[Gnumed-devel] Medication viewing

[Jim Busser]

Just wondering if some concepts may be future-compatible with current  
construction:

The universe of what is relevant for a patient could include

a. what they had *ever* taken
b. what is currently available to the patient
c. what the patient is *advised* to be taking
d. what the patient *accepts* to be taking

The above is compounded by:
- self-medication is possible, even without a prescription
- a patient may not continue to take a medication in the dosage  
originally prescribed or advised
- a patient may refuse to try a therapy which may therefore not ever  
get prescribed

Traditionally we do not capture a refusal of therapy in a medication  
list, except *after* the medication had been tried. After the  
medication had been tried with refusal of adherence, the medication  
may be considered Intolerated or maybe just ineffective and therefore  
never makes it into Allergy/Intolerance and only into an archive of  
what *had* been tried.

Leaves me wondering about pre-emptively entering (into the Allergies /  
Intolerances) drugs which the patient would refuse to take. if we  
might do it for beta-blockers in asthmatic patients there is no reason  
a clinical group might not choose to use this method.

When making therapeutic choices, one might ideally be presented  
choices based on cost-effectiveness, and these could be listed against  
what a patient currently takes (or did previously take) and against  
whether there is a recorded allergy or intolerance. Notably a patient  
may agree to use a drug even despite that it gives side effects the  
patient can accept even while the information was entered in  
Intolerances. A display might set out (side by side)
        Options History         Notes

Perfect-world would populate Options based on clinical decision  
support but even before that it should be possible to select drug  
categories (anti-depressant, anti-hypertensive, diuretic etc). The  
"Options" would list either generic single agents or maybe generic  
combos (trimethoprim-sulfa) -- not sure about that one -- or  
proprietary which may be combos.

The "History" would list whether there exists a current or past match  
for the drug.
- In absence of any match, the History would be blank
- in presence of a match, shown could be the date last started (+-  
stopped) plus the regimen
- regardless of History, if it was a drug for which there was a drug- 
specific or class Allergy / Intolerance, that info would be displayed  
under the Notes column.

When Options are not having to be considered, the History listing  
would include what we know as the "Medication list (Current  
medication)" plus previous medication and could take into account  
whether the listed medications are intended to continue in perpetuity  
(as with chronic disease, maybe a duration symbol "+" and whether they  
have an anticipated ("soft") stop or supply reassessment date that may  
be understood distinctly from (hard) stop dates that denote an  
intentional discontinuation by patient (intolerance or ineffective or  
not needed) or doctor (intolerance or ineffective or not needed).

- provide unique listings, according to drug-strength-dosage, noting a  
single drug could appear in multiple active drug-strength-dosage  
listings (since not all daily/weekly regimens can be managed by  
fractions and multiples of tablets)

- filter / sort:
	"Group A" = current (blue) = "soft_stop_date" is {NULL or future- 
dated} and hard_stop_date is NULL
	"Group B" = undefined (orange) = "soft_stop_date" is today-or-past- 
dated} and hard_stop_date is NULL
	"Group C" = stopped (grey) = hard_stop_date is not NULL (NULL not >  
today)

... the idea of Group B allowing to identify patients whose medication  
may need special review whether for decision-making and/or adequacy of  
medication supply. You would only put in the hardstop date when you  
confirmed at the next visit that the patient actually stopped their  
medication as instructed at the prior visit, and when (if able to be  
determined). Red might be useful in relation to a supply calculated to  
be expired. It is not fully thought through, I can already see a  
conflict between "supply" and "clinical intention" but though I would  
at least share the general concepts.