MS-PCC-CP-0018

Change Proposal MS-PCC-CP-0018

Official Change Proposal Template is a WORD document found at ftp://ftp.ihe.net/Document_templates/IHE_Change_Proposal-Template-V10.doc

The Change Proposal Template that you use is dependent on the committee.

Tracking Information

Domain

Patient Care Coordination

Change Proposal Number

MS-PCC-CP-0018

Status

incoming

Last Updated

11:51, 3 March 2008 (CST)

Assigned

Change Proposal Summary

Title

Entries for Unknown or No Known Medications, Problems and Allergies

Submission Date

11:51, 3 March 2008 (CST)

Profile Affected

TF

TF Version

3.0

Volume and Section

II

Rationale

When no information is present, or is otherwise unknown, there is no present way to represent this in medication, problem and allergy entries in the current technical framework.

Content

Add the following text to "Distinctions of None" under the Medical Documents Specification.

An appropriate machine readable entry must also be present to indicate the reason that no information is present.

The table below provides some thoughts in this direction.

Entry Type	Code	Display Name	Description
Problem	396782006	Past Medical History Unknown	To indicate unknown medical history
Problem	407559004	Family History Unknown	To indicate that the patient's family history is not known.
Problem	160243008	No Significant Medical History	To indicate no relevant medical history
Problem	160245001	No current problems or disability	To indicate that the patient has no current problems (as distinct from no history).
Allergy	409137002	No Known Drug Allergies	To indicate that there are no known Drug allergies for this patient.
Allergy	160244002	No Known Allergies	To indicate that there are no known allergies for this patient.
Allergy	64970000	Substance Type Unknown	To indicate the state where there is a known allergy or intollerance to an unknown substance
Medication	182904002	Drug Treatment Unknown	To indicate lack of knowledge about drug therapy
Medication	182849000	No Drug Therapy Prescribed	To indicate the absense of any prescribed medications
Medication	408350003	Patient Not On Self-Medications	To indicate no treatment

Add appropriate references to the Active Problems, Resolved Problems, Allergies and Other Adverse Reactions, and Medications sections.

Open Issues

1. How should unknown allergies be represented, vs. allergy to unknown substance? These should be perfectly clear and distinct entries.
2. Should examples for "unknown" or "no known" and/or "none" be provided under the appropriate level 3 entry using the same template identifier? Should these be a separate template or templates? In that case, how should the cardinality of the entries should be changed? I would suggest in this case to use Conditional (either 1-N of standard entry, or 1 from unknown/none entry), so that we can ensure that a machine readable entry is present providing the same information as in the text.
3. What other text changes are necessary?
4. Some suggested language from ACP (Barr):

On allergies, the difference between "No Known Allergies" and "Allergies Unknown" is that the former implies that the question was asked an the response was "none"; the latter implies that the question was not asked (or not documented that it was asked) and should be a prompt to the clinician to ask and appropriately modify that field. When the question hasn't been asked, perhaps "Allergy Status Unknown" would be even better than Allergies Unknown - which could imply that there are allergies but we don't know what they are."Substance Type Unknown" is confusing - could be "Allergy to Unknown Substance" which is a bit clearer - implies a documented allergy to a yet-to-be identified substance.

For medication, "Drug Treatment Unknown" is also confusing. It could imply that the patient is on medication but the type is unknown, or, what I think it is implying, is that the medication status is unknown. If that is the case, perhaps the display should read, "Medication Status Unknown". Likewise, "No Medication Prescribed" might follow. For the "Patient Not on Self-Medication" - I presume this is in reference to over-the-counter medications. If that is the case, perhaps a clear distinction needs to be made. I suggest the following:

1. Prescribed Medication Status Unknown 2. No Prescribed Medications 3. Non-Prescription Medication Status Unknown 4. No Non-Prescription Medication

See also: MS-PCC-CP-0017

1. Needs to be harmonized with HL7 Patient Care
2. Needs to be different template, (e.g., no frequency and route for a negative)

Accepted

Assigned to Keith and Larry to come up with proposed text.