Identifying / displaying medications based on Therapeutic Drug Class in EMR/EHR

I guess my first thought or question would be; which standard or classification system do you pick? AHFS? ATC? Third Party Provider Classifications? etc

A continuing concern I have about 'requirements' is that they are typically not comprehensive. A common situation is that a group is called together and are asked to produce a list of requirements. The first problem is that they often start with a blank sheet. Often they may be expert clinicians but have little or no informatics experience. They may be quick to learn things and then they find out that there are interesting or important things they would like to include in the requirements and they are told that those things are 'out of scope' or those issues are getting in to the weeds. The result is that the end list of requirements gloss over things that would have a significant impact on how products are developed.

Typically it is rare for any time to be spent reviewing carefully developed standards such as the ones developed by ISO. In my experience clinicians never get to see these and there are no discussions about recommendations in those standards.

Ray

Another problem is that standards should be developed looking forward, anticipating what would be needed in the future. It is unfortunate that there are many instances where the requirements get watered down because the vendors complain that they cannot do something or that no one is asking for specific functions. A good example are the 'meaningful use' requirements in the US where the bar was set so low that they are basically meaningless.

Hi Ray
If you send me your email address, I'll send you a copy of my thesis as now published. The entire thrust of it was to solve the problem you articulate in your first concern. One of its key recommendations is the ability to manage indication information more appropriately (as in your third concern, although most KBV should provide a search by indication, and indeed a search by therapeutic class). And the second use case is the research/analysis use case, which I am clear needs therapeutic class. Over here, I think all our systems support the sorts of things you describe in your second use case - they have to, it's needed for some of our care quality (and therefore payments) measures

Hi Julie,

There are some use cases that I should have mentioned. One is for the fairly frequent situation in the office when a physician wants to prescribe something and the patient says they had this before and it either did not work or there was some other issue. Then the physician might want to search previous prescriptions to see what was prescribe before and then prescribe something different. The list of previous prescriptions may be quite long and cover many years. The medications could be listed using a number of different names so it could take a while to get an understanding of what had been prescribed in the past. If it was possible to sort the list by class then it would be quicker and easier to understand what had been prescribed before. The ability to group prescriptions by class is of great value when looking at things like antidepressants, sedatives and analgesics because there are a lot of medications with very different names.

Another use case would be if the physician wanted to do a practice assessment. One search could be for patients with diabetes and renal impairment who were not prescribed an ACE or an ARB. Another search could be for patients with high cholesterol levels with a history of a heart attack that are not on a statin. Unfortunately, very few physicians do searches like this. Typically they don't know that this could be done or the EMR application they have is to rudimentary to provide an easy capability to do this. Some EMRs provide this type of capability with canned reports and even better, one EMR provides the capability for physicians or clinics to get comparisons with other clinics. The ability to do comparisons has motivated providers to improve their clinical practices.

Another incredibly useful thing would be to search by indication. This is also typically neglected by EMR vendors. A use case would be for one of the many new medications for asthma or diabetes. The physician heard about one of these but cannot remember the name. A search by indication could generate a list of names. The physician recognizes the one he wants and carries on.

Ray

I agree that the ability to browse up and down an hierarchy would be really helpful. I have seen this ability built into SNOMED browsers and in the the WHO ATC web site. I have not seen this implemented in any EMRs. The problem with EMR vendors is that they seem to be willing to implement things that are asked for by a large number of users. Unfortunately users typically have no idea of how useful things could be and don't ask their vendors for features like this.

How a therapeutic class is implemented is critical. At UHN our EHR (Harris Healthcare / Quadramed's QCPR) can identify and search medications by therapeutic drug class -- specifically AHFS classification. We have had to turn it off however as it only only classifies and displays it to the lowest applicable level of AHFS (third or fourth tier). So for example, we can classify something as "Salicylates" but the users cannot see the higher levels of "Cyclooxygenase-2 (COX-2) Inhibitors", "Nonsteroidal Anti-inflammatory Agents", "Analgesics and Antipyretics" and "Central Nervous System Agents" -- all of which likely have different clinical uses. We ideally want to be able to "walk" up the AHFS hierarchy to allow users to see medications differently depending on context and use case.

This has some big ramifications - if the user searches for "Analgesics" only those items that fall into the class of "28:08.92 Analgesics and Antipyretics, Miscellaneous" (eg. acetaminophen) are displayed rather than all the analgesics because it is only lower tier classification that actually has the key word of "Analgesics". All the narcotics etc are not displayed.