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CUP Assisted Data Import
Recommended usability enhancements for Assisted Data Import in GP software systems These recommendations will be made to vendors through the Clinical Document – My Health Record Usability Recommendations (version 1.4), following clinical consultation Clinical Information System (CIS) screens are generic mock-ups and are not representative of any software vendor system Contact your software vendor for information on how these enhancements will be incorporated in the software that you are using www.digitalhealth.gov.au 1 The following mock-ups are a visual representation of CUP recommendations for assisted data import. The enhancements demonstrated include: 1. Accessing the ‘assisted data import’ functionality 2. Displaying the assisted medicines import screen 3. ‘Importing’ a medicine to the patient’s local record i.e. selecting a medicine from the clinical document to ‘add’ to the patient’s local record www.digitalhealth.gov.au 2 Accessing ‘assisted data import’ functionality… Adverse Reactions Substance/Agent Manifestation Reaction Type Morphine Nausea ; Vomiting Adverse reaction Phenoxymethylpenicillin Nausea ; Diarrhoea Hypersensitivity reaction type ll Import Adverse Reactions Current Medications On Discharge User selects to initiate an assisted medicine or adverse reaction data import from the clinical document to the patient’s health record on the CIS. The functionality is not made available if the document is not conformant to level 3A or 3B and contains structured data. Note: Vendor’s discretion on what to call this functionality. CLD.142 (Mandatory) ; CLD.143 (Mandatory) ; CLD.144 (Mandatory) ; CLD.145 (Mandatory) Medicine Directions Dispensed Clinical indication amoxycillin 250mg One capsule three times a day 20 capsules chest infection Astrix 100 mg tablet, uncoated, 112 1 daily hypertension metformin hydrochloride 1 g tablet 60 1 in the evening diabetes Panadol Osteo 665 mg tablet: modified release Two tablets three times a day 40 tablets pain relief Salbutamol 100 actuations One daily 1 inhaler asthma Tritace 10 mg tablet: uncoated, 30 1 twice daily Hypertension Ceased Medications Medication Change Status Change Description Change Reason Zantax 150 mg table: film-coated, 60 Ceased Ceased Patient reported side effect Keflex 250 mg capsule: hard, 20 Ceased Ceased Import Medications Print Document Save to File Close www.digitalhealth.gov.au 3 Displaying the ‘assisted medicines import’ screen… to be Current Medicines on localStatement health record for displayed Jane Smithprominently (5 Items) Medicine Name near the top of the screen Directions CLD.146 (Mandatory) Astrix 100 mg tablet, uncoated, 112 metformin hydrochloride 1 g tablet, 60 Panadeine Forte tablet: uncoated, 20 Tritace 10 mg tablet: uncoated, 30 Zantac 150 mg tablet: film-coated, 60 Medicines found in Discharge Summary for Jane Smith 1 daily 112 This medicines list may not be a complete list of medicines included in the clinical document. Before importing medicines into your patient’s local record, it is important to review the full clinical document for any information contradicting that shown here. 1 in the evening 60 Current Medications On Discharge (6 Items) 2 three times a day with … 20 1 daily 30 1 twice daily 60 Side-by-side display of two medicines lists: - The left is a list of current medicines from the patient’s local health record - The right is a list of medicines from the clinical document CLD.146 (Mandatory) Qty Medicine Directions Dispensed Clinical indication amoxycillin 250mg One capsule three times a day 20 capsules chest infection Astrix 100 mg tablet, uncoated, 112 1 daily hypertension metformin hydrochloride 1 g tablet 60 1 in the evening diabetes Panadol Osteo 665 mg tablet: modified release Two tablets three times a day 40 tablets pain relief Salbutamol 100 actuations One daily 1 inhaler asthma Tritace 10 mg tablet: uncoated, 30 1 twice daily Select to add new medicine Hypertension Clicking on ‘View Document’ will open the rendered clinical document to enable the user Ceased Medications On Discharge (1 Item) to view this side-by-side with the structured Medicine Change Status Change Re data. CLD.157 Zantac 150 mg(Mandatory) table: film-coated, 60 Ceased Short term View Document Select to add new medicine Close www.digitalhealth.gov.au 4 Displaying the medicine lists… Current Medicines on local health record for Jane Smith (5 Items) Medicines found in Discharge Summary for Jane Smith Medicine Name Directions Qty Astrix 100 mg tablet, uncoated, 112 metformin hydrochloride 1 g tablet, 60 Panadeine Forte tablet: uncoated, 20 Tritace 10 mg tablet: uncoated, 30 Zantac 150 mg tablet: film-coated, 60 1 daily 112 This medicines list may not be a complete list of medicines included in the clinical document. Before importing medicines into your patient’s local record, it is important to review the full clinical document for any information contradicting that shown here. 1 in the evening 60 2 three times a day with … 20 1 daily 30 1 twice daily 60 First three columns to be displayed on the local list is the medicine name, directions and quantity dispensed (if captured by the local system). All the attributes in a medicine record are to be displayed (i.e. the same display as they normally are on the patient’s local health record). CLD.147 (Mandatory) ; CLD.149 (Mandatory) Current Medications On Discharge (6 Items) Medicine Directions Dispensed Select to add new medicine Clinical indication amoxycillin 250mg One capsule 20 capsules chest infection three times a day First four columns to be displayed on the clinical Astrix 100 mg daily hypertension document 1list is medicine name, directions, tablet, quantity uncoated, 112 dispensed and clinical indication. All the attributes in to be metformin 1 inthe the medicine section are diabetes hydrochloride displayed. evening 1 g tablet 60 CLD.153 (Mandatory) ; CLD.154 (Mandatory) Panadol Osteo 665 mg tablet: modified release Two tablets three times a day 40 tablets pain relief Salbutamol 100 actuations One daily 1 inhaler asthma Tritace 10 mg tablet: uncoated, 30 1 twice daily Hypertension Ceased Medications On Discharge (1 Item) Medicine Change Status Change Re Zantac 150 mg table: film-coated, 60 Ceased Short term View Document Select to add new medicine Close www.digitalhealth.gov.au 5 Displaying rendered clinical document side-by-side… Medicines found in Discharge Summary for Jane Smith This medicines list may not be a complete list of medicines included in the clinical document. Before importing medicines into your patient’s local record, it is important to review the full clinical document for any information contradicting that shown here. Current Medications On Discharge (6 Items) Select to add new medicine Medicine Directions Dispensed Clinical indication amoxycillin 250mg One capsule three times a day 20 capsules chest infection Astrix 100 mg tablet, uncoated, 112 1 daily hypertension metformin hydrochloride 1 g tablet 60 1 in the evening diabetes Panadol Osteo 665 mg tablet: modified release Two tablets three times a day 40 tablets pain relief Salbutamol 100 actuations One daily 1 inhaler asthma Tritace 10 mg tablet: uncoated, 30 1 twice daily Hypertension Ceased Medications On Discharge (1 Item) Medicine Change Status Change Re Zantac 150 mg table: film-coated, 60 Ceased Short term View Document Select to add new medicine Close www.digitalhealth.gov.au 6 Importing a medicine to the local health record… Add new medicine The following is a representation of a software system’s create new medicine/prescription workflow. Most systems displays a series of dialog boxes to capture the details required. Medicines found in Discharge Summary for Jane Smith Medicine Medicine NameInformation Directions Qty daily AstrixMedicine* 100 mg tablet, uncoated, Panadol112 Osteo 6651mg tablet: modified release 1 daily before meals Keflex 250 mg capsule: hard, 20 10-Apr-2015 Prescription Date* Expires* 10-Apr-2015 metformin hydrochloride 1 g tablet, 60 1 in the evening pain relief Prescription Reason 1 three times a day with … Panadeine Forte tablet: uncoated, 20 Dose* Form* Frequency* Instructions 1 daily Tritace 10 mg tablet: uncoated, 30 1 Zantac 150 mg tablet: film-coated, 60 1 2 ½ 1½ 5mL 2.5mL Apply Capsule Drop Puff Tablet If required As directed Before meals With meals After meals Left side Right side To both sides Plus as required Other Once a day 2 times a day 3 times a day 4 times a day Every 4 hours Every 6 hours 112 20 20 30 60 Dispense Information Repeat Intervals Max # repeats PBS P Print prescription? Yes Directions Dispensed Clinical indication Select to add new medicine amoxycillin One capsule 20 capsules chest infection Panadol Osteo 665 mg tablet: modified release Two tablets three times a day 40 tablets pain relief Salbutamol 100 actuations One daily 1 inhaler asthma The software allows 250mg three the timesuser to select a medicine from a day list to be ‘imported’ to the local the clinical document Astrix 100 mg 1 daily hypertension health record. tablet, In this example, selecting the tick-box will initiate the uncoated, 112 ‘add new medicine’ workflow. metformin 1 in the diabetes CLD.159 (Mandatory) hydrochloride evening; CLD.160 (Mandatory) P Tritace 10 mg 1 twice daily Hypertension tablet:In this example, the ‘add new medicine’ screen is uncoated, 30 displayed on the left hand side. The emphasis is having 40 tablets dd-MMM-yyyy Medicine 1 g tablet 60 Additional Instructions Two tablets three times a day Set reminder to renew Current Medications On Discharge (6 Items) 60 Administration route Quantity* This medicines list may not be a complete list of medicines included in the clinical document. Before importing medicines into your patient’s local record, it is important to review the full clinical document for any information contradicting that shown here. Allow brand substitution No Prescribed elsewhere P cancel create the details of the medicine item selected from the clinical document list remain visible throughout the Ceased Medications On Discharge (1 Item) Select to process of adding a new medicine. add new Medicine Change Status Change Re CLD.161 (Mandatory) medicine Zantac 150 mg table: film-coated, 60 Ceased Short term View Document Close www.digitalhealth.gov.au 7 Importing a medicine to the local health record (cont’d)… Add new medicine Medicine Medicine NameInformation Directions Qty daily AstrixMedicine* 100 mg tablet, uncoated, Panadol112 Osteo 6651mg tablet: modified release 1 daily before 10-Apr-2015 meals Keflex 250 mg capsule: hard, 20 10-Apr-2015 Prescription Date* Expires* metformin hydrochloride 1 g tablet, 60 1 in the evening pain relief Prescription Reason 1 three times a day with … Panadeine Forte tablet: uncoated, 20 Dose* Form* Frequency* Instructions 1 daily Tritace 10 mg tablet: uncoated, 30 1 Zantac 150 mg tablet: film-coated, 60 1 2 ½ 1½ 5mL 2.5mL Apply Capsule Drop Puff Tablet If required As directed Before meals With meals After meals Left side Right side To both sides Plus as required Other Once a day 2 times a day 3 times a day 4 times a day Every 4 hours Every 6 hours If the medicine item from the clinical document can be Medicines found in Discharge Summary for Jane Smith mapped to an item in the local system’s medicine This medicines list may not be a complete list of medicines included in the clinical document. catalogue, medicine be pre-populated. Beforethe importing medicinesname into yourwill patient’s local record, it is important to review the full clinical document for any information contradicting that shown here. CLD.163 (Mandatory) Current Medications On Discharge (6 Items) 112 20 30 60 Administration route Additional Instructions Two tablets three times a day 40 tablets Max # repeats Set reminder to renew dd-MMM-yyyy Allow brand substitution Print prescription? P Clinical indication amoxycillin 250mg One capsule three times a day 20 capsules chest infection Astrix 100 mg tablet, uncoated, 112 1 daily metformin hydrochloride 1 g tablet 60 1 in the evening Panadol Osteo 665 mg tablet: modified release Two tablets three times a day 40 tablets pain relief Salbutamol 100 actuations One daily 1 inhaler asthma In this example, the details of the item selected fromhypertension the clinical document medicines list are clearly visible. CLD.161 (Mandatory) diabetes Yes P Hypertension Where possible, fields are to data in the clinical document. CLD.164 (Mandatory) Repeat Intervals PBS Dispensed Tritace 10 mg 1 twice daily tablet: be pre-populated from the uncoated, 30 Dispense Information Quantity* Directions 60 20 Select to add new medicine Medicine Ceased Medications On Discharge (1 Item) No Prescribed elsewhere P cancel Medicine Change Status Change Re Zantac 150 mg table: film-coated, 60 Ceased Short term Select to add new medicine create View Document Close www.digitalhealth.gov.au 8 Importing a medicine to the local health record (cont’d)… Add new medicine Medicine Medicine NameInformation Medicines found in Discharge Summary for Jane Smith Directions daily AstrixMedicine* 100 mg tablet, uncoated, Panadol112 Osteo 6651mg tablet: modified release 1 daily before meals Keflex 250 mg capsule: hard, 20 10-Apr-2015 Prescription Date* Expires* 10-Apr-2015 metformin hydrochloride 1 g tablet, 60 1 in the evening pain relief Prescription Reason 1 three times a day with … Panadeine Forte tablet: uncoated, 20 Dose* Form* Frequency* Instructions 1 daily Tritace 10 mg tablet: uncoated, 30 1 Zantac 150 mg tablet: film-coated, 60 Qty This medicines list may not be a complete list of medicines included in the clinical document. Before importing medicines into your patient’s local record, it is important to review the full clinical document for any information contradicting that shown here. 112 Current Medications On Discharge (6 Items) 20 Medicine Directions Dispensed Clinical indication amoxycillin 250mg One capsule three times a day 20 capsules chest infection Astrix 100 mg tablet, uncoated, 112 1 daily hypertension metformin hydrochloride 1 g tablet 60 1 in the evening diabetes Panadol Osteo 665 mg tablet: modified release Two tablets three times a day 40 tablets pain relief Salbutamol 100 actuations One daily 1 inhaler asthma Additional Instructions Two tablets three times a day 1 twice daily Dispense Information Tritace 10 mg tablet: uncoated, 30 1 2 ½ 1½ 5mL 2.5mL Apply Capsule Drop Puff Tablet If required As directed Before meals With meals After meals Left side Right side To both sides Plus as required Other Once a day 2 times a day 3 times a day 4 times a day Every 4 hours Every 6 hours 60 20 30 60 Administration route Quantity* P Hypertension 40 tablets Repeat Intervals Max # repeats By default, the medicine will be not marked for printing Set reminder to renew dd-MMM-yyyy Allow brand substitution i.e. not prescribed P Yes PBS No CLD.167 (Mandatory) Print prescription? Select to add new medicine Prescribed elsewhere P cancel create Ceased Medications On Discharge (1 Item) Medicine Change Status Change Re Zantac 150 mg table: film-coated, 60 Ceased Short term It should be possible to indicate that the medicine was prescribed elsewhere. CLD.168 (Optional) ; CLD.169 (Conditional) View Document Select to add new medicine Close www.digitalhealth.gov.au 9 Utilising the existing workflow when adding a new medicine… The following is a representation of a software decision support system that displays warnings when a user tries to create a new prescription WARNING ! The patient is currently taking PANADEINE FORTE TABLET: UNCOATED, 20 which contains PARACETAMOL. You are adding PANADOL OSTEO 665 MG TABLET: MODIFIED RELEASE. Do you wish to continue or cancel? As per current clinical workflow for adding and prescribing new medicines, warnings are displayed when: - Drug being added is already on the patient’s medicine list; OR - Drug being added contains a similar or duplicate ingredient in a drug that is already on the patient’s medicine list; OR - Patient has a recorded adverse reaction to the drug or key ingredients in the drug www.digitalhealth.gov.au 10 Finalising the import of a new medicine item… Current Medicines on local health record for Jane Smith (6 Items) Medicines found in Discharge Summary for Jane Smith Medicine Name Directions Qty Astrix 100 mg tablet, uncoated, 112 metformin hydrochloride 1 g tablet, 60 Panadeine Forte tablet: uncoated, 20 Tritace 10 mg tablet: uncoated, 30 Zantac 150 mg tablet: film-coated, 60 Panadol Osteo 665 mg tablet; modified 1 daily 112 This medicines list may not be a complete list of medicines included in the clinical document. Before importing medicines into your patient’s local record, it is important to review the full clinical document for any information contradicting that shown here. 1 in the evening 60 2 three times a day with … 20 1 daily 30 1 twice daily 60 2 tablets three times a day 40 Clinician will need to decide whether PANADEINE FORTE should be removed from the list based on the warning message received when adding PANADOL OSTEO to the patient’s list of medicines on the CIS. Current Medications On Discharge (6 Items) Select to add new medicine Medicine Directions Dispensed Clinical indication amoxycillin 250mg One capsule three times a day 20 capsules chest infection Astrix 100 mg tablet, uncoated, 112 1 daily hypertension metformin hydrochloride 1 g tablet 60 1 in the evening diabetes Panadol Osteo 665 mg tablet: modified release Two tablets three times a day 40 tablets Salbutamol 100 actuations One daily 1 inhaler pain relief Item added asthma Once a medicine is added to the local record, indication is Tritace 10 mg 1 twice daily Hypertension provided to the user the item has been successfully tablet: uncoated, 30 imported. CLD.170 (Mandatory) Ceased Medications On Discharge (1 Item) Medicine Change Status Change Re Zantac 150 mg table: film-coated, 60 Ceased Short term View Document Select to add new medicine Close www.digitalhealth.gov.au 11 Editing a local medicine record… Current Medicines on local health record for Jane Smith (5 Items) Medicines found in Discharge Summary for Jane Smith Medicine Name Directions Qty Astrix 100 mg tablet, uncoated, 112 metformin hydrochloride 1 g tablet, 60 Panadeine Forte tablet: uncoated, 20 Tritace 10 mg tablet: uncoated, 30 Zantac 150 mg tablet: film-coated, 60 1 daily 112 This medicines list may not be a complete list of medicines included in the clinical document. Before importing medicines into your patient’s local record, it is important to review the full clinical document for any information contradicting that shown here. 1 in the evening 60 2 three times a day with … 20 1 daily 30 1 twice daily 60 Continue medicine… Edit medicine details… Cease medicine… User can choose to carry out actions that they would normally be able to do on the clinical record. In this example, the user has selected to cease the medicine Zantac. CLD.171 (Mandatory) Current Medications On Discharge (6 Items) Medicine Directions Dispensed Clinical indication amoxycillin 250mg One capsule three times a day 20 capsules chest infection Astrix 100 mg tablet, uncoated, 112 1 daily hypertension metformin hydrochloride 1 g tablet 60 1 in the evening diabetes Panadol Osteo 665 mg tablet: modified release Two tablets three times a day 40 tablets pain relief Salbutamol 100 actuations One daily 1 inhaler asthma Tritace 10 mg tablet: uncoated, 30 1 twice daily Select to add new medicine Hypertension Ceased Medications On Discharge (1 Item) Medicine Change Status Change Re Zantac 150 mg table: film-coated, 60 Ceased Short term Closing this screen will take the user back to the clinical document. Select to add new medicine Already on record Close www.digitalhealth.gov.au 12 ‘assisted adverse reactions import’ functionality… Adverse reactions on local health record for Jane Smith (1 item) Agent / Substance Manifestation/s Reaction Type Morphine Nausea; Vomiting Adverse Reaction Edit details… Remove adverse reaction Adverse reactions found in Discharge Summary for Jane Smith (2 items) Agent / Substance Manifestation/s Reaction Type Morphine Nausea; Vomiting Adverse Reaction Phenoxymethylpenicillin Nausea; Diarrhoea Allergic reaction Hypersensitivity reaction type II Select to add new adverse reaction The guidelines for ‘assisted medicines import’ functionality will be generally apply also for ‘assisted adverse reactions import’ Close www.digitalhealth.gov.au 13 References Name & Version Release Date Clinical Document – My Health Record Usability Recommendations v1.4 [NEHTA-2267:2016] 25 May 2016 www.digitalhealth.gov.au 14
