Streamlining Medication Authorization: A Digital Solution for Enhanced Patient Care

Scenario : Dispense Asprin 300 mg Oral medication to? Patient X in the?? ICU

Background ?of the Problem

In today's ever-evolving healthcare landscape, efficient communication between hospitals and insurance companies is essential to ensure that patients receive timely and appropriate care. This blog post explores the challenges involved in obtaining authorization for dispensing Aspirin 300 mg oral medication to Patient X in the ICU.? Present a solution that leverages two crucial data transmission standards, FHIR (Fast Healthcare Interoperability Resources) and HL7 (Health Level Seven), to streamline the authorization process and enhance patient care.

Data Transmission Protocols:

·?????? Health Level 7 (HL7): HL7 is a widely used standard for exchanging electronic health records. It is well-known for its adaptability and application in a variety of healthcare settings. HL7 is a reliable platform for transferring clinical and administrative data.

·?????? FHIR?is a newer standard that is gaining popularity in healthcare. It is designed to be more flexible and interoperable than HL7.

Authorization Process for Dispensing Aspirin 300 mg Oral Medication:

1.???? Patient Information and Consent: To initiate the authorization process, healthcare providers must ensure they have accurate patient information and the patient's consent.

2.???? Medication Request: Create a FHIR "MedicationRequest" resource that specifies the request for dispensing Aspirin 300 mg oral medication to Patient X in the ICU. Include details such as dosage, administration instructions, and the patient's identity.

3.???? Coverage Information: Retrieve Patient X's insurance coverage information using the FHIR "Coverage" resource. This should encompass the insurance company's details and the patient's policy information.

4.???? Prior Authorization Resource: If required, create a custom FHIR resource or extension to capture any specific prior authorization details not covered by standard FHIR resources. This could involve additional information necessary for insurance company authorization.

5.???? Communication and Messaging: Transmit an authorization request message to Patient X's insurance company. You can accomplish this using FHIR's messaging capabilities or by integrating with the insurance company's FHIR-compatible systems. Include the Medication Request resource and coverage information in the message.

6.???? Authorization Response: The insurance company will respond to the authorization request using a FHIR "Bundle." This bundle will contain the authorization decision (approved, denied, or pending) along with any additional information or requirements.

7.???? Documenting the Response: Store the authorization response in the hospital's Electronic Health Record (EHR) system, associating it with the Medication Request for auditing and billing purposes.

8.???? Monitoring and Follow-up: Continuously monitor the status of the authorization request. If it's initially denied or marked as pending, follow up with the insurance company as needed, leveraging FHIR messages or other communication methods.

9.???? Dispensing and Administration: Upon receiving authorization approval, the healthcare team can proceed to dispense Aspirin 300 mg oral medication to Patient X in the ICU following the Medication Request.

10.? Billing and Claims: Post-dispensation, utilize FHIR to create a "Claim" resource to submit a bill to the insurance company for reimbursement, ensuring proper billing and claims processing.

Section/Trigger Event/Specific Transaction

Section: Authorization Process for Dispensing Aspirin 300 mg Oral Medication.

Trigger Event: Patient admission to the ICU with a prescription for Aspirin 300 mg.

Specific Transaction: Creation of a FHIR "MedicationRequest" resource to initiate the medication authorization process.

SECTION:

1. The first trigger event occurs when a patient in the ICU requires medication, and the healthcare provider determines that Aspirin 300 mg is necessary as part of the patient's treatment plan.

2. The healthcare provider, in this case, the ICU nurse or attending physician, generates a medication dispensation request. This request may be electronic or paper-based, depending on the hospital's procedures. The request includes specific details about the patient, the medication (Aspirin 300 mg), dosage, frequency, and any special instructions or considerations, such as allergies or contraindications.

3. Section: Medication Dispensation Request

4. Trigger Event: P07 - Medication Request: Used when a healthcare provider requests a specific medication for a patient, especially in urgent or critical care situations.

?

5. Specific Transaction: In this scenario, the healthcare provider, at the ICU of the hospital, is formally requesting the dispensation of Aspirin 300 mg oral medication to Patient X. The request includes critical information like the patient's name, unique identification number, admission date, and specific instructions for administering the medication. The request is submitted to the hospital's pharmacy or medication dispensing system for immediate processing. The pharmacy or medication dispensing team will review the request, verify the patient's eligibility, and prepare the medication according to the provided instructions. Once prepared, the medication will be delivered to the ICU for administration to Patient X

Sample data for the area -

<?xml version="1.0" encoding="UTF-8"?>

<MedicationRequest xmlns="https://hl7.org/fhir">
    <id value="medrx0302"/> 
    <text> <status value="generated"/> <div xmlns="https://www.w3.org/1999/xhtml"><p> <b> Generated Narrative: MedicationRequest</b> <a name="medrx0302"> </a> </p> <div style="display: inline-block; background-color: #d9e0e7; padding: 6px; margin: 4px; border:
       1px solid #8da1b4; border-radius: 5px; line-height: 60%"><p style="margin-bottom: 0px">Resource MedicationRequest &quot;medrx0302&quot; </p> </div> <p> <b> identifier</b> : id:?12345689?(use:?OFFICIAL)</p> <p> <b> status</b> : active</p> <p> <b> intent</b> : order</p> <h3> Medications</h3> <table class="grid"><tr> <td> -</td> <td> <b> Reference</b> </td> </tr> <tr> <td> *</td> <td> <span title="  Linked to a RESOURCE Medication  "><a name="med0320"> </a> </span> <blockquote> <p/>  <p> <a name="med0320"> </a> </p> <p> <b> code</b> : Azithromycin 250mg capsule (product) <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a >SNOMED CT</a> #324252006)</span> </p> </blockquote> </td> </tr> </table> <p> <b> subject</b> : <a href="patient-example-a.html">Patient/pat1: Donald Duck</a>  &quot;Donald DUCK&quot;</p> <p> <b> encounter</b> : <a href="encounter-example-f001-heart.html">Encounter/f001: encounter who leads to this prescription</a> </p> <p> <b> supportingInformation</b> : <a href="coverage-example-selfpay.html">Coverage/SP1234</a> </p> <p> <b> authoredOn</b> : 2015-01-15</p> <p> <b> requester</b> : <a href="practitioner-example-f007-sh.html">Practitioner/f007: Patrick Pump</a>  &quot;Simone HEPS&quot;</p> <h3> Reasons</h3> <table class="grid"><tr> <td> -</td> <td> <b> Concept</b> </td> </tr> <tr> <td> *</td> <td> Traveller's Diarrhea (disorder) <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a >SNOMED CT</a> #11840006)</span> </td> </tr> </table> <p> <b> note</b> : Patient told to take with food</p> <blockquote> <p> <b> dosageInstruction</b> </p> <p> <b> sequence</b> : 1</p> <p> <b> text</b> : Two tablets at once</p> <p> <b> additionalInstruction</b> : With or after food <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a >SNOMED CT</a> #311504000)</span> </p> <p> <b> timing</b> : Once per 1 days</p> <p> <b> route</b> : Oral Route <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a >SNOMED CT</a> #26643006)</span> </p> <p> <b> method</b> : Swallow - dosing instruction imperative (qualifier value) <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a >SNOMED CT</a> #421521009)</span> </p> <blockquote> <p> <b> doseAndRate</b> </p> </blockquote> </blockquote> <blockquote> <p> <b> dosageInstruction</b> </p> <p> <b> sequence</b> : 2</p> <p> <b> text</b> : One tablet daily for 4 days</p> <p> <b> additionalInstruction</b> : With or after food <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a >SNOMED CT</a> #311504000)</span> </p> <p> <b> timing</b> : Once per 1 days</p> <p> <b> route</b> : Oral Route <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a >SNOMED CT</a> #26643006)</span> </p> <blockquote> <p> <b> doseAndRate</b> </p> </blockquote> </blockquote> <blockquote> <p> <b> dispenseRequest</b> </p> <p> <b> validityPeriod</b> : 2015-01-15 --&gt; 2016-01-15</p> <p> <b> numberOfRepeatsAllowed</b> : 1</p> <p> <b> quantity</b> : 6 TAB<span style="background: LightGoldenRodYellow"> (Details: https://terminology.hl7.org/CodeSystem/v3-orderableDrugForm code TAB
             = 'Tablet')</span> </p> <h3> ExpectedSupplyDurations</h3> <table class="grid"><tr> <td> -</td> <td> <b> Value</b> </td> <td> <b> Unit</b> </td> <td> <b> System</b> </td> <td> <b> Code</b> </td> </tr> <tr> <td> *</td> <td> 5</td> <td> days</td> <td> <a >Unified Code for Units of Measure (UCUM)</a> </td> <td> d</td> </tr> </table> </blockquote> <h3> Substitutions</h3> <table class="grid"><tr> <td> -</td> <td> <b> Allowed[x]</b> </td> <td> <b> Reason</b> </td> </tr> <tr> <td> *</td> <td> true</td> <td> formulary policy <span style="background: LightGoldenRodYellow; margin: 4px; border: 1px solid khaki"> (<a >ActReason</a> #FP)</span> </td> </tr> </table> </div> </text> <contained> 
      <Medication> 
          <id value="med0320"/> 
          <code> 
                  <coding> 
                      <system value="https://snomed.info/sct"/> 
                      <code value="324252006"/> 
                      <display value="Azithromycin 250mg capsule (product)"/> 
                  </coding> 
          </code> 
      </Medication> 
    </contained> 
    <identifier> 
        <use value="official"/> 
        <system value="https://www.bmc.nl/portal/prescriptions"/> 
        <value value="12345689"/> 
    </identifier> 
    <status value="active"/> 
    <intent value="order"/> 
    <medication>      <!--    Linked to a RESOURCE Medication    -->
        <reference> 
           <reference value="#med0320"/> 
        </reference> 
    </medication>  
    <subject>      <!--    Linked to the resource patient who needs the medication    -->
        <reference value="Patient/pat1"/> 
        <display value="Donald Duck"/>          
    </subject> 
    <encounter>      <!--    Linked to a resource Encounter between patient and practitioner   -->
        <reference value="Encounter/f001"/> 
        <display value="encounter who leads to this prescription"/> 
    </encounter> 
    <supportingInformation> 
        <reference value="Coverage/SP1234"/> 
    </supportingInformation> 
    <authoredOn value="2015-01-15"/> 
    <requester> 
        <reference value="Practitioner/f007"/> 
        <display value="Patrick Pump"/> 
    </requester> 
    <reason> 
      <concept> 
        <coding> 
            <system value="https://snomed.info/sct"/> 
            <code value="11840006"/> 
            <display value="Traveller's Diarrhea (disorder)"/> 
        </coding> 
      </concept> 
    </reason> 
    <note> 
        <text value="Patient told to take with food"/> 
    </note> 
    
    <dosageInstruction> 
        <sequence value="1"/> 
        <text value="Two tablets at once"/> 
        <additionalInstruction> 
            <coding> 
                <system value="https://snomed.info/sct"/> 
                <code value="311504000"/> 
                <display value="With or after food"/> 
            </coding> 
        </additionalInstruction> 
        <timing> 
            <repeat> 
                <frequency value="1"/> 
                <period value="1"/> 
                <periodUnit value="d"/> 
            </repeat> 
        </timing> 
        <route> 
            <coding> 
                <system value="https://snomed.info/sct"/> 
                <code value="26643006"/> 
                <display value="Oral Route"/> 
            </coding> 
        </route> 
        <method> 
            <coding> 
                <system value="https://snomed.info/sct"/> 
                <code value="421521009"/> 
                <display value="Swallow - dosing instruction imperative (qualifier value)"/> 
            </coding> 
        </method> 
        <doseAndRate> 
            <type> 
                <coding> 
                    <system value="https://terminology.hl7.org/CodeSystem/dose-rate-type"/> 
                    <code value="ordered"/> 
                    <display value="Ordered"/> 
                </coding> 
            </type> 
            <doseQuantity> 
                <value value="2"/> 
                <unit value="TAB"/> 
                <system value="https://terminology.hl7.org/CodeSystem/v3-orderableDrugForm"/> 
                <code value="TAB"/> 
            </doseQuantity> 
        </doseAndRate> 

    </dosageInstruction> 
    <dosageInstruction> 
        <sequence value="2"/> 
        <text value="One tablet daily for 4 days"/> 
        <additionalInstruction> 
            <coding> 
                <system value="https://snomed.info/sct"/> 
                <code value="311504000"/> 
                <display value="With or after food"/> 
            </coding> 
        </additionalInstruction> 
        <timing> 
            <repeat> 
                <boundsDuration> 
                    <value value="4"/> 
                    <unit value="days"/> 
                    <system value="https://unitsofmeasure.org"/> 
                    <code value="d"/> 
                </boundsDuration> 
                <frequency value="1"/> 
                <period value="1"/> 
                <periodUnit value="d"/> 
            </repeat> 
        </timing> 
        <route> 
            <coding> 
                <system value="https://snomed.info/sct"/> 
                <code value="26643006"/> 
                <display value="Oral Route"/> 
            </coding> 
        </route> 
        <doseAndRate> 
            <type> 
                <coding> 
                    <system value="https://terminology.hl7.org/CodeSystem/dose-rate-type"/> 
                    <code value="ordered"/> 
                    <display value="Ordered"/> 
                </coding> 
            </type> 
            <doseQuantity> 
                <value value="1"/> 
                <unit value="TAB"/> 
                <system value="https://terminology.hl7.org/CodeSystem/v3-orderableDrugForm"/> 
                <code value="TAB"/> 
            </doseQuantity> 
        </doseAndRate> 

    </dosageInstruction>  
    
    <dispenseRequest> 
        <validityPeriod> 
            <start value="2015-01-15"/> 
            <end value="2016-01-15"/> 
        </validityPeriod> 
        <numberOfRepeatsAllowed value="1"/> 
        <quantity> 
            <value value="6"/> 
            <unit value="TAB"/> 
            <system value="https://terminology.hl7.org/CodeSystem/v3-orderableDrugForm"/> 
            <code value="TAB"/>  
        </quantity> 
        <expectedSupplyDuration> 
            <value value="5"/> 
            <unit value="days"/> 
            <system value="https://unitsofmeasure.org"/> 
            <code value="d"/>  
        </expectedSupplyDuration> 
    </dispenseRequest>    
    <substitution> 
        <allowedBoolean value="true"/> 
        <reason> 
            <coding> 
                <system value="https://terminology.hl7.org/CodeSystem/v3-ActReason"/> 
                <code value="FP"/> 
                <display value="formulary policy"/>              
            </coding> 
        </reason> 
    </substitution> 
</MedicationRequest>         

HL7 Example

A structured electronic order sent from the hospital's Electronic Health Record (EHR) system to the pharmacy system. It requests the dispensing of Aspirin 300 mg oral medication for Patient X, who is currently in the ICU. The message includes detailed information about the patient, medication order, dosage, route of administration, and other relevant details to ensure the correct dispensing and administration of the medication.

MSH|^~\&|HOSPITAL|EHR|INSURANCE|HL7|20230923093000||RQA^I08|AUTH123|P|2.4|||NE|AL

PRD|RP|HOSPITAL^HOSPITAL||^^^EHR&HL7^^^^ELECTRONIC HEALTH RECORD

PRD|RT|INSURANCE||^^^HL7&INSURANCE^^^^INSURANCE COMPANY

PID|||PATIENTXID^9^M10||PATIENT^X^||DOBYYYYMMDD||||||||||||PATIENTXID

IN1|1|PPO|INS01|INSURER01||123 MAIN ST^^CITY^STATE^ZIP^USA|INS CONTACT|(123) 456-7890|POLICY12345||||20220101||||PATIENT^X^|1|DOBYYYYMMDD|456 ANY ST^^CITY^STATE^ZIP^USA|||||||||||||||||PATIENTXID||||||01|M

DG1|1|I10|I48.91|Atrial Fibrillation|20230923093000|0

PR1|1|A1|12345|Aspirin 300 mg|20230923100000|00

Overall Solution diagram of how the data can be transmitted:

Explanation of Elements (HL7):

1.MSH (Message Header Segment)- Contains metadata about the message, such as message type, source, destination, and timestamp.

2.PRD (Provider Data)? -Provides information about the healthcare provider initiating the request and the insurance company receiving it

3.PID (Patient Identification)? Contains patient identification details, including name, date of birth, and patient identifier.

4.IN1 (Insurance Segment) Includes patient insurance information, policy details, and insurer contacts.

medication request.

6.PR1 (Procedures Segment) Describes the procedure or service being requested (Aspirin 300 mg).

7.ST (Transaction Set Header) Indicates the beginning of the transaction set.

8.BHT (Beginning of the Transaction)? Marks the start of the transaction.

9.UM (Authorization Information) Contains details related to the authorization, such as dates, authorization numbers, and authorization codes.

10.DTP (Date/Time/Period) Provides date and time information for events within the transaction.

Terminology Standards :

The terminology standards that would be used for this scenario are SNOMED CT and RxNorm.

·?????? SNOMED CT?is a comprehensive clinical terminology that is used to represent health information in a standardized way.

The use of SNOMED CT in this case helps to ensure that the data that is transmitted is accurate and consistent. The use of a standardized terminology helps to avoid confusion and errors.

·????? RxNorm?is a terminology that is used to represent medications in a standardized way. . It includes over 120,000 codes for medications, as well as information about the dosage, route of administration, and indications for use for those medications.

In the case of dispensing aspirin 300 mg oral medication to Patient X in the ICU, the following RxNorm concepts would be used:

RxNorm Concept Unique Identifier (RXCUI): The RXCUI is a unique identifier that is assigned to each concept in RxNorm. In this case, the RXCUI for aspirin is 260611002.

·?????? Concept Type: The concept type indicates the type of concept. In this case, the concept type is "Semantic Clinical Drug".

·?????? Ingredient: The ingredient is the active ingredient in the medication. In this case, the ingredient is "Acetylsalicylic acid".

·?????? Strength: The strength is the amount of the active ingredient in the medication. In this case, the strength is "300 mg".

·?????? Dose Form: The dose form is the way that the medication is taken. In this case, the dose form is "Tablet".

·?????? Route: The route is the way that the medication is administered. In this case, the route is "Oral".

Benefits of using SNOMED CT and Rx norm

• It helps to improve communication between healthcare providers.
• It can be used to support clinical decision support systems.
• It can be used for research and quality improvement.
• It can be used to facilitate the exchange of clinical data between different systems.

Data transmission standards are an important part of ensuring the accuracy and safety of medication administration. By using two standards, such as HL7 and FHIR, and two terminology standards, such as SNOMED CT and RxNorm, healthcare organizations can help to ensure that the data that is transmitted is accurate and consistent.