Use case for active checking of a prescription in unscheduled care

Brief description

A patient presents at unscheduled care (urgent care, minor injuries, walk-in centre, mental health crisis team) and a clinician needs to prescribe medication for the patient. They have access to an electronic prescribing and medicines administration (ePMA) system which includes decision support (checks for allergies, adverse reactions and medical conditions).

The flow of information will be from the GP practice clinical system into the ePMA.

Information must be SNOMED-coded for allergies, adverse reactions and conditions. Allergies and adverse reactions must include SNOMED coding for the allergen as a minimum. Conditions must be SNOMED-coded. These are required for active checking support in ePMA systems to cross-check against the contraindications from the drug file.

This is in an unscheduled care setting and, as such, data-sharing agreements should not be required. This should only respect patient’s consent to share.

Use case justification

In an unscheduled care setting, the patient may not be able to communicate in detail the details of allergies, adverse reactions or conditions that are relevant to prescribing. They may do so in a lay or generic terminology and this will not be clearly medically confirmed for the purposes of active checking of medication on prescribing.

As the patient’s GP is likely to have this information recorded, including the provenance and details of that information (that is, the type and severity of the allergic reaction and, if this is medically confirmed, reported by a clinician or just reported by the patient), automatically importing this information on registration at the unscheduled care location will ensure that this:

  1. Happens
  2. Is recorded accurately
  3. Does not require repeated querying of the patient for known data

Discharge summaries supplied from unscheduled care settings are required to provide this information in a structured form (https://isd.hscic.gov.uk/trud3/user/guest/group/41/pack/34/subpack/240/releases)

Primary actors

  • Clinician (doctor, nurse prescriber)
  • ePMA

Secondary actors

  • Patient

Triggers

  • Clinician prescribes medication to the patient.

Preconditions

  • Patient has been registered in attendance at the unscheduled care location and has gone through identification including retrieving their NHS Number.
  • The clinician is a qualified prescriber with access to create allergies, adverse reactions, conditions and prescribe medication within the ePMA system.

Postconditions

  • On success:
    • Allergies, adverse reactions and conditions are imported and recorded against the patient record in the ePMA.
  • Guaranteed:
    • The list of allergies, adverse reactions and conditions are recorded on the ePMA.
    • Access is recorded for auditing purposes.

Basic flow with alternative and exception flows

Step Description
Step 1 Clinician attempts to prescribe medication.
Step 2 ePMA identifies the patient’s GP practice endpoint using Personal Demographics Service (PDS)/Spine Directory Service (SDS) lookup.
Step 3

ePMA requests list of current allergies, adverse reactions and conditions from the patient’s registered GP.

‘Current’ is defined as all allergies, adverse reactions and conditions that have been recorded as being in effect at the current date, irrespective of when they were added to the patient record.
Step 4 Spine Secure Proxy validates calling endpoint and user as being an unscheduled care setting and bypasses data-sharing agreements for this information.
Step 5 GP practice clinical system checks patient permissions and consent to share.
Step 6

The ePMA receives the list of allergies, adverse reactions and conditions for review. On confirmation, the clinician accepts the list as valid and the information is imported into the system.

The following information is provided:

  • Allergies

    • Allergic Substance

    • Reaction Type

    • Reaction Severity

    • Date Added

    • Reported By (clinician, patient)

    • Confirmed by Clinician

  • Adverse Reactions

    • Allergic Substance

    • Reaction Type

    • Reaction Severity

    • Date Added

    • Reported By (clinician, patient)

    • Confirmed by Clinician

  • Conditions (outside scope of current release)

    • SNOMED code for any diagnosed or long term condition
Step 7 Drugs to be prescribed are checked by the ePMA against the allergic substance and conditions.
Step 8 Contraindications are presented to the clinician within the context of the reaction type and reaction severity, as well as the reliability of the information for a clinical decision. For example, a patient-reported mild fatigue reaction to a particular drug may be ignored as the effect of the medicine is more important than this side effect for this patient.
Step 9 Clinician makes decision to prescribe. Drugs prescribed with warning confirmation of contraindications acknowledged in audit.
Exceptions
Step 2a GP practice is not found on SDS.
Step 2b Check allergies, adverse reactions and conditions with patient.
Step 5a1 The patient is not found on the GP practice clinical system.
Step 5b1 Check allergies, adverse reactions and conditions with patient.
Step 5a2 The patient has not consented to sharing the data from the GP practice.
Step 5b2 Check allergies, adverse reactions and conditions with patient.