Some questions of someone who starts late to come to the meetings. :)

[ZorgiLoic]

Hello,

I may ask questions that have already been addressed in previous meetings, but I only joined the group last week.

Regarding a prescription with an unknown dosage, how is it represented in a prescription line?
Example: insulin.
For a partially conditional prescription, how should it be handled?
Example: Dafalgan, 1 tablet morning, noon, evening + 1 if pain persists.
Are these two different prescription lines?
How is the "+1 if pain persists" part represented?
In the medication line, there is a property posologie.overrideReason. How do we assess a dosage override?
The SAM contains medication leaflets, but I couldn't find a structured maximum dosage.
Could you please indicate where the information is located in the XMSL files?
Visiflag seems to have changed its functionality compared to Recip-e.
Initially, Visiflag allowed the patient to hide a medication and decide which pharmacist had access.
A second flag has been added to allow a doctor to indicate that they would be the only prescriber able to see this prescription.
In this case, it's a limitation to only doctors who have a therapeutic link.
Has the idea of hiding treatments from pharmacists been abandoned?
Medication identification is based on a CNK or CTI-extended, or...
In communications, should we provide a code and the domain from which it is extracted, or all codes associated with the medication?
This (similarly to Recip-e's operation) discriminates against foreign medications. Is this intentional?
How will the prescriber be identified?
Is it through their INAMI number as with Recip-e, or via a NISS number? (In this case, is it planned to add the information to the cobrha database exports?)
Could you provide an example of a medication scheme for home infusion treatment, please?
Example: a bag with 1 medication + 1 infusion liquid with a flow rate that needs to be continuously renewed.
Best regards,
Loïc.

[smals-jy]

Hello @ZorgiLoic ,

I'm Jacques from VIDIS. With others, we are discussing topics about the Dosage in #164 which has impacts in all ressources handling medications (prescriptions, medication scheme and delivered medications). Like you will discover, I made a library called fhir-dosage-utils with examples I collected to get a better idea of dosage formats on the field.

To answer some of your questions with my point of view :

Regarding a prescription with an unknown dosage, how is it represented in a prescription line?

There are at least 3 ways :

1. You don't provide any dosageInstruction at all
2. You provide a text explaining that there is no known dosage
3. You provide a extension explaining that there is no known dosage

I think the first way is the best, in a KIS approach like FHIR did (second could work as well).

For a partially conditional prescription, how should it be handled? Example: Dafalgan, 1 tablet morning, noon, evening + 1 if pain persists.

I think the best way could be something like this :

[
	{
		"doseAndRate": [
			{
				"doseQuantity": {
					"value": 1,
					"unit": "tablet"
				}
			}
		],
		"timing": {
			"repeat": {
				"when": [
					"MORN",
					"NOON",
					"EVE"
				]
			}
		}
	},
	{
		"doseAndRate": [
			{
				"doseQuantity": {
					"value": 1,
					"unit": "tablet"
				}
			}
		],
		"asNeededBoolean": true
	}
]

Why ?

• You don't impact the part that isn't conditional
• You could add extra information for the conditional part - I used "asNeededBoolean", but you can use asNeededCodeableConcept with a SNOMED CT code as well.

Are these two different prescription lines?

Not necessarily, I guess it depends on the software and their guidelines.
Some may do it in a single line, others may prefer to do it in several lines. (I think I've heard similar thoughts about medication regimens with complex dosages in medication scheme)

The SAM contains medication leaflets, but I couldn't find a structured maximum dosage.

It seems that in CBIP / BCIP, they have something for maximum dosage like this example :

enfant: 50 mg/kg/j. en 3 prises (max. 500 mg/prise) pendant 28 jours

I don't have news about SAM roadmap for FHIR ...

Regardless of that, expressing "maximum" in dosage is going to be done by 3 specific fields in FHIR :

• maxDosePerAdministration
• maxDosePerLifetime
• maxDosePerPeriod

I would be interested to see belgian examples as I only have international examples atm for this topic

[ZorgiLoic]

Hi @smals-jy ,
Thanks for your answers. :)

About the maximum dosage if the information is given like in your example, it won't be possible to evaluate if the prescription that the prescriber as done match with that recommandation. The recommandation should be structured as the medication schema to be able to compare the two, no ? Cause just displaying the recommandation to the doctor and ask him "if you didn't respect the recommandation please justify" won't work.
To who can we ask the question about the content of the SAM exports ? Normaly it should be the official source of information no ?
Kind regards.

[JensPenny]

@ZorgiLoic
As an extra on the above answer: you could check the integration-version of samv2. This should have a couple of extra fields filled in containing the daily defined dose (or so I'm told)
Link: https://wwwint.vas.ehealth.fgov.be/websamcivics/samcivics/

For the sake of completeness: there is also an acceptation-environment, but this data should match the production-data. Link: https://wwwacc.vas.ehealth.fgov.be/websamcivics/samcivics/

[smals-jy]

Hello @ZorgiLoic ,

For comparison, I would use a binary one as this is quite simple to implement. Obviously, not a bulletproof solution but better than nothing - there is always place for improvements. Some libraries are out for that, like Lodash , UnderscoreJS , ...

It seems you are talking about extensions dosage-override and dosage-override-reason. From my understanding, it was intended to be mandatory in the medication scheme only if the recommandation & the prescriber dosage aren't equal. Maybe with examples, it would be more clear :

Scenario n°1

1. I look for a medication in SAMv2
2. I select one : its name and dosage are copied in FHIR
3. I create a medication line with it, without changing anything

=> No reason requested

Scenario n°2

1. I look for a medication in SAMv2
2. I select one : its name and dosage are copied in FHIR
3. I create a medication line with it, with some change (for example updating the quantity because the patient can't handle full dose)

=> A reason is requested

[ZorgiLoic]

Hi Jacques,

Sorry I don't see your answer before.

I'll take an example
In SAMV2 for "Inuvair" you'll see the following information in the posologyNote :
ns2:Fr- asthme, traitement d'entretien chez l’adulte: 2 x p.j. 1 à 2 doses

• asthme, à la demande: 1 dose (max. 8)
• BPCO, traitement d'entretien des formes sévères à très sévères chez l'adulte (100/6): 2 x p.j. 1 à 2 doses
  </ns2:Fr>
  With those information, I don't think that split the text will be possible or will give a good result.

So we won't be able to detect if there is a "dosage override" and to notify it to the doctor or to Vidis.

I think that without structured information in SAM we won't be able to make something good but I may be wrong.

KR.