Patient and Clinician Needs - Remember the Bigger Picture

The sub title is taken from a tip in ‘The 20th Anniversary Edition of the Pragmatic Programmer’ in a chapter labelled Stone Soup and Boiled Frogs`

As a health developer very very often we get drip fed requirements and then build a solution which doesn’t work well with the previous solutions we have made or any others.

We are more than likely to not be aware of the overall plan or the recipe. So looking at the wider picture for acute to GP process, it probably includes:

  • Informing the GP of an hospital admission or ED attendance
  • Providing a discharge letter to GP
  • Asking the GP to perform a medication review.

Taking a wider view, including time, other health providers AND the patient. This becomes:

  • Informing the all patient care providers of an hospital admission or ED attendance (real time)
  • Informing the all patient care providers of an hospital or ED discharge (real time)
  • Providing a discharge letter to GP and Patient (when completed)
  • Asking the GP to perform a medication review. (real time and to be actioned)

I’m not clinical but the latter seems more ideal.

From a developer point of view how I would have solved the former is very different to the later. I may have even condensed all the former requirements into one solution: let’s call it a ‘CDA’ document/archetype or in NHSD Terminology Transfer Of Care - it contains the other requirements but they are more critical BUT

Do you read all the correspondence you get I may skim read it and if something looks important I’ll store it and read it if I need to. I don’t read it though.
Do you action all of the requests you get

Let me put that differently.

  • FREDRICA SMITH discharge letter (attached letter)
  • FREDRICA SMITH has been admitted to hospital
  • FREDRICA SMITH needs a MedicationReview, she attended ED with an Asthma Attack

Which one gets actioned? Which one is the patient, hospital and GP more concerned about?

Where did I get the big picture from?

The exchange of documents is an established practice going back at least a hundred years.
Admission notifications is in a number of places, last one I remember is from a LHCR clinical requirements document.
The medication review comes from and NICE guidelines.

Semantics and Message Types

I mentioned at the start developers ‘get fed different parts of the recipe’ and not surprisingly we have actual and potential solutions for all three.

For semantics we are using different ‘scales - metric and imperial’ more specifically different codes and units. The include: read, snomed, icd9/10, opcs4 codes, NHS Data Dictionary codes, etc not an unsurmountable problem but very significant. Main technical standard in each of the areas. INTEROPen, NHS Digital FHIR Profiles and openEHR Archetypes are doing a good job sorting out the semantics.

So potential solutions and actual include:

  • Hospital admissions we have HL7v2 Admissions, Discharges and Transfers (ADT).
  • Orders and Medication Review we also HL7v2 Orders (ORM) - mostly for Path/Lab orders.
  • For the letter we have FHIR Transfer of Care.

So the good news here is we have potential compatibility (but the semantics need sorting), the HL7 standards are quite flexible. i.e. I created this Asthma MedicationReview example in two hours in both v2 and FHIR - ED to GP Asthma Medication Review

When you look at the detail e.g. security, transport, etc, it’s a different matter. Especially when you move outside of a hospital boundary - so although I know what the message should look like I don’t know how to get it to a GP.