Sunday, March 13, 2011

We Look Like There Is Still A Way to Go with E-Prescribing Standardisation. This is all Taking A Long While For Some Reason.

Quietly, on Friday afternoon, I published a blog on HL7 V3.0 reporting on the views of some who are concerned with some of the directions being taken by HL7.

The blog is found here:

http://aushealthit.blogspot.com/2011/03/different-view-on-hl7-version-30-there.html

By late Sunday there had been lots of comments - with an especially interesting part of the thread being initiated by Dr Eric Browne.

Here is the thread from that comment on (the rest is on the blog directly)

Eric Browne said...

"My understanding is that there are two private consortia doing e-prescribing and that NEHTA is working - at a glacial pace - on developing a standards package for the domain - and a few others - referrals etc."

Well NEHTA have produced an HL7 V3 CDA specification for electronic transfer of prescriptions (eTP) and have submitted it to Standards Australia to fast track it into an "Australian Technical Specification". I understand that this is to be used as the basis for eTP in Australia, and presumably will be adopted by the two existing private consortia and any newcomers.

However, although this CDA specification introduces a lot of new complex codes, it is actually less prescriptive than the existing HL7 v2 based AS4700.3 standard for exchanging medication information, particularly for supporting safe clinical practice. Let me give one example. I could give many others.

Quality Use of Medicine programs continually push the mantra "Right person, right drug, route dose, right route, right time". I'm not a clinician, but as a patient, I would like to know that the route and dose have been supplied on the prescription. The existing Australian Standard has a whole HL7 segment devoted to recording route of administration. NEHTA's proposed standard has NO specific field to record Route of Administration, and NO terminology to support it. Instead, it has a single free text field that conflates route with dose. Thus, no compliance checking to ensure that route has been supplied would be possible. No compliance checking to ensure that any dose information has been supplied would be possible.

I'm perturbed that from a clinical safety perspective that we might be going backwards in some areas of clinical data standards. This is not a criticism of HL7 v3 per se in this case, but yet again, illustrates the lack of proper governance in e-health in Australia.

Saturday, March 12, 2011 3:45:00 PM

Dr David More MB, PhD, FACHI said...

Eric, thanks for the detailed comment.

It is my understanding that one of the present providers is committed to implement what Standards Australia comes up with and that the other has said they will look at it when the Standard is finalised.

I should say I am aware of others besides Eric with very considerable concerns about just where the HL7 vs CDA situation currently sits - many of who are on the relevant IT-14 Sub Group.

David.

Saturday, March 12, 2011 3:56:00 PM

Anonymous said...

Eric Browne (Saturday, March 12, 2011 3:45:00 PM) said “NEHTA's proposed standard has NO specific field to record Route of Administration, and NO terminology to support it. Instead, it has a single free text field that conflates route with dose.”

That is amazing, indeed quite incredible. It simply is not good enough. I had to check conflate – which means melds or brings together.

From quality control, accreditation, and safety perspectives NeHTA would fail dismally if, what Eric says, is true.

From a medico-legal perspective any doctor, nurse, dentist or anyone else authorised to write prescriptions would be totally liable if a medication error (adverse event) occurred as a consequence of a medication being taken which did not specify precisely the ‘route’ and the ‘dose’.

Much of the rationale behind introducing electronic prescribing and transmission of scripts is to cut down on medication errors. As a doctor I can categorically state that I would never ever prescribe a medication without stating exactly the DOSE (‘n’ mgm, microgram, ml, or whatever) and the ROUTE (Intramuscular, orally, per vagina, in the eye, on the skin, on the affected area, up the nose, in the ear up the rectum, whatever).

It beggars belief to think that NeHTA could even contemplate creating standards which do not include ROUTE and DOSE. So much so that I have to think, despite Eric’s acknowledged expertise in this area, he has to be wrong in his claim that NEHTA has “NO specific field to record Route of Administration, and NO terminology to support it” and simply has a “free text field that conflates route with dose”.

I suggest someone very quickly asks a Medical Defense Organization to provide an opinion on this pronto.

And I suggest too that NeHTA be asked urgently to very clearly clarify its position on this matter.

Saturday, March 12, 2011 6:49:00 PM

Anonymous said...

I think HL7 V2 is a very under-appreciated standard and I would in general agree with the original comments.

V3 messaging appears dead, even from Graham says and CDA is mentioned as "working", but CDA is a Document format and not a messaging specification.

We do require a messaging specification and V2 is rich and flexible in this arena and there are a lot of existing implementations out there, although most are quite flawed however. CDA on its own just cannot do ePrescribing in anything but a token document transfer. HL7V2 medication messaging has all the behaviours needed to actually enable ePrescribing. By definition CDA has no behaviours as it’s a document.

The advantages of CDA are that it is xml and people can use an off the shelf parser and it allows richer structure in the body of the document.

Good HL7V2 parsers are available and V2 can be encoded in xml and the parsing side of the problem is a tiny percentage of the task.

The structuring of the clinical data in HL7V2 is an area that needs improvement, but there are several projects active working on that and in any case you could embed CDA documents in HL7V2 to get the messaging and the structured payload. Either or both approaches are appropriate, but standalone CDA will not solve our problems.

Enhancing V2 structure is a path that could be backward compatible and could be incremental but it seems that very few people have a deep understanding of both V2 and V3 and just choose the most recent technology thinking that V2 is on the way out when in fact, its expanding. Taking the lessons learn in over 12 years of V3 development and applying them to enhancing V2 is a path that is doable, but I fear that it appears to much like a failure for people to support it.

In Australia we really only have V2, so enhancing what we have with compliance testing and actually using the V2 Medication standards we have would seem a very sound choice, but Nehta appear to have a complete block when it comes to looking at working standards and enhancing them. Everything has to be done from the ground up and we end up with over complex V0.9 "standards", that would need years of trials to perfect, time they do not have.

In fact Nehta appear to show no interest in looking at what is working, it’s an arrogance that the country cannot afford. Nothing Nehta have produced so far is out there and working now so the track record is pretty poor and there is high level pressure on Standards Committees to approve the Nehta work, bypassing the normal processes which are there in an attempt to allow proposals to be critically examined. The proposals are all flawed and the new policy is to ignore Nehta work until its proven, which at this stage means ignoring everything they have done.

This Dinosaur has escaped Jurassic Park and it’s time to hit the kill switch before it eats all the people trying to do real work.

Saturday, March 12, 2011 9:03:00 PM

Anonymous said...

Saturday, March 12, 2011 9:03:00 PM thank you for a very lucid account of the HL7 issues and your comments on eprescribing.

Your comments serve to reconfirm the rationale and absolute imperative of funding an industry led eprescribing initiative in parallel with NeHTAs work. It is clear, from what you say, that is the only way we will see any progress in the foreseeable future in this vitally important application.

Sunday, March 13, 2011 11:14:00 AM

Anonymous said...

Saturday, March 12, 2011 9:03:00 PM said "there is high level pressure on Standards Committees to approve the Nehta work, bypassing the normal processes which are there in an attempt to allow proposals to be critically examined."

The Standards Committees should resist such pressures, remain true to their raison d'etre and under no circumstances bypass their normal checking processes. If they did bypass and take short cuts for political expediency or because they are being paid by NeHTA to deliver to an unrealistic timeline they would be doing the nation as a whole a gross disservice and undermining the credibility of Standards Australia.

We have standards for a very good reason. No one should be permitted to corrupt the process under any circumstances.

Sunday, March 13, 2011 1:42:00 PM

Anonymous said...

As the CDA Schema contains specific elements for both Route of Administration Codes and Dose Quantity, it would be very surprising if the NHETA specification (presumably an application layer Data Model) does not map directly to these elements. Whether all of the systems that will use the NEHTA specification currently store these elements in an atomised and (in the case of Routes) coded form is another question.

Sunday, March 13, 2011 2:14:00 PM

Grahame Grieve said...

Hi David

You asked for my opinion on how this will play out. It's too early to say - the outcomes will be driven by external events and not by the quality of the underlying standards. (A familiar story in IT)

Some of the comments on this thread are profoundly ignorant. NEHTA has an extensive consultation process. If ETP does conflate route and dose (which sounds like a bad idea to me), then the decision sure didn't come out of NEHTA, but from the consultation process. (The discharge summary does conflate the two, but I don't think ETP does). Nor is the decision driven by the standards. It's based on requirements analysis.

And I hope that all the anonymous commenters on this blog are also contributing to the NEHTA CMK (http://dcm.nehta.org.au/ckm/). Of course, you have to stand behind your comments with your name there. But the DCM models matter, particularly with regard to things like route/dose conflation.

It's true that there is tension between the consensus based standards process, and project based deadlines. That's true in all contexts, and it's a problem that IT-14 (which met this week) is well aware of. While the standards process shouldn't be compromised, committees do need to figure out how to assist meeting politically set deadlines.

Grahame Grieve

Sunday, March 13, 2011 2:25:00 PM

The first thing to be said is that is far as I can tell Dr Browne is spot on:

From Page 36 of 92 of the ETP Structured Document Template Version 3.1 of 8/12/2010

----- Begin Extract

4.9 Dose Instruction

Identification

Name Dose Instruction

Metadata Type Data Element

Identifier DE-16008

OID 1.2.36.1.2001.1001.101.103.16008

Definition

A description of the dose quantity, frequency, route instruction and cautionary advice that determines how the prescribed therapeutic substance is administered to, or taken by, the subject of care.

Definition Source NEHTA

Synonymous Names

Dosage Instruction

Data Type Text

Usage

This SHOULD include the dose quantity, frequency, route, administration schedule and any additional instructions required to safely describe the appropriate dosage. If appropriate, this MAY also include the site of administration.

Conditions of Use

Conditions of NEHTA

Use Source

Examples

1. One tablet twice a day every 12 hours, before or with the first mouthful of food.

2. Apply thin layer to affected area 3-4 times daily; reassess after 7 days if no response.

----- End Extract

Note both this element and the following Quantity of Medication are simple uncoded text.

Just what would drive going down the uncoded path for this information really eludes me.

Using uncoded text for prescribing seems odd given all the work that has been invested in the Australian Medicines Terminology - or am I missing something?

As a clinician I certainly share the concerns raised in the comments above!

Grahame Grieve mentioned the IT-14 group met last week. I wonder what their views are? I suspect we will know soon enough.

I note, in passing, that the US has moved in the drug naming / terminology area:

Drug-naming standard for EHRs expanded

March 10, 2011 — 11:15am ET | By Janice Simmons - Contributing Editor

The RxNorm standard clinical drug vocabulary produced by the National Library of Medicine (NLM) has added more accurate and complete connections between national drug codes (NDCs)--the product identifiers assigned by American manufacturers and packagers of drugs--and standard nonproprietary names of medications recommended for use in electronic health records (EHRs).

Providing new connections between NDC product codes and RxNorm standard names and identifiers will have many potential uses within an individual patient's EHR, according to the NLM. These include the use of NDCs on medicine bottles to speed up standard data entry or to trigger an alert written in the RxNorm standard to prevent a medication error.

No single source currently contains all the NDCs for all medications marketed nationwide. RxNorm, though, has included NDCs provided by the Food and Drug Administration, the Department of Veterans Affairs, and the Multum and Gold Standard drug information sources for several years.

More here:

http://www.fierceemr.com/story/drug-naming-standard-ehrs-expanded/2011-03-10

It is also worth pointing out this has all been going a long time and really should have been sorted long since. The first version of the ETP documents appeared in late 2009 - now near to 18 months ago.

I look forward to further news on all this. Eric’s comments about the lack of appropriate leadership and governance in all this sure ring true to me!

David.

20 comments:

Andrew Patterson said...

David, the drug (and corresponding unit of use) is coded by the AMT. See ETP Data Element DE-10194.

---
Where the therapeutic good can be identified by an AMT (Australian Medicines
Terminology) concept, this MUST be the AMT ConceptID and Preferred Term.
For details see Therapeutic Good Identification Values.
---

Presumably, when it came to route and dosage, NEHTA saw the horrible mess that the NHS managed to build in coming up with a computable dosage syntax model (indeed the NHS model is referenced in the actual NEHTA data item so it seems safe to assume that they know as much about it as random anonymous people commenting on your blog). They have left this as a simple single text 'dose instruction' - that explictly mentions it is the location for also describing route instructions and site of administration - whilst future analysis is done on how to codify it all (if indeed it is possible to codify it all).

(I accept Eric's point that route/dosage are actually different things - but in the absence of a computable solution think a free text string conflating the two is not a horrible idea)

Out of interest, I just wrote a script in a leading clinical package - whilst it records route of administration - it proceeds to not print it at all on the script itself. And of course, if it did print it on the script, it would presumably tack it on to the end of the dosage instructions text. Which frankly seems a lot like how the ETP spec will behave.

Then again, perhaps eRx and Medisecure have come up with a brilliant model for how they handle dosage and route information. It is a shame we can't critique that as their models aren't available for viewing by the public.

Dr David More MB, PhD, FACHI said...

"Where the therapeutic good can be identified by an AMT (Australian Medicines Terminology) concept, this MUST be the AMT ConceptID and Preferred Term. For details see Therapeutic Good Identification Values."

Thanks - we still have optional coding for some meds which is still not OK in my view.

Route and dosage also still needs to be articulated clearly to my poor addled clinical mind - and optimally be codeable.

David.

Andrew Patterson said...

Sometimes perfection is the enemy of good.

I think the statement that drugs MUST be coded where the concept exists in the AMT is a reasonably strong statement. The AMT covers about 99% of prescribable drugs for Australia. It doesn't seem there is too much wriggle room there to get out of coding meds?

With regards route and dosage - the source systems for 99% of prescriptions in Australia are about 10 GP system vendors. Perhaps NEHTA did a review and decided these aren't systems that can generate complex coded dosage and route instructions?

Perhaps the 15 or so dispensing software vendors told NEHTA that they didn't care about coded route and dosage because all they are going to do is print the free text on the bottle label anyway?

I have no idea what the truth is - but from my engineering perspective it just seems like someone made some pragmatic decisions. Everyone who feels passionately about it should probably join in the Standards Australia process if they can be bothered trying to make it better..

Andrew Patterson said...

"It is also worth pointing out this has all been going a long time and really should have been sorted long since. The first version of the ETP documents appeared in late 2009 - now near to 18 months ago."

I would also point out that the dosage instruction data item has been a single free text entry since that first draft for comment spec was released in late 2009. So we can hardly say that they sprung this on the community as a surprise.

Dr David More MB, PhD, FACHI said...

Andrew,

Not your fault, but I wonder do we make sure all those possibly affected have the risks / rewards explained or do we use a rather narrow gene pool who may not get all the issues involved?

A process, not a blame question.

David.

Eric Browne said...

I don't doubt that some pragmatic decisions should be made and have been made. That is fine, providing they are sensible. I agree totally with Andrew Patterson that dosage instructions can be very complex, and I suspect that there may even be some prescriptions for which the route of administration might vary depending on circumstances, and might be tied up in some complex dosage regime, but surely that doesn't mean there can't be a separate field to meet the 99%(?) of standard cases? Either 'route of administration' can be sufficiently important in some prescriptions to have a separate field available for computer processing, or it is not. I do know that most existing standards around the world appear to provide for it. If some vendor systems currently can't provide for it, that is a different issue - one of conformance/compliance. I'm sure there are systems out there that don't meet any standards. But surely we shouldn't drag all data exchanges down to the lowest level, nor even the mean or median level of current capability.

[ I would also point out, Andrew P, that the first draft for comment spec released late (October 2009) does indeed have a separate field for route of administration (pg 17) as well as a free text dosage description field. This version also has a considerable list of those people and organisations consulted in Appendix C, pg 54 ]

Furthermore, one of the main reasons why HL7 CDA is being embraced by a number of standards setting organisations is that it provides for a human readable narrative part that can be easily rendered in browsers and attested by clinicians - a low barrier to entry for vendors that emulates the paper world using an HTML-like syntax. It also provides for computer-processable entries, that often have explicit codes and datatypes for individual data elements.

This architecture thus provides for two levels of capability within systems. The dosage and route information can already be provided in the free text narrative. But the published NEHTA eTP specifications we are discussing don't appear to follow this paradigm. I say "don't appear", because NEHTA have not supplied in the eTP package a single typical CDA document to view and assess. Is the attested CDA narrative part ever to be displayed to pharmacists, or downstream clinicians, or patients? If so, this specification provides no guidance into how this might be laid out for Australian prescriptions. If not, then we have a peculiar application of the CDA specification and that needs to be clearly articulated to the community involved in implementing it.

Finally, I believe it is an indictment of the current governance process, or rather lack thereof, that the only public forum for discussion of these important (allbethem often highly technical) national standards issues appears to be David's blog.

Andrew Patterson said...

My only engineering concern for 'route of administration' as a separate field in the community prescribing area is that I think the route should probably be tied in with the dosage instructions.

So rather

"Take one tablet after meals and allow to dissolve" -- "Under tongue"

I would assume the combined dosage instructions and route (as presented to the patient) should be

"Place one tablet under the tongue after meals and allow to dissolve"

I would guess that the narrative instructions will include the route in most cases where route is important. Introducing a separate coded field then introduces the possibility of the instructions and the coded route not matching? Do patients benefit if every single script they get for a capsule also has the route printed on it as a separate field?

Clearly in a hospital this is not a concern - medication instructions are for trained clinicians, not patients - and the route field as a separate coded entry is vital for safety
(and to cope with the much more varied ways medications are delivered in hospitals)

So my engineering concern is not that route of administration is not important - but does it fit in with the requirements for a community prescribing specification..

"[ I would also point out, Andrew P, that the first draft for comment spec released late (October 2009) does indeed have a separate field for route of administration (pg 17) as well as a free text dosage description field. This version also has a considerable list of those people and organisations consulted in Appendix C, pg 54 ]"

Hmmm.. I don't have that one - it certainly seems to have disappeared by the time of the ePrescription SDT released in November 2009!

But as you rightly say - if the process wasn't so broken that the only place the public gets to discuss this is on David's blog - we would for instance be able to see the Wiki history for the document template to see who removed the route field, and the reason they gave for removing it!

Anonymous said...

Eric said .... "Either 'route of administration' can be sufficiently important in some prescriptions to have a separate field available for computer processing, or it is not."

Mmm -

Mary was given a prescription for pessaries (suppositories) to be inserted 6 hourly for 28 days.
When she returned to the doctor there had been no improvement in her condition. After questioning the patient to ensure she had been compliant in taking her medication he gave her a script for a further 28 days of treatment. As she rose to leave he said to her:

"well Mary it seems the rectal route has not been effective, so this time try putting them in your vagina - the front hole - and let's see if that gives the improvement we are looking for. See you in 28 days. Bye bye."

Anonymous said...

Strange as it may sound, there may be a quality and safety reason behind the 'conflation' into free text of the dose, frequency and administration instructions (e.g. take 2 tablets twice daily with food) - to explain this - many systems may store this data in different ways - some may have separate fields, but use different coding schemes, and some may have different concepts that conflate one or more of these fields. Where these are not directly comparable (or semantically equivalent)across systems, then the decision when interfacing to put them as text, as described above is actually safer than having them as separate fields that risk being misinterpreted - as the fields can at least be interpreted as English text. It is the lowest common denominator, and it is not until all interoperable systems can provide the required fields defined and coded such that there is no ambiguity that it is safe to do otherwise. This is the reason why we all need to move to terminologies like AMT (or at least be able to map to it when interfacing). Until that happens, then decisions to 'share information using the lowest common denominator' are the safest way to go.

Eric Browne said...

I don't think that there is any issue with the proposition that the free text conflation of dosage instructions should be supported. The issue is whether the provision for additionally having a standardised way to send the atomic data, particularly route of administration, should also be supported in the specification. The current version of the CDA specification before Standards Australia explicitly excludes this possibility.

I would have thought that the route of administration would be a useful parameter for computer assisted testing for potential adverse events and side effects. Some one third of prescriptions in the community setting in Australia have errors, according to pharmacist Ken Lee in his soon to be released book "How safe is your prescription" following a study which reviewed some 21,000 scripts. These errors are mainly due to incorrect dosing and inability to determine interactions and side effects.

Computers should be able to help reduce these errors. And standards should aim to help that process.

Anonymous said...

Eric said - the route of administration would be a useful parameter for computer assisted testing for potential adverse events.

Indeed and one can cite hundreds of examples why that is so.

eg. Two patients are each on an Intravenous drip. Potassium is ordered for both patients. The potassium (dose specified) is to be given intravenously via the drip.

Nurse A administers the potassium to the first patient who eventually recovers and is discharged home.

Nurse B administers the potassium to the second patient who immediately dies of a cardiac arrest.

Nurse A knew to inject the potassium into the intravenous bottle of saline.

Nurse B did not know that injecting potassium into the intravenous drip chamber can be fatal. She does now.

Anonymous said...

How about trying a different approach - in the bubble.

We should not be focusing on 'fitting' with the 'lowest common denominator'. That is futile and self defeating.

How about finding 'one' system and paying to have it modified to an acceptable standard that fully addresses all these concerns. Let’s call the end result a ‘standards compliant’ solution. Let’s define that level of compliance in the Standards.

Now let’s implement that solution (in the bubble) between some medical practices and some pharmacies (all together in the bubble). Let’s prove that this standards compliant solution works safely, securely and efficiently. Let’s now introduce financial incentives to enable other vendors to adapt their systems to the standard compliant solution.

Let’s make everyone a winner. How does the lyric go?
I’m forever blowing bubbles
Pretty bubbles in the air …..

Andrew Patterson said...

I'm not anti the recording of route of administration - I'm just saying in the world of 50/50 engineering calls, deciding to not have it as a coded value in the ETP spec at this point in time doesn't seem to me to be an outrageously incompetent decision as it was being portrayed on the blog..

And that if people feel strongly, they should join in the Standards Australia process and get it fixed to their satisfaction.


Anonymous @ 10:45

"Indeed and one can cite hundreds of examples why that is so."

And when you can give some examples of where the GP is writing scripts for intravenous potassium for a patient, who is then going to wander down to the pharmacist, get their meds and then go home to hook themselves up to a drip - perhaps you might understand the point I was making that community prescribing (i.e. ETP) may have slightly different requirements than hospital prescribing. And those requirements might drive the standard down different paths and solutions.

Anonymous said...

The argument that some systems might not do it well is a joke. They will never do it if we keep making excuses and dumb down standards to the lowest common denominator!!!

There are many reasons to do it, to actually make use of the data for decision support for instance.

What we need is compliance testing and not government handouts. If the money wasted on Nehta had been spend on rewarding compliance with existing standards we would be light years ahead from the murky backwater we find ourself in currently. The idea that Nehta can single single-handedly produce a working solution to this problem, rather than leverage existing standards is a pipe dream. The sad part is that they still think they can, despite the fact that they have failed to solve everything else they have touched.

Anonymous said...

The purist engineering concern is not good enough - for any clinically experienced person who views quality control, safety compliance, and accreditation as essential parts of the system designed to make it safer.

You do need to understand that regardless of whether the environment is a hospital, a nursing home, or a medical practice there are strict parameters which need to be adhered to when prescribing medications of any form and these include, the medication, its form, the dose, the route, the frequency, in association with, etc.

Some patients are on long term intravenous drips, some are managed in their home and some are managed in their independent living unit in the aged care facility.

More often than not the GP will oversee the patient and a nurse or patient carer will administer the medication as instructed. The example therefore was quite appropriate.

What you need to understand is that there is NO ROOM FOR ERROR OR AMBIGUITY with some medications and that should therefore be the STANDARD FOR ALL MEDICATIONS. The person who is administering the medication is ultimately responsible, although if the prescriber made an error it might be a moot point about who should carry the blame (I was only following instructions said the nurse).

There may be plenty of manual checks and balances built into the system and it is to be hoped somewhere along the line the errors will be detected before it is too late. From an engineering perspective I’m sure you would want to eliminate the possibility of leaving room for errors to creep in, at least I hope so.

Anonymous said...

Monday, March 14, 2011 11:27:00 AM said "If the money wasted on Nehta had been spend on rewarding compliance with existing standards".

Silly question I know but:
(a) what are the existing standards?
(b) how are they enforced today?

Andrew Patterson said...

The paper based community prescribing involves GP's writing English sentences including dose, route and frequency - and these sentences then get printed onto boxes/bottles/etc of medicines for use by patients. This happens approximately 100 million times each year in Australia. Before last year - not a single community prescription in Australia had ever been transferred electronically - and hence not a single one of them had ever had a 'separate' 'coded' route of administration field (which is what we are talking about - noone is suggesting dropping route of administration as a clinical concept - just whether it is coded in ETP). As far as we know, these 100 million prescriptions did not kill the patients they were given too (though Eric says that there are many mistakes and I can believe that) - and 100 million Australians managed to not stick tablets up their bums due to a lack of electronically coded route of administration.

NEHTA propose an ETP spec, taking data from source systems whose CURRENT level of sophistication is that they print words on paper scripts - and proposes a system that is no better (though with coded medications so in that regards I would contend it is better), but is also certainly no worse than the current system.

Everyone jumps on this blog and says they are idiots.

I say there seems to be good engineering reasons why in community prescribing it might be done that way.

Noone actually seems to deal with any of the issues raised - but instead wants to anonymously tell me that I don't understand quality and safety in medications and that I'm some sort of purist engineer (what does that even mean?).

But I get the underlying spirit - if I'm not a clinician I can't possibly understand the breadth of knowledge and caring that only you can bring to the analysis of this problem. Understood - I'll go back to playing with my computers now..

Anonymous said...

We have the AS4700.x group of V2 standards which cover a lot of ground, including Medication.

They are not enforced at all. Compliance is quite poor, but it still works at a basic level.

Other industries appear to be forced to comply with standards, but people thumb their nose at eHealth standards without consequences it seems.

Its quite amazing it works as well as it does really, but it could work a lot better if vendors felt there could be negative consequences to having poor implementations.

Dr David More MB, PhD, FACHI said...

Andrew,

There are a few points that need to be made:

1. Radio National - Life Matters - 14/03/2011 (Today) - A new book talks of just how bad even printed prescriptions are - 1/3 have errors. All those critical clinicians are really doing a pretty bad job despite their protestations of near perfection.

2. I think the only way we can get progress is to have both clinicians and software engineers and others actually communicating - not shouting across a valley at each other.

3. To get that I think, as Eric does, proper leadership and governance are crucial.

4. Real clinical decision support as well better software are the only ways we will get the error rates down seriously.

5. Your contributions are valued - especially as you are prepared to say who you are. There can be valid reasons for anon contributions but I am not sure there is much reason in this type of conversation.

David.

Grahame Grieve said...

Catching up: Yes, ETP does conflate the two to a single text field.

One commenter in a different thread wondered whether this would apply in CDA or not. It's possible for the CDA implementation guide to unconflate them, and say to use the structured fields. At present the implementation guide doesn't do that. But the implementation guides don't say that you can't - only that you must have the conflated text field. If users think that structured representations are useful, they can still provide them. (However the implementation guide not saying this explicitly makes it less likely.)

I think that Andrew Patterson has a point about the conflation. I'm not sure whether I agree or not - not that my opinion matters. Irrespective of this, and where the decision comes form, it's subject to review by the Medications Management reference group.

Grahame