GP Connect - Emergency Supply of Medications (ITK3)

The WG will be updating the MedicationDispense resource to adjust each affected resource to align with the workflow pattern (see workflow.html).

• dom-2: If the resource is contained in another resource, it SHALL NOT contain nested Resources
  contained.contained.empty()
• dom-1: If the resource is contained in another resource, it SHALL NOT contain any narrative
  contained.text.empty()
• dom-4: If a resource is contained in another resource, it SHALL NOT have a meta.versionId or a meta.lastUpdated
  contained.meta.versionId.empty() and contained.meta.lastUpdated.empty()
• dom-3: If the resource is contained in another resource, it SHALL be referred to from elsewhere in the resource
  contained.where(('#'+id in %resource.descendants().reference).not()).empty()
• mdd-1: whenHandedOver cannot be before whenPrepared
  whenHandedOver.empty() or whenPrepared.empty() or whenHandedOver >= whenPrepared

• rim: Entity. Role, or Act
• workflow: ..Event
• rim: Supply[moodCode=EVN]
• w5: clinical.medication

The only time that a resource does not have an id is when it is being submitted to the server using a create operation.

Asserting this rule set restricts the content to be only understood by a limited set of trading partners. This inherently limits the usefulness of the data in the long term. However, the existing health eco-system is highly fractured, and not yet ready to define, collect, and exchange data in a generally computable sense. Wherever possible, implementers and/or specification writers should avoid using this element.

This element is labelled as a modifier because the implicit rules may provide additional knowledge about the resource that modifies it's meaning or interpretation.

Language is provided to support indexing and accessibility (typically, services such as text to speech use the language tag). The html language tag in the narrative applies to the narrative. The language tag on the resource may be used to specify the language of other presentations generated from the data in the resource Not all the content has to be in the base language. The Resource.language should not be assumed to apply to the narrative automatically. If a language is specified, it should it also be specified on the div element in the html (see rules in HTML5 for information about the relationship between xml:lang and the html lang attribute).

Contained resources do not have narrative. Resources that are not contained SHOULD have a narrative. In some cases, a resource may only have text with little or no additional discrete data (as long as all minOccurs=1 elements are satisfied). This may be necessary for data from legacy systems where information is captured as a "text blob" or where text is additionally entered raw or narrated and encoded in formation is added later.

• rim: Act.text?

This should never be done when the content can be identified properly, as once identification is lost, it is extremely difficult (and context dependent) to restore it again.

• rim: N/A

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

• rim: N/A

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

• rim: N/A

• workflow: …identifier
• rim: .id
• w5: id

• rim: n/a

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

• rim: n/a

Allows the appropriate identifier for a particular context of use to be selected from among a set of identifiers.

This is labeled as "Is Modifier" because applications should not mistake a temporary id for a permanent one. Applications can assume that an identifier is permanent unless it explicitly says that it is temporary.

• v2: N/A
• rim: Role.code or implied by context

Allows users to make use of identifiers when the identifier system is not known.

This element deals only with general categories of identifiers. It SHOULD not be used for codes that correspond 1..1 with the Identifier.system. Some identifiers may fall into multiple categories due to common usage.

Where the system is known, a type is unnecessary because the type is always part of the system definition. However systems often need to handle identifiers where the system is not known. There is not a 1:1 relationship between type and system, since many different systems have the same type.

• v2: CX.5
• rim: Role.code or implied by context

There are many sets of identifiers. To perform matching of two identifiers, we need to know what set we're dealing with. The system identifies a particular set of unique identifiers.

• v2: CX.4 / EI-2-4
• rim: II.root or Role.id.root
• servd: ./IdentifierType

If the value is a full URI, then the system SHALL be urn:ietf:rfc:3986. The value's primary purpose is computational mapping. As a result, it may be normalized for comparison purposes (e.g. removing non-significant whitespace, dashes, etc.) A value formatted for human display can be conveyed using the Rendered Value extension.

• v2: CX.1 / EI.1
• rim: II.extension or II.root if system indicates OID or GUID (Or Role.id.extension or root)
• servd: ./Value

• v2: CX.7 + CX.8
• rim: Role.effectiveTime or implied by context
• servd: ./StartDate and ./EndDate

The Identifier.assigner may omit the .reference element and only contain a .display element reflecting the name or other textual information about the assigning organization.

• v2: CX.4 / (CX.4,CX.9,CX.10)
• rim: II.assigningAuthorityName but note that this is an improper use by the definition of the field. Also Role.scoper
• servd: ./IdentifierIssuingAuthority

• workflow: …part of
• rim: .outboundRelationship[typeCode=COMP]/target[classCode=PROC,moodCode=EVN]

This element is labeled as a modifier because the status contains codes that mark the resource as not currently valid.

• workflow: …status
• rim: .statusCode
• w5: status

• rim: .inboundRelationship[typeCode=COMP].source[classCode=OBS, moodCode=EVN, code="type of medication dispense"].value

If only a code is specified, then it needs to be a code for a specific product. If more information is required, then the use of the medication resource is recommended.  For example if you require form or lot number, then you must reference the Medication resource. .

• workflow: …code
• v2: RXD-2-Dispense/Give Code
• rim: .participation[typeCode=PRD].role
• w5: what

SubstanceAdministration->subject->Patient.

• workflow: …subject
• v2: PID-3-Patient ID List
• rim: .participation[typeCode=SBJ].role[classCode=PAT]
• w5: who.focus

• workflow: …context
• rim: .inboundRelationship[typeCode=COMP].source[classCode=ENC, moodCode=EVN, code="type of encounter or episode"]

• rim: .outboundRelationship[typeCode=PERT].target[A_SupportingClinicalStatement CMET minimal with many different choices of classCodes(ORG, ENC, PROC, SPLY, SBADM, OBS) and each of the act class codes draws from one or more of the following moodCodes (EVN, DEF, INT PRMS, RQO, PRP, APT, ARQ, GOL)]
• w5: context

The performer will be reviewed as part of STU4.

• ele-1: All FHIR elements must have a @value or children
  hasValue() | (children().count() > id.count())

• workflow: …performer
• rim: .participation[typeCode=PRF]

• rim: n/a

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

• rim: n/a

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

• rim: N/A

• workflow: ….actor
• rim: .role

• workflow: ….onBehalfOf
• rim: .role.scopingOrganization

Maps to basedOn in Event logical model.

• workflow: …basedOn
• v2: ORC-2 Placer Order Number
• rim: .outboundRelationship[typeCode=FLFS].target[moodCode=RQO]

• v2: RXD-33-Dispense Type
• rim: .code

• v2: RXD-4-Actual Dispense Amount / RXD-5.1-Actual Dispense Units.code / RXD-5.3-Actual Dispense Units.name of coding system
• rim: .quantity

• rim: n/a

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

• rim: n/a

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

• ele-1: All FHIR elements must have a @value or children
  hasValue() | (children().count() > id.count())
• ext-1: Must have either extensions or value[x], not both
  extension.exists() != value.exists()

• rim: n/a
• rim: N/A

Note that FHIR strings may not exceed 1MB in size

• ele-1: All FHIR elements must have a @value or children
  hasValue() | (children().count() > id.count())

• rim: n/a

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

• ele-1: All FHIR elements must have a @value or children
  hasValue() | (children().count() > id.count())
• ext-1: Must have either extensions or value[x], not both
  extension.exists() != value.exists()

• rim: n/a
• rim: N/A

The definition may point directly to a computable or human-readable definition of the extensibility codes, or it may be a logical URI as declared in some other specification. The definition SHALL be a URI for the Structure Definition defining the extension.

• ele-1: All FHIR elements must have a @value or children
  hasValue() | (children().count() > id.count())

https://fhir.hl7.org.uk/STU3/StructureDefinition/Extension-CareConnect-MedicationQuantityText-1

• rim: n/a
• rim: N/A

A stream of bytes, base64 encoded

• ele-1: All FHIR elements must have a @value or children
  hasValue() | (children().count() > id.count())

• rim: n/a
• rim: N/A

Precision is handled implicitly in almost all cases of measurement.

The implicit precision in the value should always be honored. Monetary values have their own rules for handling precision (refer to standard accounting text books).

• v2: SN.2 / CQ - N/A
• rim: PQ.value, CO.value, MO.value, IVL.high or IVL.low depending on the value

Need a framework for handling measures where the value is <5ug/L or >400mg/L due to the limitations of measuring methodology.

This is labeled as "Is Modifier" because the comparator modifies the interpretation of the value significantly. If there is no comparator, then there is no modification of the value.

• v2: SN.1 / CQ.1
• rim: IVL properties

There are many representations for units of measure and in many contexts, particular representations are fixed and required. I.e. mcg for micrograms.

• v2: (see OBX.6 etc.) / CQ.2
• rim: PQ.unit

Need to know the system that defines the coded form of the unit.

• v2: (see OBX.6 etc.) / CQ.2
• rim: CO.codeSystem, PQ.translation.codeSystem

Need a computable form of the unit that is fixed across all forms. UCUM provides this for quantities, but SNOMED CT provides many units of interest.

The preferred system is UCUM, but SNOMED CT can also be used (for customary units) or ISO 4217 for currency. The context of use may additionally require a code from a particular system.

• v2: (see OBX.6 etc.) / CQ.2
• rim: PQ.code, MO.currency, PQ.translation.code

• v2: TQ1.6 Timing/Quantity Segment Service Duration. Prior to v2.5, ORC.7.3 Common Order Segment / Quantity/Timing / Duration component. This is a formatted string, first character for the time unit (e.g., D=days), followed by the value. For example, “D14” represents “14 days supply” From v2.5 on, TQ1.6 Timing/Quantity Segment / Service Duration. This is a CQ data type (<Quantity (NM)> ^ <Units (CWE)>), thus for days supply, assuming the unit of measure is “days”, the numeric value is TQ1.6.1 (…|14^ For backwards compatibility, ORC.7 was permitted through v2.6. Both forms (field and segment) may be present in v2.5, v2.5.1, and v2.6
• rim: effectiveUseTime

• v2: RXD-3-Date/Time Dispensed
• rim: .effectiveTime[xmi:type=IVL_TS].low

• workflow: …occurrenceDateTime
• v2: RXD-3-Date/Time Dispensed
• rim: .effectiveTime[xmi:type=IVL_TS].high

• v2: RXD-13 Dispense-to Location; RXD-30 Dispense to Pharmacy; RXD-31 Dispense to Pharmacy Address
• rim: .participation[typeCode=DST].role

• rim: .participation[typeCode=RCV].role

• workflow: …note
• v2: RXD-9 Dispense Notes
• rim: .inboundRelationship[typeCode=SUBJ]/source[classCode=ACT,moodCode=EVN]

• rim: n/a

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

• rim: n/a

• v2: N/A
• rim: Act.participant[typeCode=AUT].role

• v2: N/A
• rim: Act.effectiveTime

• v2: N/A
• rim: Act.text

When the dose or rate is intended to change over the entire administration period (e.g. Tapering dose prescriptions), multiple instances of dosage instructions will need to be supplied to convey the different doses/rates. The pharmacist reviews the medication order prior to dispense and updates the dosageInstruction based on the actual product being dispensed.

• rim: .outboundRelationship[typeCode=COMP].target[classCode=SBADM, moodCode=INT]

• rim: n/a

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

• rim: n/a

If the sequence number of multiple Dosages is the same, then it is implied that the instructions are to be treated as concurrent. If the sequence number is different, then the Dosages are intended to be sequential.

• rim: .text

Free text dosage instructions can be used for cases where the instructions are too complex to code. The content of this attribute does not include the name or description of the medication. When coded instructions are present, the free text instructions may still be present for display to humans taking or administering the medication. It is expected that the text instructions will always be populated. If the dosage.timing attribute is also populated, then the dosage.text should reflect the same information as the timing.

• rim: .text

Additional instruction such as "Swallow with plenty of water" which may or may not be coded.

• rim: .text

• rim: .text

The timing schedule for giving the medication to the patient. The Schedule data type allows many different expressions. For example: "Every 8 hours"; "Three times a day"; "1/2 an hour before breakfast for 10 days from 23-Dec 2011:"; "15 Oct 2013, 17 Oct 2013 and 1 Nov 2013". Sometimes, a rate can imply duration when expressed as total volume / duration (e.g. 500mL/2 hours implies a duration of 2 hours). However, when rate doesn't imply duration (e.g. 250mL/hour), then the timing.repeat.duration is needed to convey the infuse over time period.

This attribute may not always be populated while the Dosage.text is expected to be populated. If both are populated, then the Dosage.text should reflect the content of the Dosage.timing.

• rim: .effectiveTime

Can express "as needed" without a reason by setting the Boolean = True. In this case the CodeableConcept is not populated. Or you can express "as needed" with a reason by including the CodeableConcept. In this case the Boolean is assumed to be True. If you set the Boolean to False, then the dose is given according to the schedule and is not "prn" or "as needed".

• rim: .outboundRelationship[typeCode=PRCN].target[classCode=OBS, moodCode=EVN, code="as needed"].value=boolean or codable concept

A coded specification of the anatomic site where the medication first enters the body.

If the use case requires attributes from the BodySite resource (e.g. to identify and track separately) then use the standard extension body-site-instance. May be a summary code, or a reference to a very precise definition of the location, or both.

• rim: .approachSiteCode

A code specifying the route or physiological path of administration of a therapeutic agent into or onto a patient's body.

• rim: .routeCode

A coded value indicating the method by which the medication is introduced into or onto the body. Most commonly used for injections. For examples, Slow Push; Deep IV.

Terminologies used often pre-coordinate this term with the route and or form of administration.

• rim: .doseQuantity

The amount of therapeutic or other substance given at one administration event.

Note that this specifies the quantity of the specified medication, not the quantity for each active ingredient(s). Each ingredient amount can be communicated in the Medication resource. For example, if one wants to communicate that a tablet was 375 mg, where the dose was one tablet, you can use the Medication resource to document that the tablet was comprised of 375 mg of drug XYZ. Alternatively if the dose was 375 mg, then you may only need to use the Medication resource to indicate this was a tablet. If the example were an IV such as dopamine and you wanted to communicate that 400mg of dopamine was mixed in 500 ml of some IV solution, then this would all be communicated in the Medication resource. If the administration is not intended to be instantaneous (rate is present or timing has a duration), this can be specified to convey the total amount to be administered over the period of time as indicated by the schedule e.g. 500 ml in dose, with timing used to convey that this should be done over 4 hours.

• rim: .doseQuantity

The maximum total quantity of a therapeutic substance that may be administered to a subject over the period of time. For example, 1000mg in 24 hours.

This is intended for use as an adjunct to the dosage when there is an upper cap. For example "2 tablets every 4 hours to a maximum of 8/day".

• rim: .maxDoseQuantity

The maximum total quantity of a therapeutic substance that may be administered to a subject per administration.

This is intended for use as an adjunct to the dosage when there is an upper cap. For example, a body surface area related dose with a maximum amount, such as 1.5 mg/m2 (maximum 2 mg) IV over 5 – 10 minutes would have doseQuantity of 1.5 mg/m2 and maxDosePerAdministration of 2 mg.

• rim: not supported

The maximum total quantity of a therapeutic substance that may be administered per lifetime of the subject.

• rim: not supported

Identifies the speed with which the medication was or will be introduced into the patient. Typically the rate for an infusion e.g. 100 ml per 1 hour or 100 ml/hr. May also be expressed as a rate per unit of time e.g. 500 ml per 2 hours. Other examples: 200 mcg/min or 200 mcg/1 minute; 1 liter/8 hours. Sometimes, a rate can imply duration when expressed as total volume / duration (e.g. 500mL/2 hours implies a duration of 2 hours). However, when rate doesn't imply duration (e.g. 250mL/hour), then the timing.repeat.duration is needed to convey the infuse over time period.

It is possible to supply both a rate and a doseQuantity to provide full details about how the medication is to be administered and supplied. If the rate is intended to change over time, depending on local rules/regulations, each change should be captured as a new version of the MedicationRequest with an updated rate, or captured with a new MedicationRequest with the new rate.

• rim: .rateQuantity

• ele-1: All FHIR elements must have a @value or children
  hasValue() | (children().count() > id.count())

• rim: .outboundRelationship[typeCode=COMP].target[classCode=SUBST, moodCode=EVN]

• rim: n/a

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

• rim: n/a

There can be no stigma associated with the use of extensions by any application, project, or standard - regardless of the institution or jurisdiction that uses or defines the extensions. The use of extensions is what allows the FHIR specification to retain a core level of simplicity for everyone.

• rim: N/A

• rim: .actionNegationInd

• v2: RXO-9-Allow Substitutions / RXE-9-Substitution Status
• rim: .code

• rim: .reasonCode

• rim: .participation[typeCode=PFM].role[classCode=ASSIGN]

• rim: .inboundRelationship[typeCode=SUBJ]/source[classCode=ALRT,moodCode=EVN].value

• workflow: …notDone
• rim: .actionNegationInd

• workflow: …notDoneReason
• rim: .outboundRelationship[typeCode=RSON]/target[classCode=OBS,moodCode=EVN, code="not done reason"].value

This may not include provenances for all versions of the request – only those deemed “relevant” or important. This SHALL NOT include the Provenance associated with this current version of the resource. (If that provenance is deemed to be a “relevant” change, it will need to be added as part of a later update. Until then, it can be queried directly as the Provenance that points to this version using _revinclude All Provenances should have some historical version of this Request as their subject.).

• rim: .inboundRelationship(typeCode=SUBJ].source[classCode=CACT, moodCode=EVN]