I was writing this piece when I read Ian McNicoll’s stimulating blog piece “EastendEHRs? – Dr Leggs’ Diary” Ian talks about community medication records, very much the theme of this piece.
It seems to me that a shared medication record is the single most useful thing that could be provided in any health community and that while such a service is not without it challenges it is eminently doable.
I also feel that working through what such a service would look like and how it might be delivered could help us clarify our understanding about a number of technical, clinical and governance issues that would have general applicability with regard to the sharing of other parts of records or record summaries.
In my mind a medication repository is a logical construct, that might be physically instantiated in many ways to provide a single authoritative source with regard to medication information for a particular patient I envisage that all applications that need to read or write medication data would operate against the repository, or a locally maintained cache of it, rather than managing their own medication record.
Ideally, the repository should contain details of all medication from all care setting including patients self-medication, but a useful start could be made with a more limited scope (say just GP, outpatient, community and hospital discharge medication.)
There are many potential architectures for a medication repository. I am not necessarily suggesting a single medication repository for a health community (although this might be the most practical solution), there could be many (in the extreme, one for each individual) and they don’t have to have exclusive geographical scope (patients would be free to choose from all available service providers) the important things are that there is a single authoritative source under shared governance, a means of discovering where this is for a particular patient and that all repositories support a common API so that any application can easily work with multiple repositories.
Building appropriate governance arrangements around medication repositories is perhaps the most significant challenge, but also a particularly interesting one that will allow us to explore approaches in a constrained (and therefore manageable) scope that we can later apply to other aspects of the record.
Governance arrangements need to ensure that all those with rights to the information in the repository can be confident that their rights will be respected and protected for all time even in the event of the failure of a particular repository provider – I envisage some form of information escrow to achieve both of these things.
Governance arrangements also need to ensure that the provenance of information is secured, handle the allocation and transfer of clinical responsibility associated with information held in the repository. and the ongoing responsibility for management of a patients medication (changing cancelling adding medication.)
These governance issues illustrate the inseparability of the information and clinical governance issues, an inseparability which I believe applies much more broadly and is something not properly recognised in the implementation of existing systems.
Moving this idea forward requires some proof of concept work, which in turn requires someone willing to build an operate and experimental repository and a couple of application providers willing to work with it – ANY VOLUNTEERS.