EHR System Function and Information Model

(EHR-S FIM is based on EHR-S FM R2.0)

CP.1.3 Manage Medication Listaka DC.1.4.2 in EHR-S FM

Stephen.Hufnagel@tma.osd.mil , facilitatorJanuary 23, 2012 – Original

February 24, 2012 – Last Updated

04/22/2023 DRAFT WORKING DOCUMENT 1

Call for ParticipationThis work is being done by the HL7 EHR Interoperability Work Group,

meeting every Tuesday at 4PM ET, dial-in: 1-770-657-9270, Passcode: 510269#  The most current artifacts are at: http://wiki.hl7.org/index.php?title=EHR_Interoperability_WG

CP.1.3 Manage Medication List

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Statement: Create and maintain patient-specific medication lists.

Description: Medication lists are managed over time, whether over the course of a visit or stay, or the lifetime of a patient. All pertinent dates, including medication start, modification, and end dates are stored. The entire medication history for any medication, including alternative supplements and herbal medications, is viewable. Medication lists are not limited to medication orders recorded by providers, but may include, for example, pharmacy dispense/supply records, patient-reported medications and additional information such as age specific dosage.

Example: During an encounter, a health care professional might manage a patient’s Medication List and the system also manages the filling of prescriptions, according to scope of practice, organizational policy and/or jurisdictional law.

RED: delete, Blue: insert

CP.1.3 Manage Medication ListActivities Mapped-to System-Components

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act CP.1.3 ACT Manage Medication List

CP.1.3 Manage Medication List

Manage Ev ents Manage Lists

Start END

Manage Records Manage Trusts Manage Business Rules

Medication List

Medication EventEHR

-S Components

ListEvent

Clinician

is-a

CP.1.3 Manage Medication ListConceptual Information Model (CIM) Mapped to EHR-S Functions

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class CP.1.3 CIM Manage Medication List

Event Medication List

Medication Event Medication History

CP.1.3 Manage Medication List

CPS.9.5 Ad Hoc Query and Rendering

CPS.9.3 Health Record Output

CP.3.3 Manage Clinical Documents and Notes

List

Record Infrastructure Trust Infrastructure

deoends on

depends on

depends on

is-ahas-a

0..*

CP.1.3 Manage Medication ListConceptual Data Model (CDM)

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class CP.1.3 LDM Manage Medication List

Ev ent

+ date (occurence)+ time (occurence)- change justification- circumstances- clinical information- date (entry)- date (review)- description- duration- information reviewed- information source- information validator- location- mechanism- metadata- person-role- status- trigger- type

+ deactivate()+ justify()+ manage()

Person-Role

- person identifier- role

Event Type Enumeration

- advanced directive- adverse reaction- al lergy- CDS Alerts- CDS reminders- CDS update- cl inical document or note- discharge- encounter- intolerance- medication (pharmacist change)- medication (prescription dispensing)- medication (prescription fil l ing)- medication history received (external source)- order- other- procedure- registry- reminders & alerts- report- surgical- transfer

Role Enumeration

- authenticator- author- fil ler- guardian- other- patient- prescriber- provider- relative- stakeholder- witness

Trigger Enumeration

- drug- environment- food- other

Medication List

Medication Ev ent

- date of discontinuation- date of end- date of review- date of start- dispensing information- dose- formulation- instructions- interaction checking done :boolean- interactions indicated- justi fication- medication administration information- name- order date- pharmacist change information- potential interaction- prescriber- route- SIG- source- type

«enumeration»Medication Type

Enumeration

Attributes- medication order- non-prescription- prescribed- previously unreported

«enumeration»Medication Source

Enumeration

Attributes- erroneously captured- patient- patient history

dispensing information

Medication History

- status

«enumeration»Medication History Status Enumeration

unavailable incomplete

Pharmacist's Change

Information

- date- time

Medication Potential

Interaction

Medication Administration

Information

- administrator- date- dose- exceptions- medication name- route- time

1..*

1..*

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req CP.1.3 RT Manage Medication List

CP.1.3#03 The system SHALL provide the ability to manage, as discrete data, medication information including prescriber, ordering date, dose, route, and SIG (description of the prescription, such as the quantity) ...

CP.1.3#04 The system SHALL provide the ability to capture other dates associated with medications such as start , end and discontinuation dates.

CP.1.3#08 The system SHALL provide the abil ity to tag a medication as erroneously captured and excluded from the presentation of current medications.

CP.1.3#10 The system SHOULD provide the abi lity to capture and render information regarding the fi l l ing of prescriptions.

CP.1.3#05 The system SHALL provide the abil ity to capture medications not reported on existing medication lists or medication histories.

CP.1.3#06 The system SHALL provide the ability to capture non-prescription medications including over the counter and complementary medications such as vitamins, herbs and supplements.

Ev ent

- change justification- circumstances- clinical information- date (entry)- date (occurence)- date (review)- description- duration- information reviewed- information source- information validator- location- mechanism- metadata- person-role- status- time- trigger- type

+ deactivate()+ justify()+ manage()

Medication Ev ent

- date of discontinuation- date of end- date of review- date of start- dispensing information- dose- formulation- instructions- interaction checking done :boolean- interactions indicated- justification- medication administration information- name- order date- pharmacist change information- potential interaction- prescriber- route- SIG- source- type

CP.1.3#22 The system SHALL tag and render an indicator that interaction checking will not occur against free text medications.

CP.1.3#11 The system SHOULD provide the ability to capture and render information regarding the dispensing of prescriptions.

CP.1.3#12 The system SHALL provide the abil ity to receive from an external source (for example a plan, payer or pharmacy) a medication history.

CP.1.3#14 The system SHALL provide the ability to capture a description and reason for a medication when the medication name is unknown.

CP.1.3#16 The system SHOULD provide the ability to maintain the medication list with changes from pharmacist verification including pharmacist, date, and time.

CP.1.3#17 The system SHOULD provide the ability to manage the reason or indication for the medication when recording historical or medications from external sources (e.g. from home or other provider).

CP.1.3#18 The system SHOULD provide the ability to update a medication order directly from the medication list.

CP.1.3#19 The system SHALL conform to function CPS.4.2.1 (Support for Medication Interaction and Allergy Checking) to render any potential interactions when capturing or maintaining medications.

CP.1.3#20 The system SHOULD provide the abil ity to maintain a medication order directly from medication reconci liation.

CP.1.3#21 The system SHALL provide the ability to capture free text medications and render them in a manner that distinguishes them from coded medication entries.

CP.1.3#13 The system SHALL provide the abil ity to capture that a medication history is unavailable or incomplete.

CP.1.3#15 The system SHALL provide the ability to render on the medication list active medications that the patient brings from home to take while hospitalized, which the Pharmacy may not dispense.

CP.1.3#24 The system SHOULD provide the ability to render potential side effects of medications from the medication list.

CP.1.3#25 The system SHALL provide the abil ity to capture and render that the patient takes no medications.

CP.1.3#28 The system MAY provide the abi li ty to capture medication self-administration details including timestamps, observations, complications, and reason i f medication dose was not taken.

CP.1.3#32 The system SHALL provide the abil ity to capture, maintain, and present all pertinent details of the medication administration including medication name, strength, dose, route, time of administration, exceptions to administration, and administrat

CP.1.3#29 The system MAY capture Investigational Product Exposure information including Start Date/time, End Date/Time, Dose Amount, Dose Unit, Study Treatment Name, Route, Formulation as discrete elements.

CP.1.3 Manage Medication ListCDM Requirements-Traceability

req CP.1.3 RT Manage Medication List

CP.1.3#01 The system SHALL provide the ability to manage a patient-specific medication list based on current medication orders or prescriptions.

CP.1.3#02 The system SHALL provide the ability to manage the details of the medication information including prescriber, ordering date, dose, route, and SIG (description of the prescription, such as the quantity) formulation and instructions ...

CP.1.3#30 The system SHALL capture, maintain and present pre-admission medications.

CP.1.3#31 The system SHALL present pre-admission medications at the time of discharge.

CP.1.3#07 The system SHALL provide the ability to render the medication history associated with a patient.

CP.1.3#09 The system SHALL provide the ability to render a current medication list for patient use.

Medication List

Medication History

- status

List

+ define sort restrictions()+ fil ter()+ link to problem-treatment()+ manage()+ manage reason for change ()+ sedine sort criteria()+ sort()

CP.1.3#23 The system SHOULD provide the abil ity to render side effects of medications from the medication list that have been previously experienced by the patient.

CP.1.3#26 The system SHALL provide the ability to render only current active medications (i.e. exclude prescriptions whose duration has been exceeded or end date has passed).

CP.1.3#27 The system MAY provide the abil ity to render non-active medications or prescriptions for inclusion in current medication screening.

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CP.1.3 Manage Medication ListCDM Requirements-Traceability

CP.1.3 Manage Medication List“See Also” Dependencies

class CP.1.3 DEP Manage Medication List

CP.1.3 Manage Medication List

CPS.9.5 Ad Hoc Query and Rendering

CPS.9.3 Health Record Output

CP.3.3 Manage Clinical Documents and Notes

Record Infrastructure

+ RI.1 Record Lifecycle and Lifespan+ RI.2 Record Synchronization

+ RI.3 Record Archive and Restore

Trust Infrastructure

+ TI.1 Security+ TI.2 Audit

+ TI.3 Registry and Directory Services+ TI.4 Standard Terminology and Terminology Services+ TI.5 Standards-Based Interoperability+ TI.6 Business Rules Management+ TI.7 Workflow Management

+ TI.8 Database Backup and Recovery+ TI.9 System Management Operations and Performance

CP, CPS & AS

depend on

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Action Verb Hierarches

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Manage (Data)Capture Maintain Render Exchange Determine

Manage-Data-

VisibilityAuto-PopulateEnterImportReceive

Store Update Remove Extract Present Transmit ExportImportReceiveTransmit

Analyze Decide De-IdentifyHideMaskRe-IdentifyUnhideUnmask

ArchiveBackupDecryptEncryptRecoverRestoreSave

AnnotateAttestEditHarmonizeIntegrateLinkTag

DeletePurge

Archive

• Older slides

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CP.1.3 Manage Medication ListConformance Criteria

1. 1. The system SHALL provide the ability to manage a patient-specific medication list based on current medication orders or prescriptions.

2. The system SHALL provide the ability to manage the details of the medication information including prescriber, ordering date, dose, route, and SIG (description of the prescription, such as the quantity), formulation and instructions according to scope of practice, organizational policy and/or jurisdictional law.

3. 3. The system SHALL provide the ability to manage, as discrete data, medication information including prescriber, ordering date, dose, route, and SIG (description of the prescription, such as the quantity) according to scope of practice, organizational policy and/or jurisdictional law.

4. 4. The system SHALL provide the ability to capture other dates associated with medications such as start , end and discontinuation dates.

5. 5. The system SHALL provide the ability to capture medications not reported on existing medication lists or medication histories.

6. 6. The system SHALL provide the ability to capture non-prescription medications including over the counter and complementary medications such as vitamins, herbs and supplements.

7. 8. The system SHALL provide the ability to render the medication history associated with a patient.8. 10. The system SHALL provide the ability to tag a medication as erroneously captured and excluded

from the presentation of current medications.9. 11. The system SHALL provide the ability to render a current medication list for patient use.

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CP.1.3 Manage Medication ListConformance Criteria

10. 12. The system SHOULD provide the ability to capture and render information regarding the filling of prescriptions.

11. The system SHOULD provide the ability to capture and render information regarding the dispensing of prescriptions.

12. The system SHALL provide the ability to receive from an external source (for example a plan, payer or pharmacy) a medication history.

13. The system SHALL provide the ability to capture that a medication history is unavailable or incomplete.14. The system SHALL provide the ability to capture a description and reason for a medication when the

medication name is unknown.15. The system SHALL provide the ability to render on the medication list active medications that the

patient brings from home to take while hospitalized, which the Pharmacy may not dispense.16. The system SHOULD provide the ability to maintain the medication list with changes from pharmacist

verification including pharmacist, date, and time.17. The system SHOULD provide the ability to manage the reason or indication for the medication when

recording historical or medications from external sources (e.g. from home or other provider).18. The system SHOULD provide the ability to update a medication order directly from the medication list.19. The system SHALL conform to function CPS.4.2.1 (Support for Medication Interaction and Allergy

Checking) to render any potential interactions when capturing or maintaining medications.20. The system SHOULD provide the ability to maintain a medication order directly from medication

reconciliation.

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CP.1.3 Manage Medication ListConformance Criteria

21. The system SHALL provide the ability to capture free text medications and render them in a manner that distinguishes them from coded medication entries.

22. The system SHALL tag and render an indicator that interaction checking will not occur against free text medications.

23. The system SHOULD provide the ability to render side effects of medications from the medication list that have been previously experienced by the patient.

24. The system SHOULD provide the ability to render potential side effects of medications from the medication list.

25. The system SHALL provide the ability to capture and render that the patient takes no medications.26. The system SHALL provide the ability to render only current active medications (i.e. exclude

prescriptions whose duration has been exceeded or end date has passed).27. The system MAY provide the ability to render non-active medications or prescriptions for inclusion in

current medication screening.28. The system MAY provide the ability to capture medication self-administration details including

timestamps, observations, complications, and reason if medication dose was not taken.29. The system MAY capture Investigational Product Exposure information including Start Date/time, End

Date/Time, Dose Amount, Dose Unit, Study Treatment Name, Route, Formulation as discrete elements.30. The system SHALL capture, maintain and present pre-admission medications.

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CP.1.3 Manage Medication ListConformance Criteria

31. The system SHALL present pre-admission medications at the time of discharge.32. The system SHALL provide the ability to capture, maintain, and present all pertinent details of the

medication administration including medication name, strength, dose, route, date and time of administration, exceptions to administration, and administrator of the medication.

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CP.1.3 Manage Medication List“See Also” Dependencies

• CPS.9.3 Health Record Output• OVERARCHING:

– Trust Infrastructure– Record Infrastructure

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