DUR Applied to Historic Records in the DIS

From our testing, it appears that our DIS is operating the same as yours. The issue is attached to both prescription A and B, however the date that the issue was attached is not seen (unless the issue was managed, and then the date it was managed is shown). As you stated, “there is a risk that the significance of these issues may be misinterpreted as it is not clear to the user that the issue was added later, and not at the time the transaction was created. Users may assume another provider has already dealt with the issue, and in the instance where there may be an investigation by one of the colleges, it may look like an issue was not resolved appropriately.”

We had a group discussion and agree that we would also like to see the date that the issue is attached, and feel like this would make it easier for the user to interpret what they are seeing and reduce the chances of something being missed.


Leslie Barrett
Pharmacist (SME)
Newfoundland Labrador Centre for Health Information
70 O'Leary Avenue
St. John's, NL, A1B 2C7
email: This email address is being protected from spambots. You need JavaScript enabled to view it.
(709)752-6556

Response received from Alberta:

The date the issue was logged is recorded, which the user will be able to see if they need to investigate. Most, if not all, investigations will be done via the user’s application (EMR or PPMS) so it will be up to the vendor to determine how to show the history of events. They may choose to show all activity chronically for a patient, and not just the prescribe or dispense events. They can allow the user to drill down etc.

All the pharmacy systems should already be dealing with this type of situation through its own interaction checking modules, so it may be worthwhile to ask them how they currently show the user the information.

Very early on Alberta used to have a requirement for the systems to be able to show how the provincial profile would have looked at a particular date in time. The vendors wanted this changed as it was very hard to implement without storing copies of all DIS records locally, but that would not show which records the user actually looked at, but only the information that was returned to the local system. This also did not include any other information such as what was discussed with the patient, or what was viewed locally. In the end the Drug Sub Group (Alberta’s clinical review) decided that the requirement can be dropped.

Alberta does tie the interaction to both prescriptions.

The Nova Scotia DIS applies DUR on prescriptions and dispenses, as well as other clinical transactions (e.g. other meds, immunizations). The DUR has been configured to apply system responses to detected issues according to the DUR Module (e.g. Allergy, Drug interactions, Duplicate Therapy, etc.). These system responses and management requirements are as follows:

• Reject with no override (Note: NS DIS has not implemented any DUR responses with this option)
• Reject - Override with Management Code: User must re-submit transaction with an issue management code before the clinical record can be saved in the DIS
• Accept and Warn: User receives a DUR warning and may or may not choose to add an issue management code. The issue is attached to the applicable clinical record(s) with no management.
• Accept and Suppress: User does not receive a DUR warning and no issue is attached to the clinical record(s).

As described in the CeRx Business and Technical documents, noted in the original post, the DUR detected issue may be attached to previously existing clinical records (e.g. If drug A was prescribed and then later drug B was prescribed and an drug-drug issue detected with drug A, a subsequent query response should show an issue hanging off both prescription A and prescription .

Hi Natalie,
Can you clarify if your DIS requires management of issues before a record is created and also on what types of records you perform DUR on (e.g. dispenses, prescriptions or both)?

I wonder if this issue you are raising has to do with how your DIS has implemented DUR rather than the standard.

In SK, we require management of an issue before it is added to the DIS. So all issues are resolved before they are added to records.

Thanks
Melva Peters

We have run into an issue with the standards I wanted to get feedback on. I have copied the relevant standards at the end of the message, but will summarize.

In effect what the DUR does is assign an issue to transactions in the past. This may make it appear to users that there were issues on transactions that were not resolved. For example a DUR related to an allergy is applied to a refill that occurs after the record is added, but it also applies an issue to the original prescription order, with no way for a user to see the issue was not added at the time the order was created.

There is a risk that the significance of these issues may be misinterpreted as it is not clear to the user that the issue was added later, and not at the time the transaction was created. Users may assume another provider has already dealt with the issue, and in the instance where there may be an investigation by one of the colleges, it may look like an issue was not resolved appropriately.

Our SME for pharmacy and medicine both agree that this is an alteration to the historical patient record and is a concern. We have also had preliminary discussion with one of our professional colleges and they are concerned with this behavior as well. We all are in agreement that any issues should be applied to transactions on a go forward basis, and not affect the historical record. This is how DUR functions in the local pharmacy system.

Not sure what the process is to move this forward as the SCWG is no long in place, but I am happy to get feedback from others on this. Thanks. Natalie

Natalie Borden B.Sc. (Pharm)
Program Director, Drug Information System
Nova Scotia Department of Health and Wellness
Office 1-902-424-7270
Mobile 1-902-233-8810
Email: This email address is being protected from spambots. You need JavaScript enabled to view it.

Relevant Standards

CeRx Business Document:
SC-CA-0006-EN-Implemenation Guide Volume - Overview contains details regarding issue detection, reporting and management. One key area that I will highlight is:
8.1.2.4 Recording of Issues on the EHR/DIS
In general, persist able issues tie to prescriptions, dispenses and other medication records, not to allergies or medical conditions. The reason being is you can stop the patient from having a drug, but it's hard to stop them from having an allergy or medical condition. Thus if the issue is a drug-allergy or drug-condition issue, then tying the issue to a prescription or dispense is appropriate.
If the issue is a drug-drug interaction, then logically the issue should be tied to both prescriptions, because either one of them could be stopped, suspended or monitored to mitigate the issue for both of them. This problem is made more evident when allowing managements after the fact. If drug A was prescribed and then later drug B was prescribed and an drug-drug issue detected with drug A, a subsequent query response should show an issue hanging off both prescription A and prescription B.

CeRx Technical Document:
Because you need special software to open the technical document, Matt has outlined the information contained in this document as follows:

PORX_MT980010CA.xsd – schema for the following elements provide the details of what the triggering events are:

As with all Infoway HL7 documentation, they are not always consistent on what they say for each of these, but the theme is clear. Each element indicates that the details of each should be available to the Provider:
- “records which contributed to the issue being raised”
- “Allows provider to drill-down and retrieve additional information … when evaluating appropriateness of issue management”.

PORX_MT980010CA.ObservationCodedEvent –
This is the recorded observation (e.g. allergy, medical condition, lab result, pregnancy status, etc.) of the patient that contributed to the issue being raised.
Useful for determining appropriate management and for drilling down for more information.
Unique identifier for the record of the coded observation (e.g. allergy, medical condition, pregnancy status, etc.) that contributed to the issue.
Allows lookup of the specific coded observation (e.g. allergy, medical condition, pregnancy status, etc.) for additional details when evaluating appropriateness of issue management.


PORX_MT980010CA.SubstanceAdministration
Indicates an active medication (prescription or non-prescription medication) that is recorded in the patient’s record and which contributed to triggering the issue.
Allows providers to identify the offending drugs when determining their management approach.
Unique identifier of the prescription or other medication drug record that triggered the issue.
Allows provider to drill-down and retrieve additional information about the implicated drug therapy to either modify the therapy or to learn more information in determining their management approach for the issue.

PORX_MT980010CA.SupplyEvent
Indicates a particular dispense event that resulted in the issue.
Used when the issue pertains to the supply of the drug rather than the drug itself. E.g. Duplicate pharmacy, refill too soon, etc.
Unique identifier of the dispensed event that triggered the issue.
Allows provider to drill down and retrieve additional information about the dispense event for consideration in their issue management decision.


PORX_MT980010CA.ObservationMeasurableEvent
This is the recorded observation (e.g. height, weight, lab result, etc.) of the patient that contributed to the issue being raised.
Useful for determining appropriate management and for drilling down for more information.
Unique identifier for the record of the observation (e.g. height, weight or lab test/result) that contributed to the issue.
Allows lookup of the specific observation (e.g. height, weight, or lab record) for additional details when evaluating appropriateness of issue management.