Updating the Medication List

In the previous post, we discussed using a List resource to represent a patient’s list of medications. In this post we’re going to talk about updating that list  – i.e. when a clinician changes the medications that a patient is taking, and wishes to record that change in the List. There are a few ‘gotcha’s to be aware of here. (By the way, do note that this discussion applies to any use of List – e.g. a list of conditions – as much as to medications).

Before we start, it’s important to appreciate that the List resource is something that ‘collects’ resources together (the other being the Group resource) – it contains a number of references to other resources that are stored somewhere else (often – but not necessarily – on the same server as the List).

Another thing to mention in passing is that much of what we are discussing here also applies to representing medications in other constructs such as FHIR Documents & Messages – though that is a big topic in its own right that will need to wait for another time…

Let’s consider the simple situation where a patient is taking 2 medications. There will therefore be:

• 1 Practitioner resource (at least) as prescriber of medications and author (source) of the list
• 1 Patient resource
• 2 MedicationPrescription resources describing the medications
• 1 List resource that has references (or pointers) to those resources.

This might look like this:

Note the links between the resources, representing the resource references – the meaning of those references should be evident. The List is labelled MLOM (My List Of Medicines) and has a specific code that identifies it as such as discussed in the previous post.

Now imagine that the Atenolol is stopped, and is replaced by Labetolol. This would give us the following picture:

Notes:

• There is a new version of the List resource (It has the same ID as the previous one)
• The new List version has a different ‘source’ practitioner – Dr Jones
• We have indicated that the Prescriber of the medication is also the author (source) of the List.  They may be the same (as it is here), but they don’t have to be.
• The new version of the List still points to the Atenolol resource – even though it has been stopped. We don’t strictly need this reference, but it is really useful as it suggests that the Atenolol was stopped (and possibly why) at the same time as the Labetolol was started. Of course the List resource and MedicationAdministration will have ‘formal’ properties that inform a consumer that the medication is no longer being taken – refer to the previous post for details. You can also set the date stopped in the MedicationPrescription directly as explained below.

So, lets walk through the sequence of actions that needs to occur in making this change in a RESTful fashion. We assume that we have the patient ID.

1. GET the existing List of medications (eg GET /Patient/100/List?code=http://loinc.org|10160-0 which is a FHIR query that will return a bundle containing the List). Make a note of the ID of the List. (Note that we’ve been good here and added the LOINC namespace to the query).
2. GET the medicationPrescription that we are stopping (its ID will be in the list), set the status property to ‘nullified’ and then PUT it back as an update. (You might also set the MedicationPrescription.dosageInstruction.timing.repeat.end to the date stopped if you are using a schedule datatype here).
3. Create a new MedicationPrescription resource with the appropriate properties & references, and POST it as a new resource. Make a note of the ID that was assigned by the server (it will be in the Location header).
4. Update the entry of the stopped medication in the List resource by:
   1. Setting the flag property to ‘cancelled’
   2. Setting the deleted property to true
   3. Optionally, add an extension to the entry indicating the reason why it was stopped
5. Add a new entry in the List that references the new medication (which is why we made a note of the ID above).
6. PUT a new version of the List back.

This isn’t particularly complex, but we can see that when we perform an update like this, there are a number of steps that must all succeed, or must all fail – i.e. this is really a transaction. We have a couple of ways of doing this.

• The client can perform each step in turn as described above – checking that each one succeeds and taking responsibility for ‘rolling back’ any changes in the event that there is a failure or if some other client has updated any of the resources in the mean time. This could become complicated…
• The alternative is to create or update all the resources on the client, and then place them into a bundle which is sent to the server to process as a single transaction, in which case the server takes the responsibility for ensuring the success – or failure – of the whole operation.

Lets walk through the same process as if it were a transaction – but first a few notes on using a bundle in this way.

In FHIR, a bundle is an Atom feed – and can be represented in both XML and JSON. I’ve already talked about this, and the spec has the definitive description, but just to point out a couple of things about the bundle entry elements that are pertinent. Each entry represents a FHIR resource and has a number of ID’s:

• Entry.id is the logical ID of the resource – not the version specific ID. Ie it is always the same for any given resource.
• Entry.link to self (<link rel=’self’…) is a version specific ID. Ie it points to a specific version of the resource. It’s an optional element, but its particular value here is that it will allow the server to apply update logic to avoid conflicts – as we will see in a moment.

Moving on, this is the process to update the List using a server transaction:

1. Create a new bundle (an atom feed) that will hold all our updated and new resources and populate the required properties.
2. GET the existing List of medications as described above. Make a note of the ID of the List.
3. GET the MedicationPrescription that we are stopping, set the status property to ‘nullified’ and then add it to the bundle, setting the bundle entry.id to the ID of the MedicationPrescription. As Above, you might also set the medicationPrescription.dosageInstruction.timing.repeat.end to the date stopped if you are using a schedule datatype.
4. Create a new MedicationPrescription resource with the appropriate properties & references and add it to the bundle. Create a temporary ID using the CID scheme and assign it to the bundle entry.id. (The server will know to replace this with a real ID).
5. Update the resource of the stopped medication in the List entry by:
   1. Setting the flag property to ‘cancelled’
   2. Setting the deleted property to true.
   3. Optionally, add an extension to the entry indicating the reason why it was stopped (as shown in the previous post)
6. Add a new List.entry to the List resource that references the new medication using the temporary ID that we created above, and setting the other properties of the entry as appropriate. (Unfortunately both List and Bundle use the word ‘entry’ which can be confusing).
7. Add the updated List Resource to the bundle, setting the bundle entry.id to the ID of the List.
8. POST the bundle to the root of the server.

The bundle will therefore contain:

• 2 MedicationPrescription resources (1 new & 1 updated) and
• 1 List resource

When the server receives the bundle, it will update and/or create all the resources as if they had been individually submitted – but will do so as a transaction, returning an HTTP statusCode to indicate success or failure.

The server can also implement other business and validation logic – for example checking that the version of the List resource (or any of the resources for that matter) in the bundle is the same as its current version on the server – i.e. the ‘optimistic locking’ pattern. In this case, the client should also include a “<link rel=’self’> “ element in each bundle entry that contains the version-specific URI of the resource so that the server can make the comparison. Refer to the discussion of the transaction and the bundle above for the details of this process.

So this method offloads the complexity of managing the transaction to the server, which ‘feels’ the right place to manage any transactional processing, and also minimizes the work for the client.

Incidentally, the ability for a server to require that an update operation specifies the version of the resource that it is updating can be applied to all update operations.

Notes:

• If this process is repeated with further updates, you’d probably want to remove entries in the list that are already deleted – otherwise the List will bloat with lots of deleted medications.
• You can always use the history operation to get previous versions of the List – ie the change history of medications for the patient. This allows you to create a ‘timeline’ of changes.
• We suggested setting the MedicationPrescription.dosageInstruction.timing.repeat.end to the date the medication was stopped. This is not strictly the correct use of this property as it is more intended to represent an instruction (stop on this date) rather than a record (it was stopped on this date).