How does medication information travel throughout the healthcare system?
Generally, information about patient medications is captured and documented within electronic health records (EHRs) at the point of care. From there, it travels to a pharmacy where it where more detail is added before the medications are dispensed. Finally, the insurance company receives the information to determine the appropriate payment.
What are some of the key challenges with how medication data is clinically documented?
Like many other forms of clinical documentation, providers and clinical systems vary in their choice of format, style, or abbreviation to denote the same medication. Furthermore, the need to map to two standardized systems – RxNorm and National Drug Code (NDC) – can create additional challenges with respect to cross-linking and ensuring that information is complete.
What downstream problems can this create?
The complexity involved in documenting medications can lead to a host of problems. Clinicians need to ensure that the right patient gets the right drug, in the right dosage, at the right time. If this doesn’t happen, patient safety issues can arise. Mistranslations can also happen while sending medication documentation from one system to another – such as other healthcare facilities, state health departments, and third parties – for analytics purposes. This can cause errors to perpetuate throughout the healthcare ecosystem.
What is the ideal state for clinical documentation of medication data?
In its ideal state, medication data is standardized to a common, consistent terminology that allows for greater interoperability.
How can organizations achieve this?
Partnering with an organization that specializes in understanding terminology and standardized code systems – like RxNorm and NDC – can help organizations ensure that their data is clean and optimized for future use.