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

A first or future iteration 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 duration, or timing of next desired reassessment, as might be considered a "soft" stop date. This would stay distinct from an actual (hard) stop date denoting an intentional discontinuation by patient, with or without doctor approval, on the basis of intolerance or ineffective or not needed.

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.

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

Support for storing last_used and state_of_discontinuation

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"

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

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