.g. “1 tablet at night” or “20mg at 10pm” This is the form of dosage direction text normally available from UK GP systems.

MedicationStatement.effective[x].effectivePeriod

If available may be carried in the FHIR element MedicationStatement.effective[x].effectivePeriod.

MedicationStatement.dosage.patientInstruction

Specific patient instruction may use MedicationStatement.dosage.patientInstruction

MedicationStatement.status

The FHIR element MedicationStatement.status is fixed to “active” for active medication lists and “stopped” for discontinued medication lists.

MedicationStatement.reasonCode

MUST NOT be used in Transfer of Care.

MedicationStatement.effectiveDateTime

Used to indicate when the medication was discontinued or became active.

MedicationStatement.category

This FHIR element should carried the value “inpatient” for Discharge Documents and “outpatient” for Outpatient Letters.

MedicationStatement.taken

This FHIR element should contain a value from the FHIR ValueSet medication-statement-taken to indicate whether the patient has taken the medication. For Transfer of Care the default is unk - unknown or if a value is not applicable then na - not applicable.

Medication Resource

This section gives guidance of the use of the Medication Resource

medication.code

This FHIR element is mapped to the PRSB medication name

constraint: MedicationName. Any AMP/VMP/VTM/AMPP/VMPP subsets from the dm+d terminology.

VTM NHS dm+d virtual therapeutic moiety (DD4C) 999000581000001102

VMP NHS dm+d virtual medicinal product (DD4C) 999000561000001109

VMPP NHS dm+d virtual medicinal product pack (DD4C) 999000571000001104

AMP NHS dm+d actual medicinal product (DD4C) 999000541000001108

AMPP NHS dm+d actual medicinal product pack (DD4C) 999000551000001106

The above as a SNOMED CT expression.

(^999000581000001102

OR ^999000561000001109

OR ^999000571000001104

OR ^999000541000001108

OR ^999000551000001106)

OR with preferred terms

(^999000541000001108 |National Health Service dictionary of medicines and devices actual medicinal product simple reference set|

OR ^999000551000001106 |National Health Service dictionary of medicines and devices actual medicinal product pack simple reference set|

OR ^999000561000001109 |National Health Service dictionary of medicines and devices virtual medicinal product simple reference set|

OR ^999000571000001104 |National Health Service dictionary of medicines and devices virtual medicinal product pack simple reference set|

OR ^999000581000001102 |National Health Service dictionary of medicines and devices virtual therapeutic moiety simple reference set|)

medication.form

This form is on the medication profile. Where VTM has form specified (coded) it goes here. AMP & VMP don’t need separate Form (it is optional to populate). For VTM the form could be in MedicationStatement.dosage.text (as it would be part of a dosage string) i.e. not a separately specified code.

Constraint: DrugDoseForm. SNOMED CT CfH DoseForm termset. Constraint binding: [SNOMED CT]subset=CfH DoseForm (refset 999000781000001107)

The above as a SNOMED CT expression

^999000781000001107 |NHS dm+d (dictionary of medicines and devices) dose form simple reference set|

MedicationDispense Resource

This Resource provides details of medication that has been dispensed to the patient, for example TTO(To Take Outs). For Transfer of Care only a small subset of the elements should be used.

status

This should contain the value “completed”.

quantity

This is mandated when the dispense resource is used. The FHIR element Extension-CareConnect-MedicationQuantityText-1 is used to carry the amount dispensed as a text string. Where supported the quantity may be structured, but there is no guidance at this time.

performer

Who dispensed the medication if available to the sender.

References

The references to the following must be carried:

medication
subject (patient)
context (encounter)

Medication List Examples

The Active List

The Active MedicationStatement

Note: example only shows one item in the list.

The Active Medication.

Note: example only shows one item in the list.

Medication Dispense

Discontinued List

The Discontinued MedicationStatement

Note: example only shows one item in the list.

The Discontinued Medication

Note: example only shows one item in the list.

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