The List of Current Medications

Scope

This list shows the substances the patient is currently taking in order to gain well-being. Hence it lists prescription drugs, non-prescription drugs, supplements, etc. This is not to be confused with a list of "most-recent prescriptions".

Types of medication entries

  • substances on a daily, timed schedule
    • Metoprolol 100mg 1-0-1

  • substances on an as-needed schedule with a daily maximum
    • Ibuprofen 600mg tab up to 4 times daily
    • Salbutamol inhaler up to 6 times daily

  • substances on a weekly schedule with varying daily dosages
    • Phenprocoumon 3mg tab  1 / 1 / 0.5 / 1 / 0.5 / 0.5 / 0.5
    • Alendronat 70mg every Wednesday (which really means Alendronat 70mg 0 / 0 / 1 / 0 / 0 / 0 / 0)

  • substances on a non-weekly but regular schedule
    • VitB12 injection i.m. every 4 weeks
    • Fentanyl Transdermal System 12.5µg every 3rd day

  • substances with a daily but irregular plan
    • rapid-acting insulin s.c. as per blood glucose measurement at meal time

  • substances taken randomly, ad libitum
    • palliative ad libitum dosage of morphine
    • VitC when having flu-like symptoms

Multi-component pills

  • two substances for the same episode/issue, say Metoprolol + Hydrochlorothiazide
  • two components for different episodes/issues, say a Statine + an Antihypertensive
  • two or more components for several, even wildly disjunct episodes/issues
    • this has been reported from Brasil

Single components acting on several issues

  • betablockers used for migraine prophylaxis and hypertension control

Metadata fields

  • brand name
    • quite a few number of drugs comprise two acting agent
  • acting agent (drug)
  • strength per unit
  • application type
  • start date
  • intended duration
  • regimen
  • intended treatment aim
  • relevant episode

Input considerata

  • the drug/brand phrasewheel should offer two-term matching:
    • typing dilt brings up Diltiazem SR 240mg and Diltiazem 30mg
    • typing dilt 24 brings up Diltiazem 240mg only
  • even in the absence of a drug database will the drug/brand phrasewheel pull from the existing drugs of all patients

Desirable layout inside GNUmed

  • ordering by episode is desirable
    • this is technically somewhat involved as it requires interleaving different types of row styles with each other
    • it also represents problems as to how to present multi-component-multi-episode or single-component-multi-episode drugs
  • audit trail (= history of once-current medications) should be accessible

List of current medications
brand drug dose prep schedule aim notes started duration episode
  morn mid eve night    
Sauria Gold brandy ml liq - - - 50 medicinal value   3.1.09   regulatory review
MetoHexal comp. Metoprolol 100mg tab 1 - - - RR control   3.1.09   aHT, Migraine
HCT 12.5mg aHT
MetoSim Metoprolol 50mg tab - - 1 - RR   30.11.08   aHT, Migraine
Simvastatin 40mg tab lipids report muscle pain Hyperlipidemia
SumaRapid Sumatriptan 50mg tab 1 in attack pain control not if aura! 3.3.08   Migraine
  Mo Tue We Th Fr Sa Su  
Falithrom Phenprocoumon 3mg tab 1 0.5 1 0.5 0.5 0.5 0.5 no clots   27.11.08 9/12 DVT
  Alendronic acid 70mg tab - - 1 - - - - strong bones 30mins before breakfast w/ 200ml water 27.11.08   osteoporosis

Unique listings would be according to prescribed substance (which could be a combo drug) along with component strength and dosage.

A single drug may have to appear in multiple active drug-strength-dosage listings because not all daily/weekly regimens can be managed by fractions and multiples of a single tablet strength.

Version 0.6x considerations: Supports grouping by Episode, by Brand and by Substance, and filtering based on whether or not "approved" and whether or not 'active". Takes into account whether a substance clin_when (start date) was null or future-valued, whether a long-term item intended to continue in perpetuity (as with chronic disease: the "infinity" symbol) and whether they have an anticipated duration, or timing of next desired reassessment, as might be considered a "soft" stop date.

Printouts

The actual formats are intended to be based on (manually) user-configurable templates. Candidates for the template language is any text-based format which allows for creating tables which are then auto-wrapped/scaled onto paper by a post-processor, say, LaTeX, reST, HMTL. Each of which would be intended to be converted to PDF and subsequently be sent to an OS-level spooler. Said spooler would feed a fax modem, a printer, an email account, ... Each printout should contain a certain common dataset:

Header

  • moniker Current medications
  • full patient name and date of birth
  • line printed date-of-printout (or valid as of date meds last altered)
  • allergies (here vs in footer... as yet unresolved)

List of drugs

Included fields:

  • brand name (if appropriate for locale)
  • acting agent (drug)
  • strength per unit
  • application type
  • regimen
    • precede decimal amounts by zero when less than one (e.g. 0.5)
    • optionally properly format fractional amounts where possible (e.g. ¼ or 1+½)
    • optionally append amount in translated word equivalents inside parenthesis (e.g. (one and a half))
  • intended treatment aim

report type: times-by-drug

  • for patient use
  • first column lists drugs alphabetically
  • subsequent columns list when to take, etc

report type: drugs-by-time

  • for patient use
  • first column lists when to take
  • subsequent columns list which drug
    • multiple drugs go on multiple rows

report type: drugs-by-episode

  • for admission to hospital
  • ordered by episode
  • omit aim
  • include start date
  • include duration

Footer

  • allergies
  • Surgery contact information
  • GNUmed moniker

Future consideration ≥ 0.7x

Support for storing last_used and state_of_discontinuation

Deprecated. See new discussion MedicationHistory

Example: patient had been instructed to take an antibiotic for a duration of 10 days but, at a followup visit in 10 days, admits they only took the medication for 4 days and because they were both nauseated -- and did already feel better from their original symptoms -- flushed them down the toilet. It is IMO totally wrong to alter this current medication row to change the duration to 4 days, unless the meaning of "duration" is changed from "How long is this substances intended to be taken" to "Intended (or post-hoc actual) duration of use, if known" e.g. last_actually_taken

At deletion of any substances from the current_medication list we would like to make it possible to confirm/enter details like last_used and the state of discontinuation
  • tolerability issue
  • lack of finances -- not a subtype of tolerability?
  • insufficiently effective
  • combination of above
  • not needed

Filter / sort:

  • "Group A" = current (blue) = clin_when <= today and "soft_stop_date" is {NULL or future-dated} and hard_stop_date is NULL
  • "Group B" = current (blue?) = clin_when > today and "soft_stop_date" is {NULL or future-dated} and hard_stop_date is NULL
  • "Group C" = undefined (orange) = "soft_stop_date" is today-or-past-dated} and hard_stop_date is NULL
  • "Group D" = stopped (grey) = hard_stop_date is not NULL (NULL not > today)

The idea of Group B allows 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 hard_stop 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).

At a later stage, there could be some hook or auto-resolution (administrative awareness) of the adequacy of drug supply, based on available prescription information.

Drug selector display

Options Agent history Status Caveats
angiotensin-converting enzyme inhibitors (ramipril 10mg daily) … Oct 8, 2008 angioedema Oct 7, 2008 (class)
beta-adrenergic blockers     asthma (class)
calcium entry antagonists      
diuretics, proximal tubule hydrochlorothiazide 12.5mg daily Nov 21, 2007… erectile difficulty, mild Nov 26, 2007
diuretics, potassium-sparing      

Eventual best-practice would populate Options based on clinical decision support. As a precursor step, it should be possible to prompt listings of drug category (anti-depressant, anti-hypertensive, diuretic etc) listings. It would need to be determined how "Options" would be listed in the case of multi-component drugs... where a name did not make apparent (i.e. where it might hide) a second element, some visual indication would be needed.

In the "Agent history" column would be listed whether there exists a current or a past match for the drug shown in Options.
  • 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
  • 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.
  • regardless of existence in the history, if it was a drug for which there was a drug-specific or class Allergy / Intolerance, this patient-specific info would be displayed under the Caveats column.

Temporary notes

Database schema posting in relation to above at http://lists.gnu.org/archive/html/gnumed-devel/2009-10/msg00059.html
Topic revision: 21 Nov 2010, JamesBusser
 
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