{{#customtitle:Functional Design Medicatieproces 9.1.0 English version}} For an overview of relevant wiki pages for Medication Process see Landingspagina_Medicatieproces

1 Inleiding

This document is the functional design for the Medication Process Information Standard (in Dutch: Informatiestandaard Medicatieproces). It provides a general description as well as a description of specific practical situations. The recording and exchange of information is described for specific situations using actors (people, systems) and transactions (which information is exchanged when).

Target groups for this document:

Healthcare providers
Information analysts and architects
Software suppliers

1.1 Scope and vision

This document has been produced within the Medication process program. The Medication process program aims first to take away existing obstacles in the medication process, while taking into account current legislation and the possibility of obtaining tangible results in the foreseeable future.

One of the main obstacle entails the lack of insight in the actual medication use of patients. This is partly due to the fact that therapeutic and logistical information are often mixed, which results in the medication history becoming unclear. The following distinction between therapy and logistics exist:

Therapy covers the medical side. This includes medication (and treatment) agreements, as well as the corresponding support and implementation. Therapeutic intention, (actual) medication use, self-medication and pharmacotherapy are also covered by the term ‘therapy’ as it is defined in this document.
Logistics covers the physical flow of medicinal products, including requests, planning and dispense. This also includes medication supply and consumption.

The program has taken into account current legislation and feasibility within the foreseeable future. The vision goes beyond the scope of the Medication process program and lays the foundations for a situation where a dispense request is no longer required. The ultimate objective is for prescribers to only have to concern themselves with the therapeutic side (which medicinal product, which strength, which dosage, when to start, etc.). It will no longer be necessary to create a verstrekkingsverzoek. Instead, the prescriber will make medicatieafspraken directly with the patient. Based on these medicatieafspraken, the pharmacist will take care of the logistical process, eliminating the need for a verstrekkingsverzoek altogether. Because of legislation this is not (yet) possible. The Medication process program does however take the first necessary step in the right direction.

1.2 Reading guide

The following paragraph introduces the main building blocks and the terminology used in this document. Detailed descriptions of the various processes (prescribe, dispense, administer, use) are given in Chapter 2. The purpose of the descriptions is to clarify how healthcare processes function in an ideal situation; which process steps are needed; which actors are participating; which information applies and which moments of exchange exist. The process descriptions follow a fixed format:

Current situation 
This paragraph describes the relevant differences between the current situation and the desired situation (“soll”) in accordance with this information standard. Any obstacles will be described here.
Process description with the paragraphs:
- Precondition
  The conditions that must be met before the process is started.
- Trigger Event
  The event that starts theprocess.
- One or more process steps
  Description of part of the process.
- Post-condition
  The conditions that are met after the process steps have been carried out.
- Use cases
  List of use cases associated with a specific subprocess. The use cases are detailed in Chapter 4.
- Systems and transaction groups,br />This paragraph describes the systems, system roles, transactions and transaction groups related to the process steps. All information concerning systems and transaction groups is also included in Chapter 6.

Chapter 3 describes a number of domain-specific interpretations of the medication process, for instance those of the thrombosis service and those related to service observation services in an ambulatory situation. Chapter 4 describes several use cases in more detail. The practical situations are derived from general medical practice in a large number of cases but are illustrative of similar situations in a different setting. The use cases are classified according to subprocess, as indicated in Chapter 2. Medication overview and inference rules|Chapter 5]] describes how a medication profile can be constructed from the different building blocks. Chapter 6 includes an overview of all systems, system roles, transactions and transaction groups. Guidelines for the functionality of the various systems have been detailed in Chapter 7.

1.3 Introduction of relevant terms

1.3.1 Therapeutic and logistical building blocks

The use cases include a description of the process and the data elements associated with it. Related data elements are grouped together in Clinical Building Blocks (CBB) (in Dutch: zorginformatiebouwstenen - ZIBs). The dataset details the data elements of which these ZIBs consist. The data set includes the complete set of definitions of the data elements of the building blocks. The building blocks together with their data elements can be used in various scenarios for arranging/modelling healthcare applications or for defining interfaces for data exchange. Clinical building blocks and building blocks are synonymous in this document.

The different building blocks are shown in the figure below. They have been ordered according to process and subprocesses, and according to therapy versus logistics.

The table below provides a description of the building blocks. The three additional concepts ‘voorstel medicatieafspraak’ (therapeutic) and ‘voorstel verstrekkingsverzoek’ (logistics) and ‘antwoord voorstel-verstrekkingsverzoek’ (logistics) are also described.

Bouwsteen	Afk.	Beschrijving
medicatieafspraak	ma	A medicatieafspraak is the prescriber’s proposal for medicatiegebruik with which the patient agrees. An agreement to discontinue medication is also a medicatieafspraak^[1].
verstrekkingsverzoek	vv	A verstrekkingsverzoek is a request from a prescriber to a pharmacist to supply the patient with one or more medicinal products in support of current medicatieafspraken^[2].
toedieningsafspraak	ta	An toedieningsafspraak contains the instructions for use (or administration) of the pharmacist to the patient (or his representative or administrator), adding to the medicatieafspraak^[3].
medicatieverstrekking	mve	A medicatieverstrekking is the provision of a supply of medicinal product to the patient or his administrator or representative.
medicatietoediening	mtd	Medicatietoediening is the registration of the individual administrations of the medicinal product to the patient by the person who administers them (such as a nurse or the patient himself) in relation to the agreements made
medicatiegebruik	mgb	Medicatiegebruik is a statement about historical, current or intended use of a medicinal product^[4].
medicatieverbruik	mvb	Medicatieverbruik is the logistical perspective on medicatiegebruik. It describes how long a (partial) supply of medicinal products has lasted or will last for a patient^[5].
voorstel-medicatieafspraak	vma	The voorstel medicatieafspraak is a recommendation or request from the pharmacist or the patient to the prescriber about the agreed medicinal product. The recommendation request may include evaluating, discontinuing, starting or modifying medication.
voorstel‐verstrekkingsverzoek	vvv	The proposed verstrekkingsverzoek is a proposal from the pharmacist to the prescriber to approve one or more verstrekkingsverzoeks in support of current medicatieafspraken. This is comparable with the current situation of submitting the authorization form or combined prescription or submitting a repeat prescription for signing. The patient may also submit a proposed verstrekkingsverzoek to the prescriber.
antwoord voorstel‐verstrekkingsverzoek	avvv	The antwoord voorstel- verstrekkingsverzoek is a reply from the prescriber to the proposed verstrekkingsverzoek.

Tabel 1 Bouwstenen – beschrijving

1.3.2 Medication overview

See Chapter 5 for more information about these overviews, the applicable building blocks and how a medication profile/current overview can be compiled.

1.3.3 Medicamenteuze behandeling

The different medication building blocks represent steps in the medication process, from prescribing a medicinal product (medicatieafspraak and/or verstrekkingsverzoek), followed by dispensing it (toedieningsafspraak and/or medicatieverstrekking) up to and including administering and using the medicinal product. The model is designed in such a way that therapeutic building blocks and logistical building blocks are separated from each other.
Scope
In order to be able to give a name to the interdependence of the medication building blocks, the concept of ‘pharmaceutical treatment’ (medicamenteuze behandeling in Dutch) is introduced.

Medicamenteuze behandeling is a technical concept in the information standard. Its purpose is:

To unambiguously identify the set of interdependent medication building blocks, and
To apply rules to it to unambiguously determine the present situation.

The functional application of the concept of medicamenteuze behandeling is as follows:

Medication (or medicamenteuze behandeling) is started by creating a first medicatieafspraak as part of a new medicamenteuze behandeling.
Medication (or medicamenteuze behandeling) is discontinued by creating a new medicatieafspraak within the same medicamenteuze behandeling.
Medication (or medicamenteuze behandeling) is modified by:

Discontinuing the existing medicatieafspraak and
Creating a new changed medicatieafspraak as part of the same medicamenteuze behandeling. The starting date of this new medicatieafspraak may also be in the future.

Prescribing a new medicinal product always results in a new medicatieafspraak. A medicatieafspraak is always related to a single medicamenteuze behandeling. For the time being, the PRK level (Prescription Code from the G-standard) of the medicinal product determines whether the medicatieafspraak belongs to a new or an existing medicamenteuze behandeling. This may be extended to the SNK level (Stam Naam Kode) in the future, which would mean that changes in strength or between medicinal products from the same group no longer lead to a new medicamenteuze behandeling. A detailed description can be found in paragraph 2.2.5 Process step: Creating a medicatieafspraak.Process step: Creating a
Exceptions:

Products without PRK (a non-medicine such as crutches or bandages). In this case

the HPK level (Trade Product Code from the G-Standard) determines if the medicatieafspraak will lead to a new medicamenteuze behandeling

Medication without PRK (magistrals often consist of several substances that are not covered by the same

PRK, these substances are included separately as ingredients in the medicatieafspraak). Every magisterial or adaptation to it falls under a medicamenteuze behandeling.

Own articles without PRK (articles listed in the internal system under 90 million numbers

stored, such as half tablets, commonly used magistrals). Any item or adaptation to this falls under a medicamenteuze behandeling.

IVs (still be selected)

Examples
Five examples illustrate the scope of a medicamenteuze behandeling:

Diazepam, 5 mg, 1 tablet 4x daily is changed to diazepam, 5 mg, 1 tablet 3x daily. The PRK level of both products is the same, they are both part of the same medicamenteuze behandeling.
Paroxetin tablet, 10 mg, 1 tablet 1x daily, is changed to paroxetin tablet, 20 mg, 1 tablet 1x daily. This is a modification of a medicatieafspraak with two different medicinal products at the PRK level. This change requires that the first medicamenteuze behandeling is discontinued and a new medicamenteuze behandeling is started.
A gastroprotective drugs has been agreed upon in a treatment with prednisone: prednisone and gastroprotective drugs are two different medicinal products, which are used parallel to each other and their use can be modified and discontinued independently of each other. This means they are not part of the same medicamenteuze behandeling.
Switching from a beta blocker to an ACE inhibitor means a new PRK and this is achieved by discontinuing the medicamenteuze behandeling of the beta blocker and starting a new medicamenteuze behandeling for the ACE inhibitor.
When there is no PRK and the composition of the medicinal products in the medicatieafspraak changes (any change in the ingredients), the existing medicamenteuze behandeling is discontinued and a new medicamenteuze behandeling is started. This applies, for example, to magisterial preparations, drips and proprietary products.

Setting up a medicamenteuze behandeling A schematic overview of how a medicamenteuze behandeling (MBH) is set up can be seen in the figure below. When a new building block (MA, TA, VV, MVE, MTD or MGB) is created, a check is first performed to determine whether this is a new medication or if there already is a current building block with the same product. This applies to all building blocks, both proprietary or third parties’. In most systems, the user of the system will indicate that he wants to change one of the existing medication building blocks or wants to introduce new medication. In that case, it is easy to find out whether there already is a medicamenteuze behandeling that includes the building block.

If there is no existing building block for this medication, a new building block with a new medicamenteuze behandeling is created.
If there is an existing building block with a medicamenteuze behandeling, the user of the system is asked whether the new building block and the existing building block belong to the same treatment. When this is the case, the same medicamenteuze behandeling will be used. When the building blocks do not belong to the same treatment, a new medicamenteuze behandeling will be created.

Parallel medicatieafspraken
Within a medicamenteuze behandeling, several medicatieafspraken may be active simultaneously. These are all medicatieafspraken that are valid (“current”) at this time or that will become valid in the future. In principle, only one medicatieafspraak is valid at any one time in a medicamenteuze. However, there are a number of situations where parallel medicatieafspraken are conceivable:

The same medicinal product, but a different strength, where the total strength should essentially be prescribed in one agreement.
Related (different) medicinal products that are given together, but that should be considered as a whole when evaluating treatment.
Technical omissions in systems. For example, in the case of complicated dosing schedules or combination drips.

Situation 1 can be resolved by prescribing at a higher level (SNK). G-standard/Z-Index is working on this, but it is not yet possible. Until that time, 1 or more products can be combined in the same medicatieafspraak by entering the products as ingredients. This is comparable to magisterial preparations. However, the instructions for use for all these products must be identical.^[6]
Situation 2 is solved in different ways in different systems, each with their own grouping mechanisms. It concerns the correlation between different medicamenteuze behandelingmedicamenteuze behandelings. The information standard does not provide a universal grouping mechanism.
Situation 3 is the only situation in which parallel medicatieafspraken are permitted under one medicamenteuze behandelingmedicamenteuze behandeling. Complex phasing-in and phasing-out schedules and combination drips may be included in one medicatieafspraak, but not all systems support this. For those systems it is permitted to create parallel medicatieafspraken within a single medicamenteuze behandelingmedicamenteuze behandeling.

1.3.4 Correlation between building blocks and medicamenteuze behandeling

The figure below shows the correlations between building blocks and the medicamenteuze behandeling. The relations between building blocks and the medicamenteuze behandeling as well as the relations between the building blocks themselves are described as follows:

Building blocks belong to a single medicamenteuze behandeling. A medicamenteuze behandeling includes at least one medicatieafspraak and may include 0 or more of the building blocks verstrekkingsverzoek, toedieningsafspraak, medicatieverstrekking, medicatiegebruik and medicatietoediening.
Unless, for example, self-medication has been recorded with use or there

a paper prescription has been submitted, a drug treatment can exist without it medication appointment, but with medication use or an administration appointment. A MBH will never cease to exist, but it may no longer be effective when there are no current building blocks linked to it. A voorstel medicatieafspraak, voorstel verstrekkingsverzoek and antwoord voorstel-verstrekkingsverzoek are not yet part of a MBH as these are still a draft/proposal that may or may not lead to a final medicatieafspraak or verstrekkingsverzoek linked to a medicamenteuze behandeling. A voorstel medicatieafspraak may lead to zero (if the recommendation is not followed), one or more medicatieafspraken and a voostel verstrekkingsverzoek may lead to zero (if the proposal is not honoured), one or more verstrekkingsverzoeken.

A MBH may also only have a stop-MA in addition to, for example, a user building block. For example, in the event that a healthcare provider asks a patient to stop using an free available medicine (self-care medication or Over the Counter (OTC) medication ). The healthcare provider records the use of the self-care medication in a gebruiks building block and discontinues use by creating a stop medicatieafspraak (stop-MA belonging to the same MBH).
An MA may refer to the previous MA or an TA or MGB on which it is based. This may also be an MA, TA or MGB that belongs to another medicamenteuze behandeling. It is possible that no digital MA is available (e.g. paper prescription (paragraph 4.1.17)). This MA must then be created. This MA may refer to the TA or MGB. A pharmacist is never the source of an MA but he may have a copy.
In principle, only one medicatieafspraak is valid at any one time in a medicamenteuze behandeling. Only when there are technical omissions in systems, for example in case of complicated dosing schedules or combination drips, are parallel medicatieafspraken allowed (see also the previous section).
A medicatieafspraak is supported by zero (if there is still enough supply or if no medicatieverstrekking is needed), one or more (when there is, for example, continuous medication) verstrekkingsverzoeks.
A verstrekkingsverzoek is based on current medicatieafspraken and any existing corresponding TA in a medicamenteuze behandeling. There may be several.
A verstrekkingsverzoek refers to one or more MAs (for example, in the case of an interim dosage increase, a verstrekkingsverzoek can be made that replenishes the supply for the existing MA and also starts the supply for the future MA).
A verstrekkingsverzoek may result in zero (for example when the patient does not pick up the medication) to several MVEs (medicatieverstrekkingen).
Multiple (possibly parallel) toedieningsafspraken may be based on the same medicatieafspraak (for example, when a pharmacist switches to a different commercial product or when the medicinal product is supplied as two or more medicinal products with different strengths, with the total strength remaining the same). When a paper prescription is submitted and the medicatieafspraak and the verstrekkingsverzoek are not available in digital form, there is an toedieningsafspraak without a medicatieafspraak.
A medicatieafspraak does not always have to lead to an toedieningsafspraak, for example when no verstrekkingsverzoek is required with a short use MA, where the

patient still has sufficient stock.

A toedieningsafspraak is supported by zero (when there is enough supply), one or more occasions when medication is dispensed.
A medicatieverstrekking is based on an toedieningsafspraak and, in an ambulatory situation, on a verstrekkingsverzoek. The exception are over-the-counter (OTC/self-medication) sales for the purpose of self-care medication: these have no medicatieafspraken and no verstrekkingsverzoeken. Self-care medication provided by the pharmacist may be recorded by that pharmacist as an toediendingsafspraak with medicatieverstrekking, or as medicatiegebruik by a random healthcare provider or by the patient himself.
A medicatieverstrekking may support multiple toedieningsafspraken.
A medicatie or toedieningsafspraak may be followed by a new medicatie or toedieningsafspraak. This may be the case when existing medication is changed (modification of MA and/or TA) or when medicatiegebruik is discontinued (stop-MA/TA).

1.3.5  Informing and (actively) making available

Chapter 2 describes the medication process. This includes process steps labelled ‘Inform’ or ‘(actively) make available’. The table below includes a detailed description of the reason for this. Chapter 2 further elaborates on situations in which information is actively sent or made available.

Term	Toelichting
Inform	‘Inform’ means sending an order or request addressed to another actor. This is a so-called ‘push’ of information: the actor sends the information specifically to recipient. This may be by means of An electronic message via a digital network, Paper (for example by giving a prescription intended for a pharmacist to the patient), A fax message, A combination of the above options.
(actively) make available	The healthcare provider (actively) makes information available to another actor. This process step concerns: Actively sending or informing (‘push’) as described above or Automatically making information available to healthcare providers and/or the patient when they request it on the basis of prior permission or A combination of both previous bullets. Data are always made available. Additionally, the healthcare provider has the option to specifically inform fellow healthcare providers and/or the patient at any time during the process. In consultation with the patient, data can be sent to a healthcare provider of his choice (inform).

Tabel 2 Informing versus (actively) making available

The technical mechanism (‘pull’, ‘publish and subscribe’, ‘push’, etc.) used to (actively) make data available, is infrastructure-dependent and is therefore not detailed in this document.

The Royal Dutch Medical Association (KNMG) describes in its publication Van wet naar praktijk: implementatie van de WGBO Deel 4. Toegang tot patiëntengegevens [From law to practice: implementation of the Dutch Medical Treatment Contracts Act Part 4. Access to patient data] when there is implicit consent and explicit consent. The exchange described in this information standard is subject to current legal frameworks and guidelines concerning consent and opt-in and these are therefore not explicitly described.

1.4 Legend/Explanation

A manual for this Nictiz wiki documentation can be found at:
http://informatiestandaarden.nictiz.nl/wiki/Handleiding_Wiki_documentatie
It also includes a legend for the various figures that appear in this document.

2 Medication process

This chapter describes the medication process in relation to the building blocks for first-line, second-line and third-line health care. The process is fundamentally the same in each case. The main difference is which pharmacy supplies the medication: a public pharmacy (including an outpatient pharmacy) or a hospital pharmacy. Another difference is that in an ambulatory setting a verstrekkingsverzoek is required for the supply of medicinal products. This is not required in a hospital setting: the (hospital) pharmacist ensures that the medicinal products are available as long as the medicatieafspraak continues.

The medication process is a cyclical process consisting of prescribing, dispensing, administering and using medication. The process starts when the patient/client visits a healthcare provider (general practitioner, hospital or other institution) for a treatment with a medicinal product and ends when the medication is no longer needed. The process is depicted in Figure 4. The yellow bar indicates the medication verification process, green prescription, purple dispensing, and orange administration and use. The blue bar indicates receipt or retrieval of data made available. This may occur in any of the subprocesses and is described in more detail in the continuation of this chapter for the relevant subprocesses. A larger version of the diagram can be found at the end of this document in Chapter 10. The following paragraphs describe the medication verification, prescription, dispensing, administration and medicatiegebruik processes.

_{Figuur 3 (MO = Medicatieoverzicht)}

2.1 Process: medication verification

Prior to the prescription process, the patient’s actual medicatiegebruik is determined. This is done^[7]:

In the GP practice by the general practitioner during a consultation,
At the GP service, A&E department or mental health crisis service by the triage specialist or the treating healthcare provider, as soon as possible, upon arrival or admission,
In case of clinical or day admission at a hospital or other institutions by for example the nursing staff, pharmacy assistent or outpatient/hospital pharmacist.
In case of outpatient consultation by for example nursing staff, doctors’ assistant or the treating healthcare provider.

2.1.1 Current situation

In the current situation, patients or family/informal caregivers are asked which medication they are using. The patient is sometimes unable to answer this. Family/informal caregivers (if known) are also often unable to answer this. If this is the case, the physician will contact the general practitioner or the pharmacist to find out the medication. This is difficult outside office hours and during weekends.

2.1.2 Precondition

The patient comes in for a consultation/an outpatient consultation or is admitted (in the future).

===Trigger event===

Outpatient setting: consultation of and/or prescription to outpatients and patients residing in another healthcare institution^[8]. In this case, medication verification often occurs during treatment assessment (see paragraph 2.2.4).
Clinical setting: preparation of patient admission.

===Process===

The healthcare provider collects the medication data from various sources, which may include:

Patient’s own story,
Dispense overviews from pharmacies,
Digitally available medication data from healthcare providers or personal health records (PGO),
Medication brought in by the patient,
If necessary, information by telephone from the patient’s own pharmacist or general practitioner.

The healthcare provider verifies the medication together with the patient and records the verified medication as medicatiegebruik (MGB, incl. self medication). This results in an updated medication profile; see also paragraph 5.1.

In practice, only when it proves clinically relevant will the medication verification lead to recording of use and updating of the medication profile, particularly upon admission and discharge. The medication overview and recorded data on medicatiegebruik are made available to fellow healthcare providers and the patient, so that they can access the data. The medication overview may also be sent to a specific healthcare provider.

2.1.3 Post-condition

The patient’s medicatiegebruik is recorded and the resulting medication overview is made available if created. Medication data (medicatiegebruik) are made available.

2.1.4 Systems and transaction groups

Chapter 6 includes an overview of all systems, system roles, transactions, etc. Those most important for the medication verification process are included in the overview below.

2.2 Process: prescribe

This paragraph describes the prescription process. This includes all prescribers, such as general practitioners, specialists, other physicians and specialist nurse prescribers. The prescription process consists of an evaluation of existing medicamenteuze behandeling, if any. If necessary, a medicatieafspraak is created and, only in an ambulatory situation, possibly a verstrekkingsverzoek. Finally, the recorded data are (actively) made available. See chapter 10 for a diagram depicting this process.

2.2.1 Current situation

The following deviations from the desired situation that are currently observed are:

The logistical process often determines whether information is recorded (and certainly if it is communicated). Changes in medication or discontinuation are insufficiently recorded and/or communicated, resulting in, among other things, inaccurate monitoring, incorrect use and incorrect medication profiles.

The pharmacotherapeutic policy should be leading, not the logistical process as is currently the case.

Since the therapeutic intention is not communicated to the pharmacist, it is not possible to deduce from the available data whether a request for a repeat prescription falls within that therapeutic intention. Because of this, medicatiegebruik may be erroneously resumed or continued.
If a change is not communicated, a request for a repeat prescription (through the pharmacist) may be based on outdated instructions for use. This can easily lead to errors.
In an outpatient setting, medicatieafspraken and/or verstrekkingsverzoeken are usually not (electronically) sent to the pharmacist.

2.2.2 Precondition[edit]

There is a certain reason why a prescriber wants to start or evaluate/review a medicamenteuze behandeling.

2.2.3 Trigger event

The trigger event for the process is the start of a new medicamenteuze behandeling, the evaluation of an ongoing treatment, receipt of a voorstel verstrekkingsverzoek or voorstel medicatieafspraak, receipt from a pharmacist of a prescription to be processed, or patient admission to or patient discharge from an institution.

2.2.4 Process step: Evaluating a (pharmaceutical) treatment

In order to evaluate treatment, an up-to-date overview of medication data is required. The medical file from the healthcare provider is, where possible and if necessary, updated with data from external sources. In addition, the patient may be asked which medicinal products he is currently using. This medicatiegebruik can be recorded by the healthcare provider. If desired, a more extensive medication verification can be carried out (see paragraph 2.1).

The treating physician^[9] evaluates the (pharmaceutical) treatment and decides to:

start a new medicamenteuze behandeling by creating an initial medicatieafspraak and/or
continue, discontinue, temporarily halt or modify an existing medicatieafspraak (1 or more)[10] and/or
correct/cancel an existing medicatieafspraak and/or
approve a voorstel medicatieafspraak or a voorstel verstrekkingsverzoek (including a reply via the reply voorstel verstrekkingsverzoek)

These situations are further explained in the following paragraph. See also paragraph 1.3.3 for more information on the concept of medicamenteuze behandeling. A new medication overview may be created to conclude the evaluation and the resulting new agreements and verstrekkingsverzoeks (see paragraph 5.1).

2.2.5 Process step: Creating a medicatieafspraak

When creating a medicatieafspraak, the following principle applies: each change is recorded in a new medicatieafspraak. Technically this means that the existing medicatieafspraken is terminated by entering an end date for the period of use and that a new medicatieafspraak is created with the desired changes ^[10]. Medicatieafspraak can also be created to begin at a point in the future. These medicatieafspraken will receive a period of use with future starting date which is later than the date of the agreement itself. Any prior medicatieafspraak will end just before the starting date/time of the future one. In the period of use, only one effective date can be indicated (without duration or end date), this is the case with continuous medication.

Before the medicatieafspraak is created, medication monitoring will occur in accordance with current guidelines. This is a part of this process step.

The next paragraphs describe the different situations in which a medicatieafspraak is created, i.e. initial medicatieafspraak, continuing medication, discontinuing medication, temporarily halting medication or correcting/cancelling a medicatieafspraak. Information about medicamenteuze behandelingis assumed to be known (see [[#Medicamenteuze behandeling[|paragraph 1.3.3]]).

2.2.5.1 New medicatieafspraak

A new medicatieafspraak is created at the start or modification of a medicamenteuze behandeling. When a new medicamenteuze behandeling is started, the prescriber should consider whether an existing medicamenteuze behandeling should be discontinued. The description in [[#Medicamenteuze behandeling[|paragraph 1.3.3]] is based on the most common process from prescription to administering or using. In a transitional situation or in the absence of digital data (e.g. when there is no opt-in or because of regional boundaries of the Dutch Landelijk Schakelpunt [LSP; national data exchange point]), it is also technically possible that a medicamenteuze behandeling could start with an toediendings afspraak, for example. This might occur for instance when a pharmacist has not received the medicatieafspraak with the corresponding medicamenteuze behandeling in digital form. The pharmacist will consequently start a new medicamenteuze behandeling when the toedieningsafspraak is created. This may also be the case for any other building block. A patient can, for example, start a medicamenteuze behandeling by recording medicatiegebruik, without having the original medicamenteuze behandeling.

2.2.5.2 Continuing medication

In a number of cases the therapeutic intention of the prescriber remains the same and the medicatieafspraak does not have to be modified. For instance:

In an ambulatory situation when, for a repeat prescription, only a new verstrekkingsverzoek is needed, or
At admission to an institution where the home medication continues to be used, whether or not in combination with self-medication.

In both of these cases, the existing medicatieafspraak will not be adjusted. Should there be a change in PRK, e.g. at admission or discharge, the existing medicamenteuze behandeling will be discontinued by creating a stop-MA (see Discontinuing medication (paragraph 2.2.5.3)) and a new medicamenteuze behandeling is started (see New medicatieafspraak (paragraph 2.2.5.1.)).

2.2.5.3 Discontinuing medication

Medication is discontinued by creating a new medicatieafspraak (stop-MA) within the same medicamenteuze behandeling. The reason for discontinuation is recorded in this medicatieafspraak. The medication may be discontinued immediately or in the future. The new stop medicatieafspraak (stop-MA) is a copy of the existing medicatieafspraak with:

The period of use as endate on which the medicatieafspraak endse (may also be in the future),
Its own author,
Its own agreement date,
Stop type definitief,
Reference to the specific medicatieafspraak that will be changed (future medicatieafspraken will remain in place) OR no reference causing the entire medicamenteuze behandeling to be discontinued (including already made future medicatieafspraken),
Its own reason for the medicatieafspraak to be discontinued(this does not apply to a stop-MA made as part of a modification. In that case, no reason is given).

A medicatieafspraak in which an end date is immediately agreed upon, e.g. in the case of a course of treatment, is not an additionalystop-MA but a regular medicatieafspraak needed. When a medicatieafspraak with an end date in the future is extended, it will be considered as a normal change (see Changing medication (paragraph 2.2.5.5)). A stop-MA always has the ‘Discontinuation’ stop type, even if it is a stop-MA resulting from a change. In case of a change, the stop-MA is followed by a new medicatieafspraak. A stop-MA resulting from a change is not always relevant for end users. A stop-ma as a result of a change, it is also referred to as a technical stop-ma. The user interface must adequately support this. A prescriber will be less interested than a pharmacist who may need to adjust his logistical process because of the change.

2.2.5.4 Temporarily halting and resuming medication

Temporarily halting medication is the discontinuation of medication for a known or unknown period of time. Medication may be halted immediately or in the future. When medicatiegebruik is temporarily halted, the medication still remains relevant for monitoring because the medication may be resumed in the future. Temporary substitution with another medicinal product is not considered an interruption but rather a discontinuation of the original medication and the start of a new medicamenteuze behandeling with the substitute. Temporary halting medication is covered by two medicatieafspraken[12]: a medicatieafspraak (stop-MA) is created to stop medicatiegebruik in accordance with guidelines for a stop-MA (see previous paragraph) and a new medicatieafspraak is created for resuming the medication (including the reason for this, if any). All medicatieafspraken are part of the same medicamenteuze behandeling. The reason for the interruption is recorded in the stop-MA. A stop-MA either refers to an original medicatieafspraak or it does not refer to a medicatieafspraak in which case the entire medicamenteuze behandeling is discontinued. The stop type for the stop-MA is 'tijdelijk’.

2.2.5.5 Changing medication

Medication modifications may be related to:

a) Dosage,

b) Strength of the medicinal product,

c) Method of administration,

d) Duration of treatment (such as an extension of the therapy).

Switching to a completely different medicinal product is technically a switch to a different medicamenteuze behandeling (see also paragraph 1.3.3). In that case, the physician will discontinue the existing treatment (see paragraph 2.2.5.3) and start a new one (see paragraph 2.2.5.1). If the PRK stays the same, changes will be recorded under the same medicamenteuze behandeling. When a modification needs to be made, a technical stop-MA is created (see paragraph 2.2.5.3) and , a new medicatieafspraak is made with the desired change. The appointment date of the technical stop-ma and the new medication appointment must be always be the same. The reason for the modification is included in the new medicatieafspraak with a reference to the original medicatieafspraak, if possible. Modifications may take effect immediately or in the future. A technical stop-ma and the related new medicatieafspraak are made available simultaneously. In case of renewal of a medicatieafspraak of which the duration has already expired or the end date has already expired, then this is not seen as a change (a stop-ma on the already automatically stopped medicatieafspraak is unnecessary). In this case, a new MA under the same medicamenteuze behandeling can be made.

2.2.5.6 Correcting/cancelling a medicatieafspraak^[11]

This paragraph describes correcting or cancelling a medicatieafspraak when the prescriber has made an error. The error may have been discovered by the prescriber himself or by a fellow healthcare provider. For example, a physician who makes a typing error in the dosage of a medicatieafspraak: 10 inhalations, 2x daily, instead of 1 inhalation, 2x daily. If the medicatieafspraak has not yet been shared with other healthcare providers, the prescriber can personally correct that medicatieafspraak or delete (cancel) it from his own system. If the medicatieafspraak has already been shared with other healthcare providers, the prescriber will mark the incorrect medicatieafspraak as ‘cancelled’ and he will then create a new medicatieafspraak under the same medicamenteuze behandeling with the correct information. The prescriber will actively inform the pharmacist and any fellow healthcare providers about both the cancelled and new medicatieafspraak and will make both available (see paragraph 2.2.7).

2.2.6 Process step: Creating a verstrekkingsverzoek

A verstrekkingsverzoek (besides a medicatieafspraak) only applies in an ambulatory situation. A verstrekkingsverzoek may be made when the medication supply of the patient needs to be replenished. This does not have to coincide with a medicatieafspraak. At the start of a medicamenteuze behandeling for which the patient still has a sufficient supply at home from a previous agreement, a verstrekkingsverzoek is not needed. When the dosage is reduced, the patient may also have a sufficient supply. In the case of a medicinal product that is used for a prolonged period of time (e.g. an antihypertensive drug), with a continous medicatieafspraak (meaning a period of use with only a start date), several verstrekkingsverzoeken may be made over time within the scope of this existing agreement. Logistical and emergency instructions may be included in the verstrekkingsverzoek, such as dispense location, request to not include in the GDS (individualised distribution system, in Dutch Geindividiualiseerd Distributie Systeem), etc.

In the case of a verstrekkingsverzoek, the quantity to be supplied can be stated or the consumption period. With a consumption period, the quantity must be clearly deducible from the dosing instruction of the medicatieafspraak. Note: a consumption period end date has a meaning other than the period of use end date from the medictieafspraak and may be unequal.Period of use end date: date until which the pharmacist is allowed to to provide medication (and thereby provide sufficient supplies to the patient for use until that date).

period of use end date: date on which the patient must stop the medication (this can be equal to the consumption period end date or further in the future).

2.2.7 Process step: Sending renal function value with prescription

Kidney function is important for some medicines. The renal function value then determines the choice of drug and / or drug dosage. It is legally stipulated that if a healthcare professional has further research performed on a patient according to renal function, he shares divergent kidney function values with the appropriate pharmacist, appointed by the patient (Article 6.10, regeling geneesmiddelenwet).

The renal function value is always sent in the prescription (using the building block laboratory results) for medicines for which this is important (characteristic in the G standard), so that the pharmacist can perform proper medication monitoring. The renal function value should not be older than 13 months, because with stable chronic renal impairment the renal function should be checked once a year. 1 month has been added to this, so that there is some backlash in practice.

If at the time of sending a medicatieafspraak and / or verstrekkingsverzoek no renal function is known, that is the prescription policy of that time. Sending the laboratory result renal function value without a medicatieafspraak and / or verstrekkkingsverzoek outside the scope of this information standard.

2.2.8 Process step: (Actively) making available

This step involves information exchange. Information can be sent or made available with different intentions:

A. As an order for the pharmacist to dispense medication. The prescriber sends the medicatieafspraak to the pharmacist. In an ambulatory situation, the verstrekkingsverzoek is also sent to the patient’s pharmacist. If the pharmacist is not known, this process step may also entail giving out a paper prescription and/or (reactively) making the data available (see C). When the pharmacist has filled the order, the prescriber will receive a notification (see paragraph 2.2.7).

B. As an order for the pharmacist to implement a medication change (including stop-MA and staken-MA) that impacts or may impact current medicatieverstrekking by this pharmacist. A current medicatieverstrekking indicates an order (as in A) that has been accepted, but has not yet been completely filled. For example, when medication is still being dispensed or when a verstrekkingsverzoek dictates that medication should be dispensed multiple times, but not all have taken place yet, e.g. with the GDS.

C. Making medication data (MA, VV, MGB) and possibly the medication overview available to allow fellow healthcare providers and/or patients to access these later, possibly in combination with prescription without a specified recipient (see paragraph 7.5).

D. Actively sending (informing) medication data (one or more building blocks) to a specific healthcare provider at the request of the patient when in the presence of this healthcare provider or at discharge.

In case of corrected data, the prescriber assesses who should be actively informed of this correction. This can be done, for example, by sending the new medicatieafspraak (option A or B above) or by means of a telephone consultation. In an ambulatory setting (general practitioner/outpatient clinic) medication data are usually sent or made available directly; in a clinical setting, medication data is usually made available at discharge or interim leave from the institution. This chapter deals with prescription with a specified recipient; paragraph 7.5 details prescription without a specified recipient. See also paragraph 1.3.5 for a further explanation on informing (situation A, B, D) and making available (situation C).

2.2.8.1 Post-condition[edit]

A new medicatieafspraak may have been created (starting, changing or discontinuing medication)
A verstrekkingsverzoek may have been made (only outpatient)
An order may have been sent to the pharmacist to carry out medicatieverstrekking
An order may have been sent to the pharmacist to modify medicatieverstrekking
Fellow healthcare providers and the patient have been informed or may inform themselves about the new medication data: medicatieafspraak, verstrekkingsverzoek, medicatiegebruik.
Fellow healthcare providers and the patient have been informed or may inform themselves about a medication overview.

2.2.9 Systems and transaction groups

The prescriber and the pharmacist as well as other healthcare providers and users all make use of an information system, respectively, an electronic prescribing system (EVS), a pharmacist information system (AIS, incl. ZAIS), an XIS and a PGO^[12]. These systems each have different system roles which enable the exchange of data between these systems as part of the prescription process. Chapter 6 includes an overview of all systems, system roles, transactions, etc. The most important elements for the prescription process are included in the overview below.

2.2.10 Use cases

De volgende specifieke use cases van voorschrijven zijn uitgewerkt:

Kortdurende medicatie (paragraaf 4.1.1)
Doorlopende medicatie (paragraaf 4.1.2)
Harde einddatum gebruiksperiode (paragraaf 4.1.3)
Zonodig medicatie (paragraaf 4.1.4)
Kuur zo nodig startend in de toekomst (paragraaf 4.1.5)
Twee doseringen van hetzelfde geneesmiddel tegelijkertijd (paragraaf 4.1.6)
Hetzelfde geneesmiddel met verschillende sterkte tegelijkertijd (paragraaf 4.1.7)
Toelichting in medicatieafspraak bij bewust gekozen bijzonderheid (paragraaf 4.1.8)
Nieuwe medicatieafspraak, geen verstrekkingsverzoek (paragraaf 4.1.9)
Nieuw verstrekkingsverzoek onder bestaande medicatieafspraak (paragraaf 4.1.10)
Wijziging in dosering (voldoende voorraad) (paragraaf 4.1.11)
Recept niet meer nodig na eerste verstrekkingsverzoek (paragraaf 4.1.12)
Stoppen medicatie (paragraaf 4.1.13)
Onderbreken / hervatten medicatie (paragraaf 4.1.14)
Onderbreken voor een ingreep (paragraaf 4.1.15)
Substitutie (paragraaf 4.1.16)
Papieren recept (paragraaf 4.1.17)
Uitvoeren medicatieverificatie en evaluatie bij buitenlandse of zelfzorgmedicatie (paragraaf 4.1.18)
Dagbehandeling (paragraaf 4.1.19)
Starten met medicatie voor opname (paragraaf 4.1.20)
Spoedopname (paragraaf 4.1.21)
Ontslag (paragraaf 4.1.22)
Tussentijds ontslag (paragraaf 4.1.23)
Ontslag naar andere instelling (paragraaf 4.1.24)
Niet verstrekken voor (paragraaf 4.1.25)
Stoppen van medicatie door derden (paragraaf 4.1.26)
Verschillende PRKs onder dezelfde medicamenteuze behandeling (paragraaf 4.1.27)
Achteraf vastleggen medicatieafspraak (paragraaf 4.1.28)
Parallelle medicatieafspraken (paragraaf 4.1.29)
Eenmalig gebruik (paragraaf 4.1.30)
Voorlopige en definitieve medicatieopdracht (paragraaf 4.1.31)
Onterecht openstaande medicatie of 'weeskinderen' (paragraaf 4.1.32)
Ontbreken digitale medicatieafspraak bij opname (paragraaf 4.1.33)
Eigen artikelen (90 miljoen nummers) (paragraaf 4.1.34)
Dosering met minimum interval (paragraaf 4.1.35)
Verstrekkingsverzoek met aantal herhalingen (paragraaf 4.1.36)
Voorschrijven van niet geneesmiddelen (verbandmiddelen, krukken of andere hulpmiddelen) (paragraaf 4.1.37)
Nierfunctiewaarde sturen in het voorschrift (paragraaf 4.1.38)

2.3 Process: dispense

This paragraph describes the process of dispensing medication, including repeat prescriptions and GDS. This process encompasses all actions a pharmacist must take for the patient to not only receive a medicinal product, but to also receive the associated pharmaceutical care ensuring a safe and effective use of the medicinal product by the pa tient. The dispense process starts with providing pharmaceutical care. If necessary, a toedienafspraakwill made and medication is dispensed. Medicatieverstrekking (i.e. handing out a medicinal product) does not always take place. This may be the case when the medicatieafspraak is changed (e.g., in case of dose reduction where the patient still has enough supply), when the medication is discontinued or, in an ambulatory situation, the medication is not picked up. When the medicatieafspraak and/or the verstrekkingsverzoek are not in order (see paragraph 2.3.5), the prescriber will be informed. Finally, the recorded data are (actively) made available. See Chapter 10 for a diagram of the dispense process.

Medication assessment is the process in which the physician and pharmacist consider all medication of the patient against the background of his condition, applicable treatment guidelines, the well-being of the patient, etc. Medication assessment is defined in this document as a combination of treatment evaluation (as described in the previous paragraphs) and pharmaceutical care. Depending on the findings, the previously described medication verification and prescription processes are followed, after which medicatieverstrekking takes place.

For the GDS, many pharmacists work with another organisation that handles part of the pharmacists’ logistics. This then also requires data exchange with that party. Besides, not all medication can be included in the GDS packaging, which adds to the logistical complexity for the pharmacist. The internal logistics and communication between the pharmacist and his ‘subcontractor(s) are outside the scope of this information standard. It has been established however that with the provision of the current building blocks and the underlying data elements, this logistical process can be adequately supported.

2.3.1 Current situation

The following deviations (from the desired situation that) are currently observed:
In the current situation, in the case of individualised distribution systems, the prescribing physician and other healthcare providers receive a large quantity of dispense messages. This becomes difficult to manage for these healthcare providers.
In the current situation, in the case of GDS (individualised distribution systems), pharmacists and general practitioners communicate via so-called authorisation lists. The pharmacist sends an overview of all the patient’s medication to the general practitioner for authorisation. This complicates matters for a general practitioner because he will need to verierify all medicatieafspraken. This should not be necessary, as most medicatieafspraken/verstrekkingsverzoeks have already been authorised. It would be much more efficient if the general practitioner only needs to authorise those medicatieafspraken/verstrekkingsverzoeken that have not been authorised yet, e.g. a new verstrekkingsverzoek on the basis of an existing medicatieafspraak.
In the current situation, a service pharmacy often does not inform the regular general practitioner and regular pharmacy when medication is dispensed.
In the current situation, a voorstel medicatieafspraak is usually coordinated with the prescriber over the phone and/or the pharmacist and prescriber have made an agreement about handling a signal from the medication monitoring system.
The meaning of the return message is not always clear: no distinction can be made in the return/delivery message between displaying a physical delivery and a transmission of information about a medication change.
In the current situation, pharmacists sometimes register (and communicate) medicatieverstrekking when they are readying the medication for the patient instead of at the time when the medication is actually dispensed to the patient. This means that medication that hasn’t been picked up, is sometimes erroneously registered as dispensed.

2.3.2 Precondition

A medicatieafspraak exists. In an ambulatory situation there may also be a corresponding verstrekkingsverzoek.

2.3.3 Trigger event

The pharmacist starts the medication dispense process on the basis of one of the following events:

Receipt of an order to make a medicatieverstrekking on the basis of a new medicatieafspraak. In an ambulatory situation, this order is always accompanied by a verstrekkingsverzoek.
Receipt of an order to process a new medicatieafspraak in an ongoing medicatieverstrekking.
Receipt of a trigger (for example, via a patient or a repeat module of the pharmacist information system) for a repeat medicatieverstrekking under an existing or voorstel verstrekkingsverzoek.

2.3.4 Process step: Providing pharmaceutical care

Pharmaceutical care is provided by a public, outpatient or hospital pharmacy, depending on the healthcare provider who has created the medicatieafspraak:
Medicatieafspraak, possibly with a verstrekkingsverzoek from the general practitioner or specialist: care provided by a public or outpatient pharmacy,
Medicatieafspraak from specialists and other prescribers in hospitals/institutions: care provided by a hospital pharmacy or a public pharmacy that supplies the respective institution.
Medication monitoring is also part of pharmaceutical care.
Based on the received medicatieafspraak or a change in the situation of the patient, the pharmacist decides how to apply this by:
Making one or more new toedieningsafspraken,
Continuing, permanently discontinuing, temporarily halting or modifying an existing medicatieafspraak.
Rejecting the medicatieafspraak.
Proposing a new medicatieafspraak,
Proposing a new verstrekkingsverzoek.

The last three situations are explained in the following paragraph. The first two situations are explained in paragraph 2.3.6. A new up-to-date medication overview may be compiled and made available in conclusion of provided pharmaceutical care with possible new agreements and medicatieverstrekking.

2.3.5 Process step: Informing the prescriber

There is a number of situations in which the pharmacist informs the prescriber, including:

When a new or modified medicatieafspraak is needed
When a new verstrekkingsverzoek is needed
For more information about informing, see paragraph 1.3.5.
A new or modified medicatieafspraak is needed:
When a new toedieningsafspraak cannot be created based on the received medicatieafspraak because the pharmacist suspects an error in the medicatieafspraak, or
After a signal from the medication monitoring system as part of pharmaceutical care. The signal may indicate, for example, that the dosage should be lowered or increased, that it is advisable to select another medicinal product, that a product should be temporarily discontinued, that another additional product should be added, etc., or
Based on medicatiegebruik as reported by the patient during pharmaceutical care, or
When the temporarily halted medicamenteuze behandeling may be resumed.
A toedieningsafspraak is not yet created or modified in these situations.

Instead, the pharmacist starts by contacting the prescriber by phone, informing him of the suspected error and proposing an alternative. The pharmacist may also send a digital voorstel medicatieafspraak to the prescriber. He recommends a specific medicatieafspraak in this proposal, together with the reason and arguments for that recommendation. The prescriber may approve the voorstel medicatieafspraak and make it into a final medicatieafspraak (see also paragraph 2.2.4).

A new verstrekkingsverzoek is needed when the patient’s medication supply is used up or nearly used and the treatment may need to be continued (request repeat prescription). The patient either requests a repeat medicatieverstrekking from the pharmacist or has signed up in the past for proactive repeat medicatieverstrekking and a notification signal is generated by the repeat module of the AIS when the patient requires new medication^[13]. When the existing verstrekkingsverzoek is not adequate, the pharmacist may communicate this request over the phone or send a digital voorstel verstrekkingsverzoek to the prescriber. The voorstel verstrekkingsverzoek may contain indications for the prescriber, such as urgency. The prescriber may approve the received proposal and make it into a final verstrekkingsverzoek. The prescriber informs the requestor via a antwoord voorstel verstrekkingsverzoek (see also paragraph 2.2.4 and subsequent paragraphs).

2.3.6 Process step: Creating a toedieningsafspraak

If the medicatieafspraak and, if applicable, the corresponding verstrekkingsverzoek can be processed, an toedieningsafspraak will be created. By creating an toedieningsafspraak, the pharmacist fills to the medicatieafspraak. The toedieningsafspraak is communicated to the patient or the person administrating the medication. The toedieningsafspraakbelongs to the same medicamenteuze behandeling as the medicatieafspraak it fills. As is the case with the corresponding medicatieafspraak, an toedieningsafspraakmay start in the future. The dosage in the toedieningsafspraak may deviate from that in the medicatieafspraak, for example because a certain strength is not in stock. This means that another ‘PRK’ can become part of the medicamenteuze behandeling when, for example, 1 tablet of 20 mg is changed into 2 tablets of 10 mg. Before the toedieningsafspraak is created, medication monitoring will occur in accordance with applicable guidelines, as part of this process step.

On the basis of the toedieningsafspraak, an administration list^[14] can be compiled for home care or nursing staff, among others.

When creating an toedieningsafspraak, the same principle applies as for the medicatieafspraak: each change is recorded in a new toedieningsafspraak.

The following paragraphs describe the different situations in which an toedieningsafspraak is created: new toedieningsafspraak or continuing, permanently discontinuing, temporarily halting or modifying an existing toedieningsafspraak.

2.3.6.1 New toedieningsafspraak

In case of a new medicatieafspraak, a new toedieningsafspraak is always created. A new toedieningsafspraak is also created in case of a new preference policy or a change in stock which results in the selection of a different medicinal product. When creating a new toedieningsafspraak, the pharmacist takes into account, among other things:

Preference policy,
Inclusion in GDS-packaging,
Available stock of the institution (‘hospital formulary’) or the pharmacy itself.

If, in an ambulatory situation, the first provision/medicatieverstrekking to the patient occurs later than agreed, the start date of the toedieningsafspraak will be different from the start date of the medicatieafspraak.

2.3.6.2 Continuing a toedieningsafspraak

When the existing medicatieafspraak and toedieningsafspraak are sufficient to carry out a medicatieverstrekking, the toedieningsafspraak will not be adjusted.

2.3.6.3 Discontinuing a toedieningsafspraak

A medicatieafspraak in which it has been agreed to discontinue permanently, medication leads to an stop toedieningsafspraak under the same medicamenteuze behandeling (this also applies in case of a stop-MA as a result of a change) with stoptype ‘definitief’. The stop TA prevents a new medicatieverstrekking of the discontinued medication. In an ambulatory situation, the prescriber can indicate in the medicatieafspraak that the medication will be discontinued with the next roll (with GDS). In this case, the start date of the stop toedieningsafspraak may be later than indicated in the original stop medicatieafspraak.

2.3.6.4 Temporarily interrupting a toedieningsafspraak

Temporarily interrupting a medicatieafspraak results in an stop toedieningsafspraak (stop type: tijdelijk). Upon resuming, a new toedieningsafspraak is created. Both toedieningsafspraken belong to the same medicamenteuze behandeling as the medicatieafspraak.

2.3.6.5 Modifying a toedieningsafspraak

A modified medicatieafspraak (leading to a new medicatieafspraak) leads to a new toedieningsafspraak under the same medicamenteuze behandeling. As with the medicatieafspraak, a change to an toedieningsafspraak means the termination of the existing toedieningsafspraak (a technical stop-TA) and the creation of a new toedieningsafspraak.

2.3.7 Process step: Dispense

After creating the toedieningsafspraak, the pharmacist prepares the product and dispenses it to:

The patient at home,
The patient admitted to a hospital, nursing home or other institution.
The pharmacist records medicatieverstrekking[17].
Medicatieverstrekking to patients:
In an ambulatory situation only occurs on the basis of a verstrekkingsverzoek or a repeat verstrekkingsverzoek,
In a clinical situation occurs on the basis of the medicatieafspraak without the need for a verstrekkingsverzoek.

2.3.8 Process step: (Actively) making available

This step involves information exchange. Information can be sent or made available with different intentions:

As a request to the prescriber to create a new medicatieafspraak (vma) or a new toedieningsafspraak (vvv).

Informing the prescriber about the processing of the prescription (toedieningsafspraak and/or medicatieverstrekking).

Making medication data available (verstrekkingsverzoek and medicatieverstrekking) to allow fellow healthcare providers and/or patients to access these later.

Making a medication overview available to allow fellow healthcare providers and/or patients to access these later.

2.3.9 Post-condition

A toedieningsafspraak have been created.
A medicatieverstrekking have taken place and, if necessary, the patient has received instructions on how to use the medicinal product.
Fellow healthcare providers have been informed or may inform themselves. The prescriber has been informed.
If necessary, the prescribing physician has been requested to provide a new/modified medicatieafspraak or voorstel verstrekkingsverzoek.

2.3.10 Systems and transaction groups

The prescriber and the pharmacist as well as other healthcare providers and users all make use of an information system, respectively, an electronic prescribing system (EVS), a pharmacist information system (AIS, incl. ZAIS), an XIS and a PGO^[15]. These systems each have different system roles which enable the exchange of data between these systems as part of the prescription process. Chapter 6 includes an overview of all systems, system roles, transactions, etc. The most important elements for the prescription process are included in the overview below.

2.3.11 Use cases

De volgende specifieke use cases van ter hand stellen zijn uitgewerkt:

Nieuwe medicatieafspraak, medicatieverstrekking zelfde product (paragraaf 4.2.1)
Nieuwe medicatieafspraak, nadere specificering product (paragraaf 4.2.2)
Bestaande toedieningsafspraak voldoet (paragraaf 4.2.3)
Medicatieafspraak nodig (Informeren voorschrijver) (paragraaf 4.2.4)
Aanschrijven en verstrekken (paragraaf 4.2.5)
Patiënt vraagt herhaalrecept via arts (reactief herhalen) (paragraaf 4.2.6)
Patiënt vraagt herhaalrecept via apotheker (Informeren voorschrijver) (paragraaf 4.2.7)
Proactief herhaalrecept door apotheker (Informeren voorschrijver) (paragraaf 4.2.8)
Verstrekken op basis van bestaand verstrekkingsverzoek (paragraaf 4.2.9)
Knippen van recept (paragraaf 4.2.10)
Het opstarten en continueren van GDS (paragraaf 4.2.11)
De apotheker wijzigt van handelsproduct (paragraaf 4.2.12)
Medicatie toevoegen aan GDS (paragraaf 4.2.13)
Medicatie in GDS stoppen (paragraaf 4.2.14)
GDS leverancier levert ander handelsproduct (paragraaf 4.2.15)
Afhandelen stop medicatieafspraak (paragraaf 4.2.16)
Verstrekkingsverzoek met aantal herhalingen (paragraaf 4.1.36)

2.4 Process: Administer

This paragraph describes the administration process. Medicatietoediening is carried out by the patient himself or by a healthcare provider, which in this case means a professional authorised to administer medication such as physicians/nurses/caregivers (home care/institution) as well as general practitioners/GP assistants, anaesthesiologists, midwives and dentists. Administration by, for example, an informal caregiver, is recorded as use (see paragraph 2.5). See Chapter 10 for a diagram of this process.

2.4.1 Current situation

It often happens that the administration list in home care only lists the toedientijden for medicatieverstrekking in GDS packaging (‘baxter’ medication). In that case, the nurse infers the administration times of the other medication from the information on the label. In addition, medication as needed, injection schedules (for example, for insulin) and anticoagulant dosages are often missing on the toedienlijst.
While providing home care, the nurse verifies with the client whether the medication on the administration list is still correct. Medication changes (including stop-orders) often do not appear on the toedienlijst, or not in time. The nurse will the phone the pharmacist, general practitioner or medical specialists to find out what has to be administered.

2.4.2 Precondition

The patient must either be administered medication by a healthcare provider or the patient administers medication to himself.

2.4.3 Trigger event

The moment the medicinal products are administered.

2.4.4 Process step: Administering

The administrator receives the data he needs for administering the medication or he accesses the data (for example, toedieningsafspraakwith corresponding medicatieafspraken and other relevant patient characteristics, conditions, laboratory values, previous administration data). The administrator verifies the medication to be administered on the basis of the medication present and the administration data. If agreed and if necessary, the healthcare provider prepares the medication for administration, based on the instructions provided by the pharmacist. The medication is administered. The person who administered the medication registers in his system or on the administration list how the medicatietoediening was carried out. Any abnormalities (no administration, modified dosage, patient refusal, swallowing problems, side effects, etc.) are also recorded and communicated to the prescriber and/or the pharmacist.

2.4.5 Process step: (Actively) making available

The recorded medication data (medicatietoediening) may be sent for information to a fellow healthcare provider or be made available so that the data can be accessed later. For example, the administration data can be retrieved upon transfer of the patient to another department or institution.

2.4.6 Post-condition

The client has been administered medicinal products and this has been registered. If necessary, findings have been communicated to the responsible physician and/or pharmacist.

2.4.7 Systems and transaction groups

The prescriber and the pharmacist as well as other healthcare providers and users all make use of an information system, respectively, an electronic prescribing system (EVS), a pharmacist information system (AIS, incl. ZAIS), an XIS and a PGO^[16]. These systems each have different system roles which enable the exchange of data between these systems as part of the prescription process.
Chapter 6 includes an overview of all systems, system roles, transactions, etc. The most important elements for the prescription process are included in the overview below.

2.4.8 Use cases

The following use cases for medicatietoediening have been worked out:

Double check (paragraph 4.3.1)
Administering without medicatieafspraak or toedieningsafspraak (paragraph 4.3.2)

2.5 Process: Use

This paragraph describes the process of medicatiegebruik including registration of medicatiegebruik by the patient or a healthcare provider. The information recorded by the patient or healthcare provider may be used, among other things, for medication verification by the healthcare provider. During medication verification, use is established by the healthcare provider. See Chapter 10 for a diagram of this process.

2.5.1 Current situation

There is currently a limited number of systems available in which the patient can record his own medicatiegebruik. Exchange to healthcare providers is also highly dependent on the system used and is often limited to one specific healthcare provider via, for example, one specific platform/app.
De huidige medicatieprofielen zijn vaak onvolledig en niet actueel.

2.5.2 Precondition

The patient has been prescribed medication.

2.5.3 Trigger event

The patient has used the medication or does not use it (anymore).

2.5.4 Process step: Medicatiegebruik

The patient uses the prescribed medication, selfcare medication . Medicatiegebruik may be recorded by

The patient himself or his informal caregiver,
A home care or institution nurse and/or
Another healthcare provider.
This third option often applies in the event of medication verification (see paragraph 2.1). A variety of systems is available to record use: PHR, XIS, EPF [electronic patient file] / ECF [electronic client file], app, etc.
The following can be recorded as medicatiegebruik:
Self-care and other proprietary medication,
Discrepancies compared to agreements made,
Confirmation of use (promoting compliance),
Verified medication (see medication verification),
Changes as a result of, for example, side effects (by the patient himself; a healthcare provider will record this in a different way).

Patients who are being administered medication by a nurse sometimes take the medication by themselves at a later time, depending on the BEM score (assessment of medication self-management, in Dutch: Beoordeling Eigen Beheer Medicatie); in that case, medicatietoediening data may deviate from medicatiegebruik.
While medication is being used, pharmaceutical care is provided by the pharmacist (see paragraph 2.3.4, e.g. in case of new laboratory values). There may also be follow-up contact during which the medicamenteuze behandeling is evaluated (see paragraph 2.2.4).

2.5.4.1 Recording medicatiegebruik by the patient

The patients makes use of a medication profile and indicates actual use for each medicinal product for which this is relevant. The patient can indicate whether or not he is using the product and/or whether this is ‘use according to agreement’ (whereby the medicatieafspraak and/or toedieningsafspraak is displayed) or if there were deviations. In case of deviations, it is possible to enter specific deviations (i.e. with regard to the schedule actually followed by the patient), but deviations can also be entered in more general terms (for example, I take the medication: ‘from time to time’, [x] times per [days/week] on average’, ‘1x daily instead of 2x’, ‘not anymore since 22 January 2015’ or ‘not anymore since about a month’). In case of deviation from the agreements, the patient also indicates the reason for changing or discontinuing.
The patient may also add his own medication to the overview and indicate any side effects as the reason for the changes.

Information about use will not always be present. There is also no certainty about the reliability of the information. Sometimes there are agreements between the healthcare provider and the patient about keeping track of medicatiegebruik, and sometimes the initiative is the patient’s entirely.

2.5.4.2 Recording medicatiegebruik by healthcare providers

During the process of medication verification (paragraph 2.1) or evaluating a medicamenteuze behandeling (2.2.4) the patient (or his informal caregiver) indicates, for example, that he does not use medication or uses it differently than was agreed. He may also indicate that he uses other medication as well (self-care products or foreign medication). The healthcare provider can record these data as medicatiegebruik. The data about use are recorded in addition to the primary medication data with the patient being recorded as the source of the information and the healthcare provider as the author.
Instead of or in addition to recording the medicatiegebruik, a prescriber may also choose to make a new or modified medicatieafspraak with the patient (in accordance with the process described in paragraph 2.2.5). This may occur when the prescriber sees reasons to adjust the agreement in response to the patient’s actual medicatiegebruik. When the prescriber sees no reasons to adjust the agreement, he may choose to only record the medicatiegebruik, perhaps with the remark that he has requested the patient to comply with the existing agreements.

In case of deviations in medicatiegebruik, a pharmacist may create a voorstel medicatieafspraak for the prescriber (see paragraph 2.3.5) and/or advise the patient to inform the prescriber about the deviations.

The assessment of medicatiegebruik (effect and side effect) will be recorded by the physician in the medical history or used as a reason to modify or discontinue a medicatieafspraak.

2.5.5 Process step: (Actively) making available

The recorded medication data (medicatiegebruik) and possibly the medication overview may be sent for information to a fellow healthcare provider or be made available so that the data can be accessed later.

2.5.6 Processtap: Informeren voorschrijver

The patient may also directly inform the prescriber when a new or modified medicatieafspraak or new verstrekkingsverzoek is needed. The process is analogous to the process of the pharmacist informing the prescriber (paragraph 2.3.5).

2.5.7 Post-condition

The medication list has been updated by the patient and actual use has been added. If necessary, the patient has asked the prescriber for a new or modified medicatieafspraak or verstrekkingsverzoek.

2.5.8 Systems and transaction groups

The prescriber and the pharmacist as well as other healthcare providers and users all make use of an information system, respectively, an electronic prescribing system (EVS), a pharmacist information system (AIS, incl. ZAIS), an XIS and a PGO^[17]. These systems each have different system roles which enable the exchange of data between these systems as part of the prescription process.
Chapter 6 includes an overview of all systems, system roles, transactions, etc. The most important elements for the prescription process are included in the overview below.

2.5.9 Use cases

The use cases for medicatiegebruik are described on the basis of registration by the patient. The prescriber may record medicatiegebruik in the same way but will rather record the assessment of medicatiegebruik (effect and side effect) in the medical history or use it as a reason to modify or discontinue a medicatieafspraak.

The following specific use cases for medicatiegebruik have been worked out:

Self-care product (paragraph 4.4.1)
Medication from abroad (paragraph 4.4.2)
Modification at the patient’s initiative(paragraph 4.4.3)
Discontinuation of medication at the patient’s initiative (paragraph 4.4.4)
No more supply (paragraph 4.4.5)
Feedback to patient through medication adherence app (paragraph 4.4.6)
Registration of side effects by the patient (paragraph 4.4.7)
Medicatieafspraak wanted (informing the prescriber) (see also paragraph 4.2.4)
#Patient requests repeat prescription via physician (reactive repeat) (informing prescriber) (see also paragraph 4.2.6)

3 Domain-specific handling of the medication process

3.1 GP observation service (HAP)

The GP observation service (GPS) works on behalf of the regular general practitioner. The GP service may (among other things) start, modify and discontinue medicatieafspraken in accordance with the process described in paragraph 2.1. If necessary, the GPS will also create the corresponding verstrekkingsverzoeken.
The GPS will inform the regular general practitioner about the observation. Currently, it has been agreed that the GPS does not act as a source of information for other healthcare providers of this patient. This means that the GPS will not carry out the process step ‘(actively) making available’. Instead, the regular general practitioner will make the relevant information available to the fellow healthcare providers. An exception may be made for a prescription created by the GPS without a specified recipient, see paragraph 7.5.
In principle, the GP observation service will follow the generic prescription process, except that a GP observation physician will carry out certain steps on behalf of the regular GP (‘delegated’).

3.2 Thrombosis service

3.2.1 Current situation

Communication between thrombosis service and pharmacy is carried out by fax and/or secure e-mail.
Communication between prescriber and thrombosis service is carried out by telephone and initially using the registration form.
In order to get a complete picture of the medication the patient uses, the thrombosis service may sometimes ask for an AMO (Actueel Medicatie Overzicht) overviews from different pharmacies.

3.2.2 Process

When a patient has to start using anticoagulant medication, the prescribing physician (general practitioner or specialist) creates a medicatieafspraak with the patient stating which anticoagulant medication will be used, in accordance with the prescription process as described in paragraph 2.1. Fellow healthcare providers may inform themselves about anticoagulant use ‘in accordance with the thrombosis service schedule’.
The prescriber determines the therapeutic INR range (International Normalised Ratio, a measure for blood clotting time) and refers the patient to the thrombosis service. The prescribing physician remains responsible for verstrekkingsverzoeken. The thrombosis service however determines the specific dosing schedule on the basis of the therapeutic INR range and the measured INR (. The thrombosis service uses this to further complete the medicatieafspraak (‘dosage in accordance with the thrombosis service schedule’) documented in the toedieningsafspraak. The thrombosis service also creates medicatieafspraken, including verstrekkingsverzoeken themselves, about the use of vitamin K and heparin, in accordance with the prescription process as described in paragraph 2.1.
At the start of treatment and after each admission, the thrombosis service asks for current medication data (including allergies), receives notification signals from pharmacists about newly provided interacting medication and asks the patient at each visit for particulars, such as hospital admissions, illnesses and use of selfcare medication. Based on this information and possibly after consultation with the prescriber, interim dosage changes may be made.

The patient is informed via mail and/or a patient portal about the dosing schedule and possible use of vitamin K and heparin. In case of self-measurement, the patient enters their INR and medicatiegebruikd through a patient portal and makes it available.

All medication is dispensed by the pharmacist; the pharmacist is responsible for medicatieverstrekkingen. There are pilots ongoing to dispense anticoagulant medication in GDS. To facilitate this, the pharmacist receives the dosing schedule from the thrombosis service. Repeat prescriptions are handled by the general practitioner, possibly under the medicatieafspraak of the specialist.

When anticoagulant medication may be discontinued, the physician creates a stop-mediatieafspraak with stoptype ‘definitief’. Anticoagulant medication may also be temporarily halted, for example in case of surgery.

3.3 Mental health care

There are only few planned admissions in mental health care (almost only in departments for eating disorders, clinical rehabilitation, etc.). Most admissions are admissions as a result of acute crisis situations and are therefore comparable to admissions via the emergency departments in hospitals (see also paragraph 4.1.20).

3.3.1 Current situation

IIn the current situation, patient or family/informal caregivers are asked which medication the patient is using. In most cases, the patient is unable to give an answer (often the reason for admission). Family/informal caregivers (if known) are also not always able to answer this. If this is the case, the admitting physician/psychiatrists will contact the general practitioner or the pharmacist to find out the medication. This is difficult outside office hours and during weekends. When data do come in, only part of them is retyped in the system of the healthcare providers.

3.3.2 Process

In the new situation, it will be possible to retrieve the available medication data and medication overviews. On this basis, medication verification, medicamenteuze behandeling assessment (as soon as possible) and medicatietoediening (in accordance with Chapter 2) can be started. Medicatieverstrekking is carried out by public pharmacists on an outpatient basis and, in clinical practice, often by a contracted hospital pharmacy.
As is the case with hospital discharge, medicamenteuze behandeling will be assessed at discharge from a mental health institution (paragraph 2.2.4 and subsequent). Clinical medication is discontinued and, if necessary, new medication is prescribed or temporarily halted outpatient medication is resumed or permanently discontinued. The physician/psychiatrist focuses mainly on psychiatric medication; somatic medication usually remains unaffected.
Having the psychiatric patient record his own medicatiegebruik may be experienced as undesirable control instead of it stimulating actual use.
The medication data will be made available.

3.4 Nursing, care and home care (VVT)

The medication process in a VVT institution (nursing home, care home and home care) is analogous to that of the clinical situation. However, in a VVT institution, a geriatrics specialist is responsible for prescribing medication to admitted clients and medication is being dispensed by one or more public pharmacists, as part of GDS if needed. VVT institutions and home care make use of administration lists, which are drawn up based on the toedieningafspraken. The administration list is used to check medication before administering it and to sign off actual medicatietoediening. Communication of the administration list between pharmacist, prescriber and nursing staff will be explained in more details further on in this information standard.

4 Description of use cases

This chapter contains a description of various use cases. Specific practical situations have been described for the various subprocesses. A large number of the practical situations are based on general medical practice, but are illustrative of similar situations in a different setting. This chapter assumes the knowledge as previously described in Chapter 2.

4.1 Use cases, Prescribe

4.1.1 Kortdurende medicatie

A 35 year old female patient with a history of urinary tract infection brings her urine to the doctor’s assistant and tells her she has the same symptoms as the previous times. The assistant enquires about other symptoms such as fever and pain in the flank and checks the urine. There are no other symptoms and the urine reveals a urinary tract infection. She tells the patient that the general practitioner will prescribe a course of treatment and that she can pick it up from the pharmacist later. The General practitioner checks the previous courses of treatment and any cultures and records a medicatieafspraak. On 27 January it was agreed:

Nitrofurantoin CR capsule, 100 mg, 2x daily, 1 capsule, from now on^[18] for 5 days.

He records this medicatieafspraak in his system. The general practitioner then immediately also makes a verstrekkingsverzoek for the pharmacist chosen by the patient:

Nitrofurantoin CR capsule, 100 mg; 10 capsules.

The general practitioner also records this verstrekkingsverzoek in his system.
The general practitioner consults with the patient to find out from which pharmacist she wants to pick up the medication. The general practitioner can then inform this pharmacist about the verstrekkingsverzoek and the medicatieafspraak.
The system of the general practitioner makes this information (verstrekkingsverzoek and medicatieafspraak) available to the other healthcare providers of this patient.

4.1.2 Continuing medication

The process for continuing medication is practically the same as for short-term medication (see paragraph 4.1.1), except that in the case of continuing medication the medicatieafspraak is made for an indefinite period of time.

For example: the prescriber agrees with a patient who has hypertension that he should use a diuretic on a continuous basis. On 30 March 2013 it was agreed:

Hydrochlorothiazide tablet, 12.5 mg; 1x daily, 1 tablet; from now on for an indefinite period.

For example, the prescriber chooses in the verstrekkingsverzoek for an initial dispensing quantity of 100 pieces.

4.1.3 Hard end date for period of use

A start date, end date and/or duration can be included in the period of use of a medicatieafspraak. If a hard end date is desired, this must also be explicitly stated in the explanation. Including an end date alone is not sufficient because this does not provide enough clarity about the intention of the prescriber.

4.1.4 Medication as needed

A 31-year-old female patient has had headaches a few times in a year, with migraine now being diagnosed. The general practitioner prescribes:

Rizatriptan tablets, 10 mg, as needed 1c1t under the tongue. First tablet at the next clear migraine attack.

De huisarts legt de medicatieafspraak vast en doet een verstrekkingsverzoek:

6 sublingual rizatriptan tablets, 10 mg.

4.1.5 Course of treatment as needed starting in future

A 60-year-old patient with post-thrombotic syndrome experiences erysipelas (severe infection of the leg which can require admission if medication is not started quickly) sometimes every other year, sometimes three times a year. At the request of the patient, the general practitioner prescribes an antibiotic treatment the patient can start immediately in case of a recurrence of erysipelas. The following medicatieafspraak is created:

Flucloxacillin capsules, 500 mg, 1 capsule 4x daily, for 10 days. In the medicatieafspraak is indicated (if necessary): start in case of recurrence, as needed.

The general practitioner immediately creates a verstrekkingsverzoek:

Flucloxacilline 500mg capsules 40stuks.

4.1.6 Two dosages of the same medication at the same time

A 79-year-old man with metastatic prostate cancer is increasingly suffering from pain and his medication is being changed. The specialist prescribes oxycodone tablets, 10 mg, 1 tablet 4x daily and as needed for pain during the night, 1 tablet 1x daily, on October 9. The specialist records this in one single medicatieafspraak with two dosing instructions and creates a verstrekkingsverzoek for 60 tablets of oxycodone of 10 mg.

4.1.7 The same medicinal product with different strengths at the same time

The same 79-year-old patient (see paragraph 4.1.6) is experiencing even more pain. The specialist discontinues the 10 mg tablets of oxycodone on Octobr 16 and prescribes 20 mg retard tablets of oxycodone, 2 tablets 3x daily, and 20 mg normal release tablets of oxycodone as needed in case of nocturnal pain, 1 tablet 1x daily. The specialist records this in two medicatieafspraken (with, for the time being, two separate medicamenteuze behandelings) and creates a verstrekkingsverzoek for both medicatieafspraken, respectively 45 retard tablets of 20 mg oxycodone and 30 tablets of 20 mg oxycodone (normal release).

4.1.8 Explanation in medicatieafspraak with deliberately chosen special characteristic

This use case is described in the ZIB medicatieafspraak/additional information. Here it is described for information purposes only. When selecting a medicinal product, it is possible to deviate from what is expected or standard. For example, when a hospital uses a different formulary than a public pharmacy. For reasons of efficiency the hospital has opted for a single gastric acid inhibitor: pantoprazole.
At admission, a patient with omeprazole is switched to pantoprazole for the duration of the hospitalization. At discharge, the patient returns to omeprazole.
It is clear that this may sometimes go wrong and that the patient might end up taking both omeprazole and pantoprazole if nothing is done. In the medicatieafspraak of the hospital for pantoprazole, a remark can be made about this deviation in order to make it clear that pantoprazole is the replacement of omeprazole or that it has to be used in addition to omeprazole.

Half-strengths are another example. The hospital sometimes disposes of tablets with half the strength of the normal commercial preparation (proprietary production). When a patient enters the hospital with a prescription of 25 mg of chlorthalidone, half a tablet 1x daily, he will receive 12.5 mg of chlorthalidone, 1 tablet 1x daily. In this specific case, this means that nursing staff does not have to break tablets in half. There is a risk that the patient will use the 25 mg again at home, but now a whole tablet at the time. An explanation in the medicatieafspraak (additional information) regarding the last 25 mg of chlorthalidone, makes it possible to indicate whether this was a deliberate increase.

If a prescribed product has to be a very specific commercial product, this can be indicated with ‘Medische Noodzaak’.

4.1.9 New medicatieafspraak, no verstrekkingsverzoek

A 50-year-old man comes to the general practitioner with back problems. The symptoms have been present for three weeks and he is already using paracetamol. The general practitioner agrees with the patient that he can additionally use diclofenac:

On 30 January it was agreed:

Diclofenac tablet, 50 mg, 1 tablet 3x daily, from now on for 3 weeks.

He records this medicatieafspraak in his system. The patient indicates there is sufficient supply at home: his wife still has an ample supply of diclofenac left because of a different problem a year ago.

A verstrekkingsverzoek is therefore not needed and the pharmacist also does not dispense any medication.
The general practitioner makes the new medicatieafspraak available to any fellow healthcare providers of this patient. This allows the regular pharmacist to inform himself about this new medicatieafspraak.

Another example: Mr Simons receives medication from the pharmacy weekly. In the past there were many requests for extra medication, which led to clear agreements about the dispense policy.

This is about:

Medicatieafspraak: Diazepam, 5 mg, 1 tablet 4x daily, from 1 January 2012 for an indefinite period

Verstrekkingsverzoek: 28 tablets with 10 repeats; remark: weekly medicatieverstrekking

The verstrekkingsverzoek is repeated approximately every 11 weeks. The last verstrekkingsverzoek was on 3 March 2016:

one week (28 tablets) with 10 repeats

This way, the pharmacy can go on for 11 weeks.

The last few years have been quiet. Mr. Simons is no longer asking for extra medication. At the last consultation he indicated that diazepam, 3x daily, is sufficient. This has been recorded in a medicatieafspraak:

1 April 2016 Diazepam, 5 mg, 1 tablet 3x daily, from 1 April 2016 for an indefinite period.

The previous medicatieafspraak will be terminated as of 31 March 2016 (see discontinuation of medication in paragraph 2.2.5).

In the current situation, the general practitioner would have called the pharmacy to make sure that 21 tablets of diazepam would be given with the following medicatieverstrekking, instead of 28. No new verstrekkingsverzoek would have been needed at the time.

In the new situation, the general practitioner sends the new medicatieafspraak to the pharmacy. Based on the new medicatieafspraak, the pharmacy provides 21 tablets per week, the previous verstrekkingsverzoek is still sufficient.

4.1.10 New verstrekkingsverzoek under existing medicatieafspraak

A prescriber may also create a new verstrekkingsverzoek as part of an existing medicatieafspraak. This medicatieafspraak may have been created by a different prescriber, for example a psychiatrist. This concerns repeat medication. This use case is described in paragraph 4.2.6.

4.1.11 Dosage change (sufficient supply)

Patient (37 years old, asthma) visited the pulmonologist on 13 August 2013 for a check-up of his asthma. The pulmonologist has established that patient’s asthma is not adequately controlled.
The patient is currently using beclomethasone in accordance with a previously made and registered medicatieafspraak: on 10 June 2010 it was agreed:

Beclomethasone aerosol, 100 microgram/dose, inhaler; 1 inhalation 2x daily; from 10 June 2010 for an indefinite period.

On 13 August 2013, the pulmonologist agrees with the patient on a dosage increase:

Beclomethasone aerosol, 100 microgram/dose, inhaler; 2 inhalations 2x daily; from 13 August 2013 for an indefinite period; reason for adjustment: insufficient effect.

The previous medicatieafspraak of 10 June 2010 it is no longer valid: it is terminated (see Changing medication in paragraph 2.2.5). The patient still has a sufficient supply, a verstrekkingsverzoek is therefore not needed.

In case the patient has no more supply, a new verstrekkingsverzoek will be created.
The system of the pulmonologist makes the new medicatieafspraak available to the other healthcare providers of this patient. This modification is received by the pharmacist (fellow healthcare provider). The pharmacist processes the modification. The pharmacist may also choose to accept the modifications automatically.

4.1.12 Prescription no longer needed after first verstrekkingsverzoek

A 16-year-old woman has a boyfriend and does not want to become pregnant. After explanation she opts for the pill. The general practitioner prescribes ethinylestradiol/levonorgestrel tablets of 20/100 µg, 1 tablet 1x daily for 21 days, then no tablet for 7 days, then another 21 days of taking a tablet once a day. Start on the first day of the next menstruation. The general practitioner records the medicatieafspraak and creates a verstrekkingsverzoek for 63 coated microgynon 20 tablets. He explains to her that if she does not experience any problems, she can continue to get the pill via the pharmacy.
Three months later, the woman sends a request for repeat supply to the pharmacy. The pharmacy provides the product and communicates the medicatieverstrekking to the general practitioner.

4.1.13 Discontinuing medication

Patient (37 years old, asthma) visits the pulmonologist on 13 August 2013 for a check-up of his asthma. The patient is suffering from a side effect. The patient is currently using Beclomethasone in accordance with a previously made and registered medicatieafspraak. On 10 June 2010 it was agreed:

Beclometasone aerosol, 100 microgram/dose, inhaler; 1 inhalation 2x daily; from 10 June 2010 for an indefinite period.

On 13 August 2013, the pulmonologist agrees with the patient to discontinue the medication (medicamenteuze behandeling is discontinued). Medication verification is also applicable here. In addition, medication monitoring may also be relevant here, for example if gastroprotrective drugs are being used because of the use of the medication to be discontinued (the system will not always signal this automatically).
The pulmonologist records:

Beclometasone aerosol, 100 microgram/dose, inhaler; stoptype ‘definite’; from 13 August 2013. Because of a side effect.

This modification is received by the pharmacist (fellow healthcare provider). The pharmacist processes the modification. The pharmacist may also choose to accept the modifications automatically. The pulmonologist decides to also actively inform a fellow healthcare provider (such as a specialist) about this (part of the process step (actively) making available).
The system of the pulmonologist makes this information (agreement to discontinue) available to the other healthcare providers of this patient.

4.1.14 Temporarily halting/resuming medication

A patient is being treated with simvastatin (cholesterol-lowering agent): 40 mg, 1 tablet 1x daily, for an indefinite period. Because of a throat infection in combination with an allergy for the first antibiotic of choice, Clarithromycin, 250 mg, 1 tablet 2x daily (antibiotic) is prescribed for 1 week. During that week, simvastatin is temporarily halted because of an interaction.
The general practitioner records:

Simvastatin 40 mg; halt temporarily; for 1 week; reason: interaction

Clarithromycin, 250 mg; 1 tablet 2x daily; for 1 week (and a corresponding verstrekkingsverzoek)

The pharmacist is actively informed by the general practitioner about the temporary halt of simvastatin. A new medicatieafspraak is also created with which simvastatin is resumed after one week. The pharmacist will also receive the medicatieafspraak and the corresponding verstrekkingsverzoek for clarithromycin. See also Temporarily halting and resuming medication in paragraph 2.2.5.

4.1.15 Temporarily halting for an intervention

A 62-year-old man uses acetylsalicylic acid, 100 mg, 1 tablet 1x daily because of coronary disease. He has an intestinal polyp that must be removed. The general practitioner informs him that he should stop using acetylsalicylic acid three days before the intervention and resume the day after the intervention. The general practitioner records the temporary halt in a medicatieafspraak with an enddate 3 days before the intervention; stoptype ‘temporary’; reason for halting: ‘intervention’. In the (second) medicatieafspraak for presuming, 1 day after the intervention is used as the start date. The general practitioner actively informs the pharmacist and the gastroenterologist about the medicatieafspraken.
When the date of the intervention is unknown or uncertain, the explanation will indicate that the medication should be halted three days before the intervention and resumed one day later. The duration of the temporary halt is then 4 days. See also Temporarily halting and resuming medication in paragraph 2.2.5.

4.1.16 Substitution

Upon admission, home medication may be switched to medication from the hospital formulary. The existing (home medication) medicatieafspraak will then be discontinued and a new medicatieafspraak will be created under a new (institution medication) medicamenteuze behandeling (see also paragraph 1.3.3). This (institution medication) medicatieafspraak refers to the medicatieafspraak for the home medication. At discharge, the institutional medication is discontinued and, if necessary, the home medication under the previous or a new medicamenteuze behandeling will be restarted by creating a new medicatieafspraak that refers to the original medicatieafspraak for the home medication.

4.1.17 Paper prescription

The physician gives the patient a paper prescription^[19]. A paper prescription contains a medicatieafspraak and a verstrekkingsverzoek. The patient can use this prescription to pick up the medication from any pharmacist. The general practitioner does not inform the issuing pharmacist in this case. However, the process is actually the same: the activity ‘(actively) making available’ is now only ‘handled’ by the paper prescription in the hands of the patient. The supplying pharmacist will copy this paper medicatieafspraak and verstrekkingsverzoek in his own system and complete it with a toedieningsafspraak. The pharmacist may also retrieve the medicatieafspraak and verstrekkingsverzoek that were made available digitally and process them in his own system this way.
The system of the general practitioner makes the new medicatieafspraak and verstrekkingsverzoek available for fellow healthcare providers. When the system of the general practitioner has not made these available this may be because it concerns a toedieningsafpsraak without digitally available medicatieafspraak and verstrekkingsverzoek. The pharmacist will not make the medicatieafspraak and verstrekkingsverzoek obtained ‘from paper’ available because he is not he owner. Next to that, this could lead to, possibly only in the future, wrongful duplication of medicatieafspraken and verstrekkingsverzoeken.

4.1.18 Carrying out medication verification and evaluation of foreign or self-care medication medication

When medication cannot be found in the system (such as foreign medication and self-care medication), this medication will be recorded as medicatiegebruik (see paragraph 2.2.5).

4.1.19 Day treatment

An admission for day treatment is comparable with an outpatient consultation or an emergency admission during which the medication is supplied by the hospital pharmacist. In the case of admission for a day, extensive medication verification does not usually occur. In the case of admission for a day, the medication prescribed is recorded (often on the basis of protocols according to which verification is carried out afterwards) and administered.
For treatments with cytostatics, for example, there is a medicatieafspraak, but it is not always clear in advance when the medicatieverstrekking/administration takes place. Reason: treatments are often postponed and then supplied and administered later.

4.1.20 Starting with medication before admission

Prior to cataract surgery, Nevanac is started three days before the surgery. The eye drops are used until three weeks after surgery (a total duration of use of 24 days). The specialist creates a medicatieafspraak for Nevanac, 1 drop in the morning, for 24 days. When the date of the surgery is unknown or uncertain, the explanation may indicate that Nevanac should be started 3 days before surgery takes place.

4.1.21 Emergency admission

In the event of an emergency admission, extensive medication verification is not carried out beforehand as would normally be the case with clinical admissions. Agreeing on medication with the patient is also often not possible in the event of an emergency admission. Often, the patient is administered medication as soon as possible and verification only takes place afterward

4.1.22 Discharge

When a patient is discharged home, all clinical medication is discontinued. The medicamenteuze behandeling is evaluated during which it is decided which medication the patient will use after discharge:

Previous outpatient medication that was discontinued at admission is started again (new medicatieafspraak under previous or new medicamenteuze behandeling) with possible reference to medication from before admission.
Previous outpatient medication that was temporarily halted at admission (without substitution) is resumed using a new medicatieafspraak under the same medicamenteuze behandeling
New outpatient medication is agreed upon: as an outpatient replacement of clinical medication or as a new therapy (new medicamenteuze behandeling with possible reference to institutional medication)

See Chapter 2.2.4 for this. The medication overview and the medication data are (actively) made available.

4.1.23 Interim discharge

When a patient temporarily leaves the hospital/institution to go home, for example, for weekend leave, the clinical medication continues. In order to keep the patient’s own general practitioner informed, the medication overview is provided to the patient and the medication data are made available.

4.1.24 Discharge to another institution

In case of discharge to another institution, the medicamenteuze behandeling is evaluated (see Chapter 2.2.4 and paragraph 2.2.5). Medication overview and medication data are (actively) made available. The new attending physician evaluates the medicamenteuze behandeling and determines the institutional medication.

4.1.25 Do not dispense before

The prescribing physician creates a verstrekkingsverzoek on 14 April 2017, but wants to indicate in that same verstrekkingsverzoek the medicatieverstrekking may only take place on or from a later date, for example, 23 April 2017. This cannot be recorded in a structured manner in the verstrekkingsverzoek, but is included in the explanation (as free text).

4.1.26 Discontinuation of medication by third parties

Medication can be discontinued by the prescriber himself (see paragraph 4.1.13) but also by another prescriber. For example, the specialist can end medicatieafspraken made by a general practitioner that are up to date according to the system, but that turn out not to be, for example after medication verification. When a healthcare provider discontinues medication, he creates a new stop-MA. The healthcare provider cannot modify someone else’s medicatieafspraak, only create a stop-MA. He therefore actively informs the healthcare provider of the original medicatieafspraak about this change. The healthcare provider of the original medicatieafspraak modifies the end date in the existing medicatieafspraak. If required, this may also be automated by the system. This prevents the second healthcare provider from not having to produce data after a period of time because the production period has expired (also no stop-MA), while the healthcare provider of the original medicatieafspraak continues to produce it for no reason (without an end date).

4.1.27 Two PRKs in a single medicamenteuze behandeling

In certain circumstances, the pharmacy is allowed to select a different PRK for the toedieningsafspraak than is indicated in the medicatieafspraak made by a prescriber. If for instance a failure of the prescriber’s system would result in only the communication of the toedieningsafspraak, a subsequent prescriber will only have this toedieningsafspraak with the new PRK. The next prescriber will then probably assume that this PRK is also the PRK of the medicatieafspraak. A modification of the medicatieafspraak will then also result in a stop-MA (without referring to the original MA) and a new medicatieafspraak on the basis of this PRK. This means that there are now two medicatieafspraken with different PRKs under the same medicamenteuze behandeling. These two medicatieafspraken continue to exist. After any system failure, (the system of) the prescriber must check whether there have been changes and implement them, if necessary (see also paragraph 4.1.26).

4.1.28 Creating a medicatieafspraak after the fact

In emergency situations, for example, it may happen that the medicatieafspraak is only created after the medication has been dispensed or administered. This may lead to conflicting medicatieafspraken. This means that one or more medicatieafspraken must be discontinued in order to prevent the occurrence of parallel medicatieafspraken. The only exception for parallel medicatieafspraken is described in paragraph 1.3.3.

4.1.29 Parallel medicatieafspraken

See paragraph 1.3.3.

4.1.30 Single use

For medication meant for single use, only an end date is included in the period of use. An example would be a vaccination (for example, a tetanus shot) or a situation in which a patient should take a medication just once, for example 3 weeks before he leaves on holiday.

4.1.31 Provisional and final medication order

The prescriber at the clinic prescribes medication. This is recorded in a provisional medication order (the medicatieafspraak). The hospital pharmacist verifies this order and records it as a final medication order (the toedieningsafspraak). See also ^[3].

4.1.32 Inadvertently ‘outstanding’ medication or 'orphans'

In a transitional situation and in a situation where not every XIS is connected, medicatieafspraken for the same treatment may exist that have been created by different systems under different medicamenteuze behandelings. These medicatieafspraken should ideally be combined in a single medicamenteuze behandeling. This particularly applies to medication with an open end date, as this medication may have been discontinued under a different medicamenteuze behandeling. The medicatieafspraak therefore remains open, resulting in continued medicatieverstrekking. This is a so-called ‘orphan’ (a building block that has been registered, but in which, at a certain point, the healthcare provider no longer has an active role. However, his system continues to provide the building block, even if it has already been discontinued elsewhere). For medication with an end date, this problem will solve itself. Therefore, it is not necessary to take any action. When medication verification or medication assessment reveals that the medication is inappropriately still ‘open’, a stop-MA is created under the same medicamenteuze behandeling. The original prescriber is actively informed about this stop-MA and enters an end date for the medicatieafspraak in his own system. Depending on the supplier and the client’s wishes, setting this end date can be done automatically or through an intervention of the prescriber. See also paragraph 4.1.26.

4.1.33 Missing digital medicatieafspraak at admission

If no digital medicatieafspraak is available when medication verification is carried out, a new medicamenteuze behandeling is started by recording medicatiegebruik. When this use has to be discontinued, a stop-medicatieafspraak is created under the same medicamenteuze behandeling that refers to the recorded medicatiegebruik. If possible, the original prescriber (for example, general practitioner) and the pharmacy are actively informed about the discontinuation of this medication.

4.1.34 Own articles (90 million numbers)

It is possible to exchange a 90 million number. The condition is that within an organization a 90 million number once created may never be modified. During the exchange, the root OID (unique technical identification of the organization) in combination with the 90 million number ensures that it is unique compared to all 90 million numbers form other organizations. The substances that make up this article are included as ingredients in the medicatieafspraak (at least one ingredient), as is the case with magistrals.

4.1.35 Dosing with minimum interval

Medication can be prescribed at a fixed interval (for example: 2 tables every 6 hours). Prescribing medication with a minimum interval should be partly in free text. For example, if needed, a maximum of 3 times a day, a minimum of 6 hours between the intake moments: if needed, a maximum of 3 times a day is recorded in the standard way. The section “at least 6 hours between intake times” is recorded in free text as an Additional Instruction.

4.1.36 Verstrekkingsverzoek with number of repetitions

The prescriber makes a verstrekkingsverzoek with a medicatieafspraak in which she enters the number of repetitions. The prescriber hereby indicates to the provider that it may make additional provisions. The number of repetitions in combination with the quantity to be dispensed results in: (Number of repetitions + 1) X quantity to be dispensed. In case of “number of repetitions =3” and “quantity to be supplied = 30 pieces” the provider may provide 4 times 30 pieces (total 120 pieces). The number of repetitions in combination with the duration of use period results in: (number of repetitions + 1) x duration of use. The amount to be dispensed depends on the dosage. In case of “dosage = 3 x per day 2 pieces”, and “Duration of use period = 30 days” the provider may provide 180 pieces 4 times (6 pieces per day X 30 days = 180, 4 times = a total of 720 pieces).

4.1.37 Prescribing non-medicines

Non medicines can be prescribed from the G-standard at HPK level. For example, this could be an inhaler (Aerochamber, HPK 1915185) as an aid to prescribed aerosols. Non-medicinal products are not applicable for the medication overview or medication monitoring.

4.1.38 Send kidney function value in the prescription

A) Renal function value with a new prescription:
For the prevention of stroke, a patient (male, 65 years old) is prescribed Dabigatran for the first time. The patient has renal impairment and the prescriber has a recent renal function value available. Based on this renal function value, the prescriber deviates from the standard dose and makes a medicatieafspraak with a lower dosage of Dabigatran twice a day 1 capsule of 110 mg, starting from January 15, 2020. The prescriber also makes a verstrekkingsverzoek and sends the prescription (medicatieafspraak, verstrekkingsverzoek and the laboratory result of the renal function value) to the pharmacist.

B) Renal function value reason for a change:
A 70-year-old man was prescribed 1 tablet of metformin 500 mg 3 times a day a few days ago (medicatie afspraak and verstrekkingsverzoek). At the same time, the doctor initiated a blood test to determine the renal function value of the patient. The value was not yet known at the time of prescription. The blood test shows that renal function is impaired and gives reason to adjust the medicatieafspraak. The prescriber adjusts the dose on January 17, 2020 to 2 tablets metformin 500mg twice a day and discuss this with the patient. The new prescription (the 'technical' stop medicatieafspraak, new medicatieafsrpaak and the laboratory result of the renal function value) is sent to the pharmacy by the prescriber. Because the patient had already collected the medication and therefore has enough stock, no new verstrekkingsverzoek is sent along.

C) Renal function value due to drug:
The patient is prescribed Nitrofurantoin 100 mg, 1 capsule twice daily as a 5-day course due to a bladder infection and must start immediately on January 6, 2020. With this drug, the renal function value (if known and not older than 13 months) needs to be sent along. The prescriber has a renal function value available for this patient, but this does not lead to an adjusted dosage. The prescriber sends the prescription (medicatieafspraak, verstrekkingsverzoek and the laboratory result of the renal function value) to the pharmacist.

4.2 Use cases, Dispense

4.2.1 New medicatieafspraak, medicatieverstrekking of the same product

The patient is at the pharmacist on 27 January 2013 to collect his medication. The pharmacist opens the file of the patient and verifies the medication file. It is a new medicatieafspraak for this patient. The relevant information of the prescribing physician is displayed on the screen of the pharmacist.
Medicatieafspraak: Nitrofurantoin CR capsule, 100 mg, 1 capsule 2x daily, from now on for 5 days.
Verstrekkingsverzoek: Nitrofurantoin CR capsule, 100 mg; 10 capsules.
The pharmacist selects a product on the basis of the medicatieafspraak and other factors (such as the pharmacist’s stock and the preference policy of the healthcare insurer):
FURABID CR CAPSULE, 100 MG. The pharmacist carries out medication monitoring using the system, no (warning) signals are given.
The pharmacist carries out pharmaceutical care (compliance, education, et cetera) and agrees with the patient on how she will use the medication. This toedieningsafspraak on 27 January 2013 reads:
FURABID CR CAPSULE, 100MG; 1 capsule 2x daily; from now on for 5 days. The pharmacist provides the medication to the patient:
on 27 January 2013, FURABID CR CAPSULE, 100 MG; 10 capsules. The pharmacist actively informs the prescribing physician about the medicatieafspraak and the medicatieverstrekking.
The system of the pharmacist makes the new toedieningsafspraak and medicatieverstrekking available to the other healthcare providers of this patient.

4.2.2 New medicatieafspraak, more precise product specification

Here, the difference when specifying the product is that the toedieningsafpsraak and also the medicatieverstrekking deviates from the medicatieafspraak the patient has made with the prescribing physician. The process is otherwise the same as described in the previous paragraph.

Example
Medicatieafspraak: Nitrofurantoin capsule mga 100 mg, 1 capsule 2 times a day from today for 5 days.

The pharmacist specifies a different product:
Nitrofurantoine MC Actavis capsule 50 mg. The pharmacist agrees with the patient on how she will use the medication. This toedieningsafspraak on 27 January 2013 reads:
Nitrofurantoin MC CR capsule 50 mg, 1 capsule 2x daily, from now on for 5 days.
The pharmacist provides the medication to the patient:
on 27 January 2013, Nitrofurantoin MC Actavis capsule 50 mg; 20 pieces.

4.2.3 Medicatieafspraak wanted (informing prescriber)

The process of repeat medicatieverstrekking on the basis of an existing medicatieafspraak and possibly existing verstrekkingsverzoek and toedieningsafsrpaak occurs in case of repeat prescriptions and is described in paragraph 4.2.10, situation 2.

4.2.4 Medicatieafspraak gewenst (Informeren voorschrijver)

Example 1 - adjusting dosage:
For a 70-year-old patient with a creatinine clearance of 45 mL/min, the pharmacist enters an toedieningsafspraak for gabapentin tablets of 600 mg, 1 tablet 3x daily. Renal function has been recorded in the patient’s file at the pharmacy, and based on this a signal appears that the maximum dosage is 900 mg daily. The pharmacist sends the prescriber a proposed medicatieafspraak with an adjusted dosage of 300 mg, 3x daily, and the reason for this proposal (maximum dosage exceeded). The prescriber receives the proposed medicatieafspraak in hisEVSand sends an adjusted medicatieafspraak back to the pharmacist.

Example 2 – temporarily halting a medicinal product:
For a 50-year-old patient with on oral fluconazole as part of his current medication, the pharmacist enters an toedieningsafspraak for simvastatin. A message appears with the advice to consider temporarily halting simvastatin. The pharmacist can make a proposed medicatieafspraak for halting the simvastatin (stoptype ‘temporary’). See example 1 for further steps.

Example 3 – adding a medicinal product:
For a 55-year-old woman, the pharmacist enters an toedieningsafspraak for prednisone, 10 mg daily for three months. The patient is not using osteoporosis prophylaxis. A message appears with the advice to add a biphosphonate drug and to check whether the patient is taking calcium and vitamin D. If the patient is not, the pharmacist can make a proposed medicatieafspraak for these products. See example 1 for further steps.

PLEASE NOTE: it will depend on the situation whether it is useful to create an automated proposal for adjustment/addition of a MA. If the advice is complex, it may still be useful to phone and to consult instead of sending a digital proposal.
The proposed medicatieafspraak may help the prescriber to enter this change in the system. The latter is important when medicatieafspraken are consulted, for example, by service observation general practitioners.

4.2.5 Request and dispense

When a medicatieafspraak and verstrekkingsverzoek arrives at the pharmacy, it is processed by the pharmacy system as an intended medicatieverstrekking. This is called the request date, which is captured as the request date of the medication dispensing The date of dispensing is only registered at the moment of pick up or hand over of the medication. The pharmacist informs the prescriber about the handling of the prescription (toedieningsafspraak and/or medicatieverstrekking).

It is possible to create multiple dispensings under the same toedieningsafpsraak:

A verstrekkingsverzoek comes in with a medicatieafspraak with a one-year use period
There will be a first provision with a new toedieningsafspraak and a medication supply that is sufficient for, for example, a period of 4 months.

The second dispensing is performed based on the existing medicatieafpsraak, verstrekkingsverzoek and toedieningsafspraak (no new prescription or new administration appointment is needed). The new second medication dispensing (with new write-up date and the pre-existing associated toedieningsafspraak) is sent to the prescriber when the dispensing date is registered.

4.2.6 Patient requests repeat prescription via physician (reactive repeat)

A physician has previously diagnosed hypertension in a patient (57 years old) and has prescribed the patient medication for this. The patient uses this medication and the medication is running out. The patient makes a request to repeat the medication, for example through the repeat line, by phone, by email to the practice, counter/boxes, website, app or portal of the physician. The physician approves the repeat. This leads to a new verstrekkingsverzoek.
For example: The general practitioner makes, in the context of the medicatieafspraak of 30 March 2010:

Nifedipine CR 30 mg; 1 tablet 1x daily, from 30 March 2010 for an indefinite period

on 13 April 2013 a verstrekkingsverzoek to a pharmacist chosen by the patient:

Nifedipine, CR tablet, 30 mg; ‘for three months’.

In consultation with the patient, the prescriber can send the verstrekkingsverzoek with the corresponding medicatieafspraken and toedieningsafspraken as an order to a pharmacy of the patient’s choice. The prescriber also makes the new verstrekkingsverzoek available to fellow healthcare providers and the patient. The existing medicatieafspraken had already been made available.
The pharmacist receives the verstrekkingsverzoek together with the medicatieafspraak and processes it in accordance with the dispense process and starts with the pharmaceutical care process step.

When the patient, on the basis of an toedieningsafspraak or on the basis of his use asks for a repeat prescription, and the medicatieafspraak is not digitally available, the physician creates a new medicatieafspraak based on this toedieningsafspraakor the patient’s use of the medication. No reference is made to the existing medicatieafspraak in that case.

4.2.7 Patient requests repeat prescription via pharmacist (informing prescriber)

The patient requests a repeat medication from the pharmacist, for example through repeat line, by phone, email, counter/boxes, website, app or portal of the pharmacist.
The pharmacist sends a proposed verstrekkingsverzoek including a copy of the existing medicatieafspraak for authorisation to the prescriber. The physician evaluates the proposed verstrekkingsverzoek and approves it. He informs the pharmacist via the reply proposed verstrekkingsverzoek and sends a new verstrekkingsverzoek together with the current agreements to the pharmacist. The pharmacist continues the dispense process and starts with the pharmaceutical care process step.
If the prescriber does not provide a verstrekkingsverzoek, he informs the pharmacist via the answer proposed verstrekkingsverzoek.

4.2.8 Proactive repeat prescription by pharmacist (informing prescriber)

The patient has signed up in the past for proactive repeats and the pharmacist has registered this in his proprietary pharmacist information system (PIS). The repeat module of this system will generate a signal when a patient needs new medication. When a new verstrekkingsverzoek is needed, this is similar to the process described in the previous paragraph, only the trigger is not the patient but the pharmacist (or his system). Proactive repeats are also used for GDS, see paragraph 4.2.11.

4.2.9 Dispense based on an existing verstrekkingsverzoek

The patient submits a repeat prescription to the pharmacist. In this case, it is a request for medicatieverstrekking on the basis of an existing, still valid, verstrekkingsverzoek. See paragraph 4.2.10 situation (3).

4.2.10 Splitting a prescription

The patient has been using the same medication for a number of years, which means that the medicatieafspraak can be created for an indefinite period. The toedieningsafspraak is also valid for an indefinite period. In such a case, the patient can be given a prescription for a year. This single year prescription will be split into several prescriptions by the pharmacist. These split prescriptions are commonly called ‘repeat prescriptions’, even though strictly speaking this is not true.
There are three possible situations: 1) The patient returns to his attending physician still suffering from the same symptoms. The prescriber prescribes the same medication (in the case of an expired medicatieafspraak, a new medicatieafspraak is created with a new verstrekkingsverzoek and in the case of a medicatieafspraak that is still valid, only a new verstrekkingsverzoek is created).
2) Prescriber and patient initially agree on 90 tablets with 3 repeat prescriptions. The patient receives the first 90 tablets. The next time the patient visits the pharmacist, a medicatieverstrekking is made under the existing agreements.
3) Prescriber and patient initially agree on 360 tablets for one year. The pharmacist splits this into 4 separate occasions of medicatieverstrekking. The patient is initially dispensed 90 tablets and without a new verstrekkingsverzoek, can go to the pharmacist 3 more times to pick up another 90 tablets each time.
Situation 3 best describes the way in which a pharmacist splits a year prescription.

4.2.11 Starting and continuing a GDS

The following example shows the process for one medicinal product used by the patient for an indefinite period of time. The system of the general practitioner and the pharmacist contains (among other things) the following data on a patient:

The medicatieafspraak of 2 January 2013 reads: Metoprolol, CR tablet, 100 mg (succinate); 1x tablet daily; from 2 January 2013 for an indefinite period.
The toedieningsafspraak of 2 January 2013 reads: Metoprolol PCH retard, 100 CR tablets of 95 mg; 1x tablet 1x daily; from 2 January 2013 for an indefinite period.
This elderly patient is taking so much medication that he has problems overseeing it all: a potentially dangerous situation. On 6 February, the pharmacist and the general practitioner agree that the medicatieverstrekking of medicinal products to this patient will take place via GDS.
The GDS is started: the pharmacist sends a proposed verstrekkingsverzoek (a similar event to the current combined prescription or authorisation form).
The proposed verstrekkingsverzoek of 6 February reads:
Verstrekkingsverzoek for the medicatieafspraak of 2 January 2013: Metoprolol, CR tablet, 100 mg (succinate), and a period of use to ensure enough stock up to and including 1 May 2013.
The pharmacist sends the proposal to the general practitioner. The general practitioner approves the proposal on February 6 and sends it unchanged to the pharmacist as a verstrekkingsverzoek. The GDS indicator is switched on in the system of the general practitioner as well as in the pharmacist’s system.
The pharmacist and the patient select a partial duration for the product. This toedieningsafspraak reads as follows:
On 7 February it was agreed: Metoprolol PCH retard, 100 CR tablets of 95 mg, 1 tablet in the morning, from 11 February (week 6), for an indefinite period.
Every second week, the pharmacist dispenses a Baxter medication roll containing (among other things) the metoprolol:
Medicatieverstrekking 1: The pharmacist dispenses, on Friday, 8 February 2013: 14 tablets, scheduled for weeks 6 and 7 (a period of use of 2 weeks).
Medicatieverstrekking 2: The pharmacist dispenses, on Friday, 22 February: 14 tablets, scheduled for weeks 8 and 9.
Medicatieverstrekking 3, 4, 5, etc.
With each medicatieverstrekking, it is indicated that medicatieverstrekking was carried out via GDS.

After three months, there is a new proposed verstrekkingsverzoek from the pharmacy to the general practitioner, etc.

Consideration

The application of a proposed verstrekkingsverzoek instead of an authorisation form makes its meaning unambiguous.
In the current situation, toedieningsafspraken and medicatieverstrekkingen are registered as a single dispense. This makes it difficult to find useful information in the large number of messages. By dividing the dispense order into two building blocks, the overview is easier to understand: there are no new medicatieafspraken and only one new toedieningsafpsraak is created. There are no hidden surprises in the remaining logistical data and the general practitioner does not have to monitor the multiple medicatieverstrekkingen.
This way of registering and exchanging prevents double registration, and errors caused by this.
The toedieningsafspraken are the basis for the administration list and checklists of nursing homes and care homes. Signing them corresponds to the administration(s).

4.2.12 The pharmacist changes commercial product

This scenario builds on the previous scenario: after half a year a different commercial product is agreed with the patient (toedieningsafspraak), because the original product is not available. No new medicatieafspraak is made, as there is no change needed on that level. The toedieningsafspraak is changed:

On 1 July it was agreed: Metoprolol Sandoz ret, 100 CR tablets, 95 mg, 1 tablet in the morning; from 3 July, for an indefinite period. Reason: not available.

The toedieningsafspraak is a modification of the toedieningsafspraak of 7 February, which stops on 2 July (11:59 p.m.) and is an actual handling of the medicatieafspraak of 2 January. The pharmacist informs the general practitioner about this.

Consideration
This change in the actual handling of the medicatieafspraak using an toedieningsafspraak, changes nothing to the validity of the medicatieafspraak itself, improving the overall view for all parties. In addition, since the pharmacist records and communicates the reason for the adjustment, the prescriber is better able to assess whether the information is relevant.

4.2.13 Adding medication to a GDS

When new medication is added to an existing GDS, the prescriber may opt for immediate addition to the current medicatieverstrekking roll (Change in GDS immediately) or for addition starting from the next roll (Change in GDS per change of roll). The prescriber indicates this in the medicatieafspraak (additional information). If ‘Modification in GDS when rolls are changed’ is chosen, the pharmacist will first dispense the medication separately, in addition to the existing GDS. This means that a toedieningsafspraak is created by the pharmacist for the bridging period. Starting with the new roll, the new medication is added to the roll. Starting with the start date of the new roll, a toedieningsafspraak can be made by the pharmacists with specific administration times. If the ‘bridging-toedieningsafspraak’ already includes the correct administration times, no new toedieningsafspraak is created at the date of inclusion in the roll.

4.2.14 Discontinuing medication in a GDS

When medication is discontinued, the prescriber creates a discontinuation-medicatieafspraak. In accordance with the process, the pharmacist is informed about this stop-MA and can adjust the medicatieverstrekking accordingly. The pharmacist will create a staken toedieningsafspraak . See paragraphs 2.2.5.3 and 2.3.6.3.

4.2.15 GDS supplier supplies other commercial product

It is possible that a GDS supplier delivers a different commercial product than that which is included in the toedieningsafspraak by the pharmacy. This is therefore a change in the HPK which results in a changed toedieningsafpsraak. This may only be afterwards, after feedback from the GDS supplier of the filling details.

4.2.16 Handling a medication discontinuation agreement

When the prescriber agrees to discontinue medication, a discontinuation medicatieafspraak is created. This stop-MA this processed by the pharmacist by discontinuing the corresponding toedieningsafspraak.

4.3 Use cases, Administer

4.3.1 Double check

For a number of high-risk medicinal products (for example, insulin, anticoagulants, oral cytostatics, all parenterals) the medicatietoediening and/or any preparations are checked by another person (from a legal point of view this should be a random passer-by, but in practice this is often a nurse) than the person who has prepared the medication. This is also entered in the administration list. The pharmacist ensures that medications that have to be double-checked are marked in the administration list. When the medicatietoediening is made available, the information of the double check on the medicatietoediening is also provided.

4.3.2 Administering without medicatieafspraak or toedieningsafspraak

Sometimes, medicatietoediening is carried out on the basis of an oral medicatieafspraak. In such cases, the prescriber/pharmacist records the medicatieafspraak toedieningsafspraak, only after the medicatietoediening. In other cases a medicatieafspraak has been made, but no toedieningsafspraak exists yet. In such a case, the pharmacist only records the toedieningsafspraak after the medicatietoediening.
In the case of a single medicatietoediening without toedieningsafspraak, the administrator must carry out an allergy check as well as a dosage check.

4.4 Use cases, Use

4.4.1 Self-care product

A patient has acquired Ibuprofen from the drugstore and takes 1200 mg every day. The patient enters this product as gebruik, with such data as starting dates and dosage, and possibly the reason for use.

4.4.2 Medication from abroad

A patient has been prescribed medication on holiday and is taking this. The patient enters the medication as gebruik, with data such as start date and dosage, and possibly the reason for use. If known, the name of the prescriber and the pharmacist are also recorded.

4.4.3 Modification on the patient’s initiative

The patient has been prescribed propranolol. The patient is having severe problems sleeping because of this and has reduced the medication herself. The patient records gebruik with the modified dosage and the start date for this lower dose. The patient also indicates that she initiated this change herself.
In the case where a patient initiates a dose reduction, the patient can keep on using the medication for a longer period than initially agreed because she still has a supply. The patient can indicate this as additional gebruik.
In the case where a patients initiates a dosage increase, the patient’s supply may run out sooner. The patient may then have to return to the physician earlier than expected.

4.4.4 Discontinuation of medication on the patient’s initiative

Since he started using propranolol, the patient suffers from insomnia. He decides to stop without immediately informing the prescribing physician. The patient himself records that he has discontinued medication, indicating the date and giving insomnia as the reason for discontinuing.

4.4.5 No more supply

A patient has received medication ‘as needed’ for his skin problems. The medication is still active in the medication profile, but is no longer available at the pharmacist. The patient indicates that the medication has been discontinued because it is no longer available, possibly with the addition that the symptoms have disappeared. The patient may also make a proposed verstrekkingsverzoek to replenish his supply In this case, the reply proposed verstrekkingsverzoek comes back to the patient (and if approved, a verstrekkingsverzoek is also sent from the prescriber to the pharmacist).

4.4.6 Feedback to patient through a medication adherence app

In this example the patient uses an app on his mobile phone to help manage his medication. The patient or the pharmacist has created an administration schedule with reminder times (where possible using the app to obtain the toedieningsafspraken from the medicatietoediening). When it is time to take his medication, the patient receives a reminder signal from the app. The patient then records in the app whether or not he has taken his medication (for instance because he forgot to bring it along with him). If the app is linked, for example, to the patient’s PGO [personal health file, medication adherence is tracked automatically.

4.4.7 Registration of side effects by the patient

Since he started taking propranolol, a patient has been suffering from insomnia. The patient records this side effect in the explanatory notes to the medicatiegebruik. When the patient changes the use of this medication from what was previously agreed, for example when he takes less tablets, he can give the side effect as a reason for this change. When his symptoms diminish or cease, the patient records this in the explanation for medicatiegebruik.
It is possible that the patient is suffering from side effects without exactly knowing which medicinal products cause them. There is no provision within medication process to record this (yet).

4.4.8 Register usage based on provision

This applies in the transition period from the old medication process standard 6.12 to this medication process information standard.

Only verstrekking (dispensing) is available digitally (according to medication process version 6.12). However, the user's system offers the possibility to record all medication use. In that case, the medication use can be recorded with reference to the ID of the version 6.12 verstrekking.

5 Medication overview and inference rules

This chapter shows a sample medication overview and also specifies inference rules for 'The most current relevant building block', Verification for each medicamenteuze behandeling, etc.

5.1 Inleiding

The term 'current medication overview' has been replaced by the term 'basisset medicatiegegevens’ (basic set of medication data): the medication overview in combination with additional information that is required (at least) to be able to prescribe, change, stop or safely provide medication in a safe and responsible manner in the Transfer of Medication Data in the Chain (Leidraad Overdracht van Medicatiegegevens in de keten, final draft 2017).

This page contains an example of a medication overview. This example was developed in the Medication Process Information Standard program and serves as an example of how data can be displayed in an application. The data numbered in the pictures below are normative, they are mandatory to show. The other (unnumbered) data in the example is optional and may be added as normative in the future. The layout of the overview in a system can differ per target group and per device. For pharmacists, for example, only toedieningsafspraken are initially visible, after which it is possible to click further to get to the corresponding medicatieafspraak and the medicatiegebruik. If only medicatiegebruik or a medicatieafspraak is known, this will of course be shown immediately. The basic principle is that the overview shows all medication of the patient, not just the medication that is registered in the patient's own system.

The overview is described generically and therefore the same for all suppliers. The requirements of the end users are included on this page and no statements are made about the technical realization or implementation. The existing KNMP specification “User requirements specification Medication overview 2.0”, final concept “Guidance Transfer of Medication data in the chain (Leidraad OVerdracht van Medicatiegegevens in de keten)” and the new insights from the Medication process program have been incorporated in this.

Principles for the overview are:

Healthcare providers want to see a distinction between the therapeutic building blocks on a medication overview:
- Medicatieafspraak
- Toedieningsafpsraak
- Medicatiegebruik
Logistical building blocks (verstrekkingsverzoek, dispensing) and the medicatietoedieningbuilding block are not relevant for the medication overview.

5.2 Functional specification

In the figures below the parts with normative data are included. The other parts are not yet normative. The numbered elements in the table are normative, other elements are optional for the time being.

5.2.1 Heading and General

Filter: N/A

Sort: N/A

Medication Overview Date: This is the date that the last change to a medicatieafspraak, toedieningsafspraak or medicatiegebruik was recorded within the system providing the medication overview.

NOTE: In the viewer, all dates are shown with the month in characters, so that there is no confusion between day-month and month-day (American format).

Nr	Kop	Dataset	Toelichting
1	Naam	Patient – Naamgegevens (Initialen, Geslachtsnaam, GeslachtsnaamPartner), Geboortedatum, Geslacht
2	Telefoon	Patient – Contactgegevens – Telefoonnummers	Door patiënt als preferent opgegeven telefoonnummer
3	BSN	Patient – Patientidentificatienummer	Altijd BSN
4	Adres	Patient – Adresgegevens
5	Naam zorgaanbieder	Zorgaanbieder – Organisatienaam	Zorgaanbieder die het medicatieoverzicht heeft samengesteld
6	Zorgaanbieder Adres	Zorgaanbieder – Adres – Adresgegevens
7	Zorgaanbieder Telefoon	Zorgaanbieder – TelefoonMail – Contactgegevens – Telefoonnummers
8	Zorgaanbieder Email	Zorgaanbieder – TelefoonMail – Contactgegevens – Emailadressen
9	Datum medicatieoverzicht	Documentgegevens – Documentdatum
	Lengte	Lichaamslengte – LengteWaarde, LengteDatumTijd
	Gewicht	Lichaamsgewicht – GewichtWaarde, GewichtDatumTijd
	Gecontroleerd door zorgverlener	Documentgegevens – Verificatie zorgverlener
	Geverifieerd met patient/mantelzorger	Documentgegevens – Verificatie patient

Elements 5 through 8 are not shown if the patient is the creator of the medication summary.

5.2.2 Intolerances, contraindications, allergies (ICA)

Active intolerances, contraindications and allergies.

Filter: end date is not filled, is in the future or was less than a year ago when compiling the overview.

Sort: most recent effective date at the top . This part will be elaborated at a later time and is not yet normative.

5.2.3 Current medication

Filter: all current medication, i.e. all medicatieafspraken and toedieningsafspraken that apply at the time the overview is compiled and the associated medicatiegebruik per source. The temporarily interrupted medication is also shown in this category. When only medicatiegebruik is known, it is shown if it is not older than three months. When medicatiegebruik is recorded by both a healthcare provider and a patient, the last registered medication use is shown for both.

Sorting: by medicamenteuze behandeling (MBH): medicatieafpsraak, toedeiningsafsrpaak, medicatiegebruik (recorded by patient, care provider). Medicatmenteuze behandelingen are sorted in descending order by starting date medicatieafspraak, toedieningsafspraak, mediatiegebruik.

Nr	Kop	Dataset
1	Type	Medicatieafspraak	Toedieningsafspraak	Medicatiegebruik
2	Geneesmiddel	Afgesproken geneesmiddel-	Geneesmiddel bij Toedieningsafspraak-	Gebruiksproduct-
2	Geneesmiddel	Product – ProductCode (als afwezig: ProductSpecificatie, ProductNaam)
3	Ingangsdatum	Ingangsdatum
4	Einddatum/Duur	Einddatum (als afwezig: Duur)
5	Dosering	Gebruiksinstructie – Omschrijving
6	Toedieningsweg	Gebruiksinstructie – Toedieningsweg
7	Reden	Reden van voorschrijven & evt. Reden van staken/onderbreken	Reden van staken/onderbreken	Reden van staken/onderbreken
8	Toelichting	Toelichting & Aanvullende Informatie		Toelichting
9	Bron	Voorschrijver-	Verstrekker-	Auteur-
		Zorgverlener – Zorgverlenernaam, Specialisme
		n.v.t	n.v.t	of "Patient"

5.2.4 Future medication

Filter: all medication that will become actual in the next 3 months. This includes intended medication use. For a description of the mapping, the same applies as with the current medication, see Current medication.

5.2.5 Recently discontinued medication

Filter: any medication that has ended or stopped in the past 2 months.

For a description of the mapping, the same applies as with the current medication, see Current medication.

5.2.6 Additional lab values

Most recent lab values and abnormal kidney function values.

This part will be elaborated at a later time and is not yet normative.

5.2.7 Remarks

For example, relevant (limited) health skills (competences: literacy, calculation and digital skills) that can have an impact on medication use / treatment.

This part will be elaborated at a later time and is not yet normative.

5.3 Building block instantiations

This section describes which instantiations of the building blocks belong to the medication overview. This concerns 'own' and 'other people's' building blocks (section 3.1) and then only the latest, relevant instantiations of this (section 3.2).

5.3.1 Own and other people

Both the own and a copy of (known to the sender) building blocks from other sources are included in the medication overview. This so that the medication overview is as complete as possible for the recipient. This ensures that recipients can start using it immediately and that they are not dependent on other sources. The technical representation of someone else's building block may differ from that of the real source. It is important that the recipient is aware of this. The original OID of someone else's building block should simply be given. The recipient can then choose to also collect the building block from its source in its original form.

The medicatieafspraak, toedieningsafspraak and medicatiegebruik building blocks have been extended with a feature that indicates whether:

there is an 'own' building block or
that of "someone else" (an accent building block: MA’, TA’, MGB’)

This attribute only applies in the medication overview transaction, because that is the only transaction where other people's building blocks may be delivered.

The 'building block of someone else' attribute is on two levels:

The template ID of an MA’, TA’, MGB’ differs from an MA, TA and MGB.
In addition, the element copy indicator is always sent with value true in MA’, TA’, MGB’.

For the medication overview, it is permitted to offer the medicatieafspraken, toedieningsafspraken and medicatiegebruik via a system-generated MGB or MGB '(Healthcare provider is author MGB). This must have a reference to an MA, TA or MGB.

5.3.1.1 Medication overview and derivation rules

An overview of medication that the patient is using (or should be using) can be put together in a system in two ways:
1) displaying a current medication overview (or overviews) obtained from another source (or sources)
2) showing coherent medication building blocks obtained from one's own system and from other sources.
In both cases, this overview of medication consists of the information as included in the building blocks medicatieafspraak, toedieningsafspraak and medicatiegebruik.

Re 1) When this document refers to a current medication overview, this means a coherent overview in which current medicatieafspraken, toedieningsafspraken and medicatiegebruik are included. This current medication overview is built up by the source on the basis of the data known at that time at the source. This overview can be exchanged with the transaction group Medicatieoverzicht (Medication overview) (PULL or PUSH).

The data and building blocks that are known at the source, but originating from another source, are supplied in the transaction with the 'accent' indicator so that they are recognizable as building blocks from someone else (MA accent, TA accent, MGB accent).

Re 2) It is also possible for a system to compile an overview by combining own and other people's separate individual medication building blocks. The transaction group Medicatiegegevens (medication data) (PULL) is used to request individual building blocks.

With the transaction group Medicatiegegevens (medication data) (PUSH), separate building blocks can also be sent directly to another healthcare provider or the patient (so without requests). This happens, for example, at discharge or at the request of a co-practitioner who has the patient in front of him (e.g. patient appears to a GP or pharmacist outside the region, where this GP or pharmacist requests the data by telephone from the patient's own GP and receives it digitally).

Both Medicatiegegevens (medication data) PUSH and PULL should not provide data obtained from other sources.

5.3.2 Last relevant

Only the last relevant building blocks (per medicamenteuze behandeling) are part of the medication overview. This section describes what exactly those last relevant building blocks are for a medication overview. Firstly for prescription medication (section 3.2.1), then for "over the counter" medication (section 3.2.2). The following section 3.2.3 further discusses the special situation that, in addition to a current, a future medicatieafspraak within the same medicamenteuze behandeling is valid. Finally, the last paragraph summarizes the rules to be applied.
Note: The (technical) stop-medicatieafspraken are not shown in the examples, but are implicitly assumed.

5.3.2.1 Prescription medication

5.3.2.1.1 Most simple "happy flow"

In a medicamenteuze behandeling, the simplest "happy flow" results in a sequence of:

Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik.

Usually, medicamenteuze behandeling (drug treatment) starts with a medicatieafspraak. A toedieningsafspraak concretely completes the medicatieafspraak. Medicatiegebruik says something about the actual use of the patient in this medicamenteuze behandeling. All three building blocks are relevant in such a case and are part of the delivery of a medication overview, as indicated in green below.

Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik.

A toedieningsafspraak refers to the medicatieafspraak he enters. If no referral is available in the toedieningsafspraak, the appointment date (administration appointment) must be later than that of the medicatieafspraak to be relevant to delivery.
Medicatiegebruik can refer to a medicatieafspraak or toedieningsafspraak. If no referral is available in the medicatiegebruik, the registration date (medicatiegebruik) must be later than that of the medicatieafspraak to be relevant for delivery.

5.3.2.1.2 New medicatieafspraak in medicamenteuze behandeling

If you create a new medicatieafspraak in an existing medicamenteuze behandeling (drug treatment), the currently existing medicatieafspraken, toedieningsafspraken and records of medicatiegebruik are no longer relevant for the medication overview. The idea is that all older building blocks than the current medicatieafspraak are by definition "overruled" by this new medicatieafspraak and consequently no longer relevant for the medication overview.

Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik - Medicatieafspraak

If a toedieningsafspraak and possibly also medicatiegebruik are created and available following such a medicatieafspraak medication appointment, these will be included in the medication overview.

Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik – Medicatieafspraak – Toedieningsafspraak
Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik – Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik

5.3.2.1.3 Medicatiegebruik earlier than toedieningsafspraak

It is possible that you have registered medicatiegebruik before the toedieningsafspraak has been made. Here too, the idea is that the newer toedieningsafspraak "overrules" the older registration of toedieningsafspraak and medicatiegebruik. The older medicatiegebruik is therefore no longer relevant for the medication overview.

Medicatieafspraak – Medicatiegebruik
Medicatieafspraak – Medicatiegebruik – Toedieningsafspraak

Of course, a new record of medicatiegebruik can then be made, which is also relevant for the medication overview.

Medicatieafspraak – Medicatiegebruik – Toedieningsafspraak - Medicatiegebruik

5.3.2.1.4 New toedieningsafspraak

Sometimes you make a new toedieningsafspraak under an existing medicatieafspraak. For example, because another product must be provided (as a result of preference policy or stock). In that case, too, such a new toedieningsafspraak may overrule older medicatieafspraken and medicatiegebruik.

Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik - Toedieningsafspraak

Of course you can then record medicatiegebruik, which is also relevant for the medication overview.

Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik – Toedieningsafspraak - Medicatiegebruik

5.3.2.2 Over the counter

Sometimes a patient uses medication for which there is no prescription. This applies, for example, to painkillers such as paracetamol or ibuprofen, which are available without a prescription. We call this “over the counter” medication. Such use of "over the counter" medication can be recorded with the medicatiegebruik building block. This is also relevant for the medication overview.

Medicatiegebruik

A new record of medicatiegebruik by the same type of author (type of author is patient or healthcare provider) "overrules" any older records of medicatiegebruik. Elaborated below, in order of registration date:

Medicatiegebruik - Medicatiegebruik

When a prescriber decides to formalize this medicamenteuze behandeling with a medicatieafspraak the rules as described above apply. Elaborated below, in order of appointment date (medicatieafspraak or toedieningsafspraak) / registration date (medicatiegebruik):

Medicatiegebruik – Medicatiegebruik – Medicatieafspraak
Medicatiegebruik – Medicatiegebruik – Medicatieafspraak - Medicatiegebruik
Medicatiegebruik – Medicatiegebruik – Medicatieafspraak – Toedieningsafspraak - Medicatiegebruik
Medicatiegebruik – Medicatiegebruik – Medicatieafspraak – Medicatiegebruik - Toedieningsafspraak - Medicatiegebruik
Medicatiegebruik – Medicatiegebruik – Medicatieafspraak - Medicatiegebruik - Medicatiegebruik

5.3.2.3 Future medicatieafspraken and toedieningsafspraken

A medicamenteuze behandeling may include more than one topical medicatieafspraak and toedieningsafspraak. Namely one for the current situation and one or more for the future situation. This section describes an example with one current and one future. For clarity, the future building blocks have a “T-” in the examples. Both current and future building blocks are relevant for the medication overview. The building blocks for toedieningsafspraak and medicatiegebruik must have adequate references to either the current or future appointment. Below are three examples, in order of appointment date / registration date (if these are equal, then sorted by period of use):

Medicatieafspraak – T Medicatieafspraak
Medicatieafspraak – Toedieningsafspraak – T Medicatieafspraak – T Toedieningsafspraak
Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik – T Medicatieafspraak – T Toedieningsafspraak – T Medicatiegebruik

Suppose that the toedieningsafspraak changes because the provider provides a different strength (2x 500mg tablets instead of 1x 1000mg tablets) and the patient still has enough stock for two weeks based on the first toedieningsafspraak:

Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik – T Toedieningsafspraak – T Medicatiegebruik

5.3.2.3.1 New medicatieafspraak

If you make a new medicatieafspraak in this situation, you always make a (technical) stop-medicatieafspraak. This stop-medicatieafspraak has two manifestations:
1) with reference to a specific medicatieafspraak that you stop
2) without a referral, and with that you stop the entire medicamenteuze behandeling (drug treatment)

Ad 1) Stop medicatieafspraak for one current medicatieafspraak. With this stop medicatieafspraak you stop one specific medicatieafspraak. You also make a new one for that medicatieafspraak. Suppose you only want to change the current medicatieafspraak, then this applies to the examples above, in order of appointment date:

Medicatieafspraak – T Medicatieafspraak – Medicatieafspraak
Medicatieafspraak – Toedieningsafspraak – T Medicatieafspraak – T Toedieningsafspraak – Medicatieafspraak
Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik – T Medicatieafspraak – T Toedieningsafspraak – T Medicatiegebruik – Medicatieafspraak

Suppose you only want to change the future medicatieafspraak, then this applies to the examples above, in order of appointment date:

Medicatieafspraak – T Medicatieafspraak – T Medicatieafspraak
Medicatieafspraak – Toedieningsafspraak – T Medicatieafspraak – T Toedieningsafspraak – T Medicatieafspraak
Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik – T Medicatieafspraak – T Toedieningsafspraak – T Medicatiegebruik – T Medicatieafspraak

Ad 2) Stop medicatieafspraak for the entire medicamenteuze behandeling. With this stop medicatieafspraak you stop all existing (current and future) medicatieafspraken in the medicamenteuze behandeling. If you now want to make a medicatieafspraak for the future in addition to a current one, you must also make it again. Elaborated below for the same three examples as above, in order of appointment date.

Medicatieafspraak – T-Medicatieafspraak – Medicatieafspraak – T Medicatieafspraak
Medicatieafspraak – Toedieningsafspraak – T-Medicatieafspraak – T-Toedieningsafspraak – Medicatieafspraak – T Medicatieafspraak
Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik – T-Medicatieafspraak – T-Toedieningsafspraak – T Medicatiegebruik – Medicatieafspraak – T Medicatieafspraak

5.3.2.3.2 New toedieningsafspraak

However, you can also make a new toedieningsafspraak for the current medicatieafspraak only. This new toedieningsafspraak must then have a reference to that current medicatieafspraak. Elaborated below for three examples, in order of appointment date.

Medicatieafspraak – T Medicatieafspraak – Toedieningsafspraak
Medicatieafspraak – Toedieningsafspraak– T-Medicatieafspraak – T Toedieningsafspraak – Toedieningsafspraak
Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik – T Medicatieafspraak – T-Toedieningsafspraak – T Medicatiegebruik – Toedieningsafspraak

A new toedieningsafspraak with a reference to the future medicatieafspraak looks like this.

Medicatieafspraak – T Medicatieafspraak – Toedieningsafspraak – T-Toedieningsafspraak
Medicatieafspraak –Toedieningsafspraak – T-Medicatieafspraak – T Toedieningsafspraak – T Toedieningsafspraak
Medicatieafspraak –Toedieningsafspraak – Medicatiegebruik – T Medicatieafspraak – T Toedieningsafspraak – T Medicatiegebruik – T-Toedieningsafspraak

5.3.2.4 Rules of overruling listed

Based on the above description / examples, the following general rules for overruling can be derived. This concerns the rules for determining whether a building block is relevant for delivery in the medication overview. Within a medicamenteuze behandeling:

A new medicatieafspraak overrules all older building blocks (medicatieafspraak, toedieningsafspraak, medicatiegebruik) belonging to the medicatieafspraak /medicatieafspraken that this medicatieafspraak has stopped.
A new toedieningsafspraak overrules all older building blocks of the type of toedieningsafspraak or medicatiegebruik that belong to the same medicatieafspraak as the new toedieningsafspraak.
In principle, a new record of medicatiegebruik overrules (see exception below) older records of medicatiegebruik that belong to the same medicatieafspraak as the new medicatiegebruik.
- Exception to this rule: medicatiegebruik with the author as a patient DOES NOT overrule an older record of medicatiegebruik with the care provider as author and vice versa. Both are therefore relevant to the medication overview.

The latter exception applied to a number of situations:

Deze laatste uitzondering toegepast op een aantal situaties:

Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik-ZVL – Medicatiegebruik-PAT
Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik-PAT – Medicatiegebruik-ZVL
Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik-PAT – Medicatiegebruik-PAT
Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik-ZVL – Medicatiegebruik-PAT – Medicatiegebruik-PAT
Medicatieafspraak – Toedieningsafspraak – Medicatiegebruik-ZVL – Medicatiegebruik-PAT – Medicatiegebruik PAT – Medicatiegebruik-ZVL

5.4 Verification by medicamenteuze behandeling

A healthcare provider records verification per medicamenteuze behandeling with the medicatiegebruik building block:

Author = Healthcare provider
Possible informant: the patient, a care provider or another person
Possible characteristic "according to agreement": according to the author, is the medicatiegebruik in accordance with the medicatieafspraak or toedieningsafspraak?
Possible link to medicatieafspraak or toedieningsafspraak:
- Medicatieafspraak or toedieningsafspraak that has been the reference for recording this use.
- When it is indicated "by appointment", this is the medicatieafspraak or toedieningsafspraak according to which the patient uses.

Such a record of medicatiegebruik means: "I think the patient uses this drug as follows: ... ..".

Known: it is not currently provided in the information standard to indicate that a medicatieafspraak or toedieningsafspraak is correct, regardless of whether the patient uses it as such.

5.5 Proces van het medicatieoverzicht uitwisselen

Naast de inhoud en de verificatie is ook het proces rondom het medicatieoverzicht van belang.

5.5.1 Wie, wanneer, met welke informatie

De betrouwbaarheid en de compleetheid van een medicatieoverzicht hangt af van:

wie het heeft samengesteld,
op welk moment en
met welke basisinformatie.

Daarover kunnen we afspraken maken, bijvoorbeeld:

een medicatieoverzicht pas uitwisselen/beschikbaar stellen zodra deze enige vorm van betrouwbaarheid heeft
- na een expliciete actie van een zorgverlener of
- automatisch als aan bepaalde voorwaarden is voldaan.
medicatieoverzicht volledig automatisch uitwisselen/beschikbaar stellen zonder voorwaarden
medicatieoverzicht volledig automatisch beschikbaar maken zonder dat een nieuwe gegevenssoort nodig is (dus bij aanmelding van één van de andere medicatie gegevenssoorten ben je automatisch ook bron voor een medicatieoverzicht).

5.5.1.1 Besluit

Bovenstaande vragen zijn nog niet beantwoord. Besloten is dat tijdens de Proof-Of-Concept alle partijen die een medicatieoverzicht kunnen opleveren dit ook doen.

5.5.2 Verantwoordelijkheden opvrager en bron

De opvrager krijgt medicatieoverzichten uit meerdere bronnen. Het verwerken hiervan is de verantwoordelijkheid van de ontvanger. De actualiteit van een medicatieoverzicht is hierbij van belang.
Actie: de transactie medicatieoverzicht moet de meest recente datum bevatten van de verzameling van beschikbare afspraakdatums/registratiedatums van de opgeleverde instantiaties van bouwstenen. De samensteller (bron) van het medicatieoverzicht moet deze datum dus opleveren. Dit helpt de ontvanger om de actualiteit van het medicatieoverzicht beter in te schatten.

5.5.3 Afspraken vervolg

Met de uitkomsten van de Proof-Of-Concept vervolgen we de analyse om te komen tot een goed proces voor het medicatieoverzicht.

5.6 Afleidingsregels

Het is van belang dat iedere partij de arts, apotheker, verpleging en ook de patiënt uit de medicatiebouwstenen kan opmaken wat de bedoeling is (c.q. wat de actuele afspraken zijn). Die bedoeling mag niet per systeem verschillen. Daarom moeten systemen volgens dezelfde afleidingsregels de actuele situatie kunnen berekenen.

De actuele therapeutische situatie wordt berekend aan de hand van zowel medicatie- als toedieningsafspraken. Toedieningsafspraken hebben een relatie met de medicatieafspraak die zij concreet invullen. Toedieningsafspraken zijn daardoor te koppelen aan de medicatieafspraak die zij invullen.
Het medicatiegebruik is uiteraard ook zinvol om te weten. Het geeft echter niet weer wat de bedoeling van de zorgverlener is, maar wat de patiënt heeft gebruikt. Onderstaande regels nemen daarom niet het ‘gebruik’ mee. Het gebruik is wel onderdeel van een medicatieprofiel maar wordt apart getoond onder de betreffende medicamenteuze behandeling.

5.6.1 Effectieve periode

De effectieve periode bestaat uit een effectieve ingangsdatum en een effectieve einddatum.

De effectieve periode beschrijft de periode waarin een medicatie- of toedieningsafspraak (uiteindelijk) geldt /van toepassing is.

De effectieve periode is afhankelijk van aanpassingen (wijzigen / staken / onderbreken / hervatten) van medicatie en door de ‘concrete invulling’ van een medicatieafspraak door een toedieningsafspraak. De effectieve periode is niet beschreven in de dataset, omdat het een afgeleid gegeven is dat alleen wordt gebruikt om de actuele situatie te bepalen. De effectieve ingangsdatum, effectieve einddatum en effectieve periode zijn geen gegevens om aan de eindgebruiker te tonen.
Medicatie voor onbepaalde duur heeft een effectieve einddatum die in de toekomst ligt, maar op een (nog) niet af te leiden moment. Het is alleen bekend dat hij 'ergens' in de toekomst ligt.

5.6.2 Actuele en huidige medicatie

Actuele (medicatie– en toedienings)afspraken: de afspraken waarvan de effectieve einddatum in de toekomst ligt.
Huidige (medicatie– en toedienings)afspraken: de afspraken waarvan het heden tussen de effectieve ingangsdatum en de effectieve einddatum ligt.
Actuele medicatie: de verzameling van actuele (huidige en toekomstige) medicatie- en toedieningsafspraken en het actuele gebruik. Voorbehoud hierbij is dat nooit met zekerheid te zeggen is in hoeverre de patiënt zich aan de afspraken houdt en het daadwerkelijk gebruik meldt.

5.6.3 Uitwerking

Aanpak
Aan de hand van een aantal situaties worden de afleidingsregels beschreven om te komen tot de effectieve therapeutische periode in een medicatieprofiel:

1) Medicatie starten

2) Maken toedieningsafspraak

3) Medicatie wijzigen

4) Medicatie definitief stoppen

5) Medicatie tijdelijk onderbreken en hervatten

Hieronder worden de afleidingsregels beschreven. Het nummer bij iedere afleidingsregel staat voor de volgorde waarin de regels moeten worden uitgevoerd.

1) Medicatie starten
Medicatie wordt gestart door het maken van een nieuwe medicatieafspraak. De medicatieafspraak kent een:

Afspraakdatum - de datum waarop de afspraak is gemaakt met de patiënt.
Gebruiksperiode - de periode bestaat uit:
- ingangsdatum - de ingangsdatum van de medicatieafspraak kan in de toekomst liggen;
- gebruiksduur;
- einddatum - tot wanneer geldt de medicatieafspraak.

1a: De effectieve periode van een nieuwe medicatieafspraak is gelijk aan diens gebruiksperiode

2) Maken toedieningsafspraak
Een toedieningsafspraak vult een medicatieafspraak concreet in. In zekere zin, door de ogen van de patiënt gezien, zou je kunnen zeggen dat een toedieningsafspraak een medicatieafspraak vervangt. Dat is immers dichter bij wat hij zou moeten gebruiken.

Afleidingsregel 1 wordt uitgebreid:

1b: De effectieve periode van een nieuwe toedieningsafspraak is gelijk aan diens gebruiksperiode

Afleidingsregel 2 is van toepassing als een medicatieafspraak onderliggende toedieningsafspraken kent (zie afleidingsregel 2b voor nadere toelichting):

2a: De effectieve periode van een medicatieafspraak is gelijk aan de effectieve periode van de onderliggende toedieningsafspraak.

3) Medicatie wijzigen

a) Door een medicatieafspraak

De voorschrijver wijzigt medicatie (c.q. de medicamenteuze behandeling) door het maken van een nieuwe medicatieafspraak (en het beëindigen van de bestaande) binnen een bestaande medicamenteuze behandeling.
Doordat de ingangsdatum van een medicatieafspraak in de toekomst kan liggen kunnen er meerdere medicatieafspraken tegelijk actueel zijn. Bijvoorbeeld wanneer een medicatieafspraak geldt ‘voor onbepaalde duur’ (ma1) en er wordt afgesproken over twee weken de dosering te wijzigen (ma2) blijft de eerste medicatieafspraak (ma1) nog twee weken geldig, daarna gaat de tweede medicatieafspraak (ma2) in. De voorgaande afleidingsregels veranderen hierdoor niet.

b) Door een toedieningsafspraak

Een medicatieafspraak wordt concreet ingevuld door een toedieningsafspraak. Op deze toedieningsafspraak kan een wijziging plaatsvinden. Bijvoorbeeld wanneer deeltijden veranderen (wanneer GDS wordt geïnitieerd), of wanneer er van handelsproduct wordt gewijzigd (door bijvoorbeeld een preferentiebeleid). Er kunnen dus meerdere achtereenvolgende toedieningsafspraken onder één medicatieafspraak worden gemaakt. Daarom wordt regel 2 uitgebreid zodat effectieve periode van de medicatieafspraak wordt bepaald door de gehele reeks onderliggende toedieningsafspraken.

2b: Wanneer er meerdere toedieningsafspraken onder een medicatieafspraak gemaakt worden dan is de effectieve ingangsdatum van de medicatieafspraak gelijk aan de meest vroege ingangsdatum van de onderliggende toedieningsafspraken en de einddatum van de laatste toedieningsafspraak.

Er kunnen parallelle toedieningsafspraken onder één medicatieafspraak zijn waarvan de afspraakdatum en ingangsdatum gelijk zijn. Beide zijn dan tegelijk geldig en daarmee wijzigt regel 2b niet.

In onderstaande figuur is een zeer eenvoudig voorbeeld opgenomen van een actueel profiel samengesteld uit de verschillende bouwstenen. De patiënt-, verificatie-, ICA- en labgegevens zijn in dit overzicht geheel buiten beschouwing gelaten. Er is verder een zeer beperkt aantal gegevens opgenomen om vooral de werking van de effectieve periode te tonen. Regels met een ‘-‘ zijn detailregels en kunnen desgewenst ‘ingeklapt’ worden in het medicatieprofiel. In de eerste regel is de effectieve periode getoond voor de onderliggende ma en ta’s. Daaronder is ook gebruik zichtbaar, deze heeft geen invloed op de berekening van de effectieve therapeutische periode in de eerste regel.

4) Medicatie definitief stoppen
Het stoppen van medicatie (c.q. medicamenteuze behandeling) gebeurt door het maken van een medicatieafspraak, waarin stoptype 'definitief' is aangegeven. De ingangsdatum van deze medicatieafspraak is de datum waarop de originele medicatieafspraak inging. De einddatum is de datum waarop de medicatie gestopt wordt. De effectieve periode van de originele medicatieafspraak is daarmee vervangen door de effectieve periode van deze nieuwe stop-ma.

1c: Wanneer een medicatieafspraak gestopt wordt dan is de effectieve periode van de medicatieafspraak de effectieve periode van de stop-ma.

Een stop-toedieningsafspraak kan een stop-medicatieafspraak concreet invullen. Zo kan bijvoorbeeld worden uitgedrukt dat het stoppen ingaat met de volgende GDS uitgifte.

5) Medicatie tijdelijk onderbreken en hervatten
Het onderbreken van medicatie gebeurt op dezelfde wijze als medicatie stoppen. Er wordt een stop-ma gemaakt (stoptype 'tijdelijk') met dezelfde ingangsdatum als de originele medicatieafspraak. De einddatum van de stop-ma is het moment van tijdelijk onderbreken, het stoptype is 'tijdelijk'. Hervatten gebeurt door een medicatieafspraak te maken met de oude (of aangepaste) dosering waarbij de ingangsdatum de hervattingsdatum is. Een aansprekende reden (bijvoorbeeld: hervat eerder gemaakt beleid) kan e.e.a. verduidelijken. Als niet hervat wordt kan 'medicatie stoppen (stoptype 'definitief')' worden uitgevoerd om de medicamenteuze behandeling definitief te beëindigen waarmee het niet meer actuele medicatie is. Medicatie die onderbroken wordt blijft actueel zodat deze op het medicatieprofiel zichtbaar blijft.

1d: Wanneer medicatie tijdelijk wordt onderbroken wordt de effectieve periode daardoor niet beïnvloed. De effectieve periode wordt bepaald door de effectieve periode van de originele medicatieafspraak.

Deze afleidingsregels vormen de basis voor het bepalen van de actuele afspraken. Er zijn uitzonderingssituaties denkbaar die gerelateerd zijn aan het slechts deels beschikbaar hebben van medicatiegegevens. Deze zijn niet uitgewerkt. In de open-source beschikbare medicatie-viewer zijn alle afleidingsregels opgenomen en geïmplementeerd.

5.7 Gegevens die niet getoond hoeven te worden

Diverse gegevens zijn belangrijk voor het correct kunnen verwerken van informatie, maar zijn voor de eindgebruiker niet relevant:

Een applicatie hoeft niet de (technische) identificatie van een MBH te tonen (noch die van de bouwstenen zelf), maar wel de uitwerking daarvan: namelijk in samenhang getoonde bouwsteen instantiaties.
De kopie-indicator bij de MA, TA en MGB bij het raadplegen van medicatieoverzicht. Of een bouwsteen een kopie betreft, is voor een gebruiker niet zo belangrijk en kan afgeleid worden door andere gegevens uit die bouwsteen (zoals auteur van de bouwsteen). Het is dus niet zo belangrijk dat een gebruiker kan zien dat dit 'als kopie' is opgeleverd en vermoedelijk alleen maar verwarrend. Voor leveranciers is dit gegeven echter wél belangrijk, bijvoorbeeld omdat zij soms met de gegevens willen rekenen en het dan veiliger is om het gegeven bij de échte bron op te halen. Het ligt daarom voor de hand om in je systeem wél bij te houden of je het gegeven van de échte bron hebt ontvangen.
Een applicatie hoeft niet het stoptype (tijdelijk/definitief) van een stop-afspraak te tonen, maar wel de uitwerking daarvan: namelijk het verwerken van de betekenis, waardoor een gehele MBH als gestopte medicatie getoond wordt of als onderbroken medicatie (blijft inzichtelijk onder huidige medicatie) of als een wijziging in geval van een 'technische stop-afspraak'.

6 Systemen en transacties

Dit hoofdstuk bevat een opsomming van alle systeemrollen en transacties. In de verschillende proceshoofdstukken wordt hiernaar verwezen.

Onderstaande figuur (Figuur 10) bevat een overzicht van alle systemen met hun bijbehorende systeemrollen. De systeemrollen zijn beschreven in de daaronder opgenomen Tabel 3. De systeemrollen die betrekking hebben op raadplegen/beschikbaarstellen van medicatiegegevens en medicatieoverzicht zijn voor alle systemen van belang al naar gelang het proces waarin zij gebruikt worden. Het elektronisch voorschrijfsysteem (EVS) heeft daarnaast de systeemrollen voor het ontvangen van een voorstel verstrekkingsverzoek, het versturen van een antwoord voorstel verstrekkingsverzoek en het ontvangen van een voorstel medicatieafspraak en in de ambulante situatie voor het versturen van een voorschrift en het ontvangen van een vervulling van het voorschrift. Een XIS en PGO hebben naast de generieke systeemrollen ook de systeemrollen voor het versturen van een voorstel medicatieafspraak en voorstel verstrekkingsverzoek en het sturen van gebruik en ontvangen antwoord voorstel verstrekkingsverzoek. Een apotheekinformatiesysteem heeft naast de basis systeemrollen ook de rollen voor sturen van voorstel medicatieafspraak, voorstel verstrekkingsverzoek en afhandeling voorschrift en het ontvangen van een voorschrift en antwoord voorstel verstrekkingsverzoek. In hoofdstuk 2 zijn de belangrijkste systeemrollen per proces benoemd.

Naam systeemrol	Afk.	Omschrijving
MedicatieGegevensBeschikbaarstellend	MP-MGB	Beschikbaarstellen medicatiegegevens aan medebehandelaars/patiënt
MedicatieGegevensRaadplegend	MP-MGR	Raadplegen medicatiegegevens bij medebehandelaars/patiënt
MedicatieGegevensSturend	MP-MGS	Sturen medicatiegegevens aan medebehandelaar/patiënt
MedicatieGegevensOntvangend	MP-MGO	Ontvangen medicatiegegevens van medebehandelaar/patiënt
MedicatieOverzichtBeschikbaarstellend	MP-MOB	Beschikbaarstellen medicatieoverzicht aan medebehandelaars/patiënt
MedicatieOverzichtRaadplegend	MP-MOR	Raadplegen medicatieoverzicht bij medebehandelaars/patiënt
MedicatieOverzichtSturend	MP-MOS	Sturen medicatieoverzicht aan medebehandelaar/patiënt
MedicatieOverzichtOntvangend	MP-MOO	Ontvangen medicatieoverzicht van medebehandelaar/patiënt
VoorschriftSturend	MP-VOS	Sturen verzoek tot medicatieverstrekking van medicatie of verwerking van wijziging in medicatieafspraak
VoorschriftOntvangend	MP-VOO	Ontvangen verzoek tot medicatieverstrekking van medicatie of verwerking wijziging in medicatieafspraak
VoorschriftAfhandelingSturend	MP-VAS	Sturen afhandeling van de medicatieafspraak en evt. verstrekkingverzoek in toedieningsafspraak en/of medicatieverstrekking
VoorschriftAfhandelingOntvangend	MP-VAO	Ontvangen afhandeling van de medicatieafspraak en evt. verstrekkingverzoek in toedieningsafspraak en/of medicatieverstrekking
ToedienGegevensSturend	MP-TGS	Sturen gegevens ten behoeve van medicatietoediening
ToedienGegevensOntvangend	MP-TGO	Ontvangen gegevens ten behoeve van medicatietoediening
GebruikSturend	MP-MGS	Sturen medicatiegebruik
GebruikOntvangend	MP-MGO	Ontvangen medicatiegebruik
VoorstelVerstrekkingsverzoekSturend	MP-VVS	Informeren voorschrijver over voorstel tot nieuw verstrekkingsverzoek, ontvangen antwoord op voorstel verstrekkingsverzoek
VoorstelVerstrekkingsverzoekOntvangend	MP-VVO	Ontvangen voorstel tot nieuw verstrekkingsverzoek, sturen antwoord op voorstel verstrekkingsverzoek
VoorstelMedicatieafspraakSturend	MP-VMS	Informeren voorschrijver over voorstel tot nieuwe of gewijzigde medicatieafspraak
VoorstelMedicatieafspraakOntvangend	MP-VMO	Ontvangen voorstel tot nieuwe of gewijzigde medicatieafspraak

Tabel 3 Overzicht systeemrollen

In Tabel 4 is een overzicht opgenomen van alle transactiegroepen, transacties, bijbehorende systeemrollen en de bouwstenen die met deze transactiegroep worden uitgewisseld. De namen van de transactiegroepen en transacties linken naar de Art-decor publicatie waarin per scenario is uitgewerkt welke gegevenselementen daarin voorkomen.

Transactiegroep	Transactie	Systeemrol	Bouwstenen
Medicatiegegevens (PULL)	Beschikbaarstellen medicatiegegevens	MP-MGB	Eén of meer: ma, vv, ta, mve, mtd, mgb
Medicatiegegevens (PULL)	Raadplegen medicatiegegevens	MP-MGR	Eén of meer: ma, vv, ta, mve, mtd, mgb
Medicatiegegevens (PUSH)	Sturen medicatiegegevens	MP-MGS	Eén of meer: ma, vv, ta, mve, mtd, mgb
Medicatiegegevens (PUSH)	Ontvangen medicatiegegevens	MP-MGO	Eén of meer: ma, vv, ta, mve, mtd, mgb
Medicatieoverzicht (PULL)	Beschikbaarstellen medicatieoverzicht	MP-MOB	ma, ta, mgb
Medicatieoverzicht (PULL)	Raadplegen medicatieoverzicht	MP-MOR
Medicatieoverzicht (PUSH)	Sturen medicatieoverzicht	MP-MOS
Medicatieoverzicht (PUSH)	Ontvangen medicatieoverzicht	MP-MOO
MedicatieVoorschrift (PUSH)	Sturen medicatievoorschrift	MP-VOS	ma met of zonder vv, lengte, gewicht, nierfunctiewaarde
MedicatieVoorschrift (PUSH)	Ontvangen medicatievoorschrift	MP-VOO	ma met of zonder vv, lengte, gewicht, nierfunctiewaarde
MedicatieVoorschrift Afhandeling (PUSH)	Sturen afhandeling medicatievoorschrift	MP-VAS	ta met of zonder mve
MedicatieVoorschrift Afhandeling (PUSH)	Ontvangen afhandeling medicatievoorschrift	MP-VAO	ta met of zonder mve
Toediengegevens (PUSH)	Sturen toediengegevens	MP-TGS	ma en/of ta
Toediengegevens (PUSH)	Ontvangen toediengegevens	MP-TGO	ma en/of ta
Medicatiegebruik (PUSH)	Sturen medicatiegebruik	MP-GBS	mgb
Medicatiegebruik (PUSH)	Ontvangen medicatiegebruik	MP-GBO	mgb
Voorstel verstrekkingsverzoek (PUSH)	Sturen voorstel verstrekkingsverzoek	MP-VVS	vvv
Voorstel verstrekkingsverzoek (PUSH)	Ontvangen voorstel verstrekkingsverzoek	MP-VVO	vvv
Antwoord voorstel verstrekkingsverzoek (PUSH)	Sturen antwoord voorstel verstrekkingsverzoek	MP-VVO	avvv
Antwoord voorstel verstrekkingsverzoek (PUSH)	Ontvangen antwoord voorstel	MP-VVS	avvv
Voorstel medicatieafspraak (PUSH)	Sturen voorstel medicatieafspraak	MP-VMS	vma
Voorstel medicatieafspraak (PUSH)	Ontvangen voorstel medicatieafspraak	MP-VMO	vma

Tabel 4 Overzicht transactiegroepen

In hoofdstuk 2 zijn per proces alleen de relevante transacties per processtap aangegeven. Daarin zijn de transactiegroepen niet opgenomen. Bovenstaande tabel bevat alle transactiegroepen en transacties.

7 Functionaliteit

Dit hoofdstuk beschrijft aanwijzingen voor de functionaliteit van een informatiesysteem.

7.1 Filteren van medicatie uit 2e/3e lijn (alle systemen)

Een instelling stelt alle eigen medicatiegegevens (alle bouwstenen) beschikbaar. Deze gegevens zijn voor de ontvangende zorgverleners mogelijk niet allemaal relevant. De ontvangende systemen kunnen een filter opnemen afhankelijk van de behoefte van de betreffende zorgverlener/patiënt. Onderstaande lijst (Tabel 5) bevat typen medicatie waarvan benoemd is dat medicatietoediening tijdens de opname relevant is voor zorgverleners buiten de instelling.

ATC-groepscode	Naam
L01	Cytostatica
L03AX03	BCG-vaccin urologie
L04AA23; L04AA25; L04AA26; L04AA33; L04AA34; L04AB; L04AC	Immunosuppresiva
B03AC; B03XA; B06AC	IJzer, epo, middelen tegen angioedeem
G03GA; G03GB02	Gonadotropines (HCG etc), clomifeen
H01CA; H01CC; L02AE04	Gonadoreline, hypothalamus hormonen, triptoreline
J06; J07	Immunoglobulines, vaccins
M03AX01	Botox
R03DX05	Omalizumab
S01LA04; S01LA05; S01LA	Oogheelkundige anti neovasculaire stoffen

Tabel 5 Typen klinische medicatie relevant voor extramurale zorgverleners

7.2 Beschikbaarstellen medicatiegegevens (alle systemen)

Alle eigen medicatiegegevens mogen beschikbaargesteld worden wanneer de patiënt daarvoor toestemming heeft gegeven (conform vigerende wet- en regelgeving). Gegevens ontvangen van anderen (zorgverleners/patiënt) die men in het eigen systeem heeft overgenomen en aangemerkt als kopie worden niet beschikbaargesteld. De enige uitzondering is de transactie Medicatieoverzicht PUSH en PULL, daar worden bouwstenen van anderen beschikbaar gesteld mits zij voorzien zijn van de originele identificatie (zie ook paragraaf 5.1).

7.3 Aanschrijfdatum of verstrekkingsdatum (apotheekinformatiesysteem)

In de medicatieverstrekking kan zowel de aanschrijfdatum als de daadwerkelijke datum van uitgifte worden vastgelegd. Wanneer een verstrekkingsverzoek direct verwerkt wordt en de patiënt komt het nog dezelfde dag ophalen zijn beide datums gelijk. Wanneer de patiënt de medicatie één of meerdere dagen later komt ophalen dan moeten deze datums verschillend worden ingevuld. De verstrekkingsdatum is de datum dat de daadwerkelijke medicatie-uitgifte heeft plaats gevonden. De aanschrijfdatum is het tijdstip waarop een apotheker een voorgenomen uitgifte vastlegt. Wanneer er meerdere verstrekkingen worden gedaan onder hetzelfde verstrekkingsverzoek (bijv. bij knippen recept) dan heeft elke verstrekking een eigen aanschrijfdatum. Wanneer er gewerkt wordt met een uitgifte-automaat is de verstrekkingsdatum het tijdstip waarop de patient de medicatie uit de automaat haalt. Wanneer dit tijdstip niet beschikbaar is in het AIS mag tot die tijd ook het tijdstip worden gebruikt waarop de medicatie in de uitgifte-automaat wordt gelegd. Zie ook paragraaf 4.2.5 Aanschrijven, verstrekken en niet afhalen.

7.4 Bijwerken na systeemstoring

Na systeemuitval moet het systeem van de voorschrijver controleren of er wijzigingen zijn doorgevoerd in medicatieafspraken. Zie voor use cases en onderbouwing paragraaf 4.1.26 en paragraaf 4.1.27.

7.5 Constructie voor interval eenmaal per 36 uur

Wanneer de doseerinstructie luidt 1 tablet per 36uur kan dit normaliter in één medicatieafspraak worden weergegeven (keerdosis: 1 tablet, interval: 36uur). Maar wanneer een systeem niet verder gaat dan een interval van bijvoorbeeld 24 uur dan is er een andere oplossing nodig.

Variant 1: Gebruik maken van een Zo nodig instructie waarbij het criterium is: ‘er is 36 uur verstreken sinds de laatste medicatietoediening’. Maar dit levert een bepaalde mate van vrijblijvendheid die mogelijk niet gewenst is.

Variant 2: Er kan ook een repeterend schema worden gemaakt waarbij gewisseld wordt tussen ochtend en avond en een dag niet:

Herhaalperiode: 3 dagen 
Doseerinstructie
 Volgnummer: 1
 Doseerduur: 1 dag
  Dosering
   Keerdosis: 1 stuks
   Toedientijd: 9uur (bijvoorbeeld, kan ook een dagdeel zijn)
 Volgnummer: 2
 Doseerduur: 1 dag
  Dosering
  Keerdosis: 1 stuks
  Toedientijd: 21uur (bijvoorbeeld, kan ook een dagdeel zijn)

Wanneer het systeemtechnische niet mogelijk is om een interval van 36uur te kiezen wordt variant 2 toegepast.

7.6 EVS/HIS verwerken Afhandeling voorschrift

Het voorschrijvende systeem wordt door de apotheker geïnformeerd over alle verstrekkingen en wijzigingen in toedieningsafspraken middels de transactie Afhandeling voorschrift. Deze afhandeling moet automatisch verwerkt worden in het voorschrijvende systeem. De voorschrijver beoordeelt alleen de toedieningsafspraken en hoeft niet alle verstrekkingen te beoordelen.

7.7 Voorbeelden doseringen

Zie Voorbeelden doseringen 9.1.0 (zowel functioneel als technische uitwerking in HL7v3 CDA én in FHIR)

7.8 Medicatiegebruik: gebruikindicator, volgens afspraak indicator, stoptype, gebruiksperiode en doseerinstructie

Gebruikindicator (wordt dit product gebruikt)	Ja	Ja	Nee	Nee	Ja
Situatie	1. Medicatie is/wordt in gebruiksperiode gebruikt volgens afspraak	2. Medicatie is/wordt in gebruiksperiode gebruikt maar niet volgens afspraak	3. In tegenstelling tot de afspraak is/wordt in gebruiksperiode de medicatie niet gebruikt	4. Medicatie is/wordt in de gebruiksperiode niet gebruikt en dat is ook volgens afspraak	5. Medicatie is/wordt in de gebruiksperiode gebruikt maar onbekend of dit volgens afspraak is of er is geen afspraak (zelfzorgmedicatie)
Volgens afspraak indicator	Ja	Nee	Nee	Ja	-
Stoptype	Nvt	Nvt	Definitief of Tijdelijk	Definitief of Tijdelijk	Nvt
			Stoptype afhankelijk of er gestaakt of onderbroken wordt	Stoptype conform de stop-afspraak
Gebruiksperiode	Conform ma of ta	Max. 2 van de 3	Max. 2 van de 3	Max. 2 van de 3	Max. 2 van de 3
ingangsdatum	Het tijdstip waarop het gebruik is gestart.	Het tijdstip waarop het afwijkende gebruik is/wordt gestart.	Het tijdstip vanaf wanneer gestaakt of onderbroken wordt.	Het tijdstip vanaf wanneer gestaakt of onderbroken wordt.	Het tijdstip waarop het gebruik is gestart.
gebruiksduur	De beoogde gebruiksduur.	De beoogde duur van het afwijkende gebruik.	De (beoogde) duur van het onderbreken. (nvt. voor staken)	De (beoogde) duur van het onderbreken. (nvt. voor staken)	De beoogde gebruiksduur.
einddatum	Het tijdstip waarop de gebruiksperiode eindigt (of geëindigd is of zal eindigen).	Het tijdstip waarop het afwijkende gebruik eindigt (of geëindigd is of zal eindigen).	Het tijdstip waarop het onderbreken eindigt en gebruik is/wordt herstart (of beoogd wordt te herstarten). (nvt. voor staken)	Het tijdstip waarop het onderbreken eindigt en gebruik is/wordt herstart (of beoogd wordt te herstarten). (nvt. voor staken)	Het tijdstip waarop de gebruiksperiode eindigt (of geëindigd is of zal eindigen).
Doseerinstructie	Conform ma of ta	Verplicht	Nvt	Nvt	Verplicht
	Medicatie is/wordt in gebruiksperiode gebruikt volgens afspraak	Medicatie is/wordt in gebruiksperiode niet gebruikt volgens afspraak, daadwerkelijk gebruikte dosering moet doorgegeven worden.	De medicatie is/wordt niet gebruikt, er is geen dosering.	De medicatie is/wordt niet gebruikt, er is geen dosering.	Dosering die patiënt met zichzelf heeft afgesproken.

VOORBEELDEN:
Situatie 1: Medicatie is/wordt in gebruiksperiode gebruikt volgens afspraak
Patiënt heeft Ferrofumaraat voorgeschreven gekregen tegen bloedarmoede. Dosering is 3x daags 1 tablet een half uur voor het eten innemen, met als startdatum 4 juni 2018 en zonder einddatum.
Op 10 juni registreert de patiënt het medicatiegebruik over de afgelopen periode (van 4 t/m 10 juni).

Situatie 1
Geneesmiddel	FERROFUMARAAT 100MG TABLET
Gebruiksindicator	Ja
Volgens afspraak indicator	Ja
Stoptype	nvt
Ingangsdatum	4 juni 2018
Einddatum	10 juni 2018
Doseerinstructie	Overeenkomstig de afspraak

Situatie 1: Medicatie is/wordt in gebruiksperiode gebruikt volgens afspraak
Patiënt heeft Ferrofumaraat voorgeschreven gekregen tegen bloedarmoede. Dosering is 3x daags 1 tablet een half uur voor het eten innemen, met als startdatum 4 juni 2018 en zonder einddatum.
Op 10 juni registreert de patiënt het medicatiegebruik en het voornemen om deze medicatie te blijven gebruiken volgens de afspraak.

Situatie 1
Geneesmiddel	FERROFUMARAAT 100MG TABLET
Gebruiksindicator	Ja
Volgens afspraak indicator	Ja
Stoptype	nvt
Ingangsdatum	4 juni 2018
Einddatum	-
Doseerinstructie	Overeenkomstig de afspraak

Situatie 2: Medicatie is/wordt in gebruiksperiode gebruikt maar niet volgens afspraak
Patiënt heeft Ferrofumaraat voorgeschreven gekregen tegen bloedarmoede. Dosering is 3x daags 1 tablet een half uur voor het eten innemen, met als startdatum 4 juni 2018 en zonder einddatum.
De patiënt is overdag veel op pad en vergeet een werkweek lang om telkens de medicijnen voor de lunch in te nemen. Wel worden de tabletten 's ochtends en 's avonds voor het eten ingenomen

Situatie 2
Geneesmiddel	FERROFUMARAAT 100MG TABLET
Gebruiksindicator	Ja
Volgens afspraak indicator	Nee
Stoptype	nvt
Ingangsdatum	11 juni
Einddatum	15 juni
Doseerinstructie	2x daags 1 tablet

Situatie 3: In tegenstelling tot de afspraak is/wordt in gebruiksperiode de medicatie niet gebruikt
Patiënt heeft Ferrofumaraat voorgeschreven gekregen tegen bloedarmoede. Dosering is 3x daags 1 tablet een half uur voor het eten innemen, met als startdatum 4 juni 2018 en zonder einddatum.
De patiënt gaat een lang weekend op vakantie en komt er te laat achter dat de medicatie niet ingepakt is. De komende paar dagen zal de patiënt de tabletten niet nemen en ze wil dit registreren.

Situatie 3
Geneesmiddel	FERROFUMARAAT 100MG TABLET
Gebruiksindicator	Nee
Volgens afspraak indicator	Nee
Stoptype	Tijdelijk
Ingangsdatum	20 juli
Einddatum	23 juli
Doseerinstructie	nvt

Situatie 4: Medicatie is/wordt in de gebruiksperiode niet gebruikt en dat is ook volgens afspraak
Patiënt heeft Ferrofumaraat voorgeschreven gekregen tegen bloedarmoede. Dosering is 3x daags 1 tablet een half uur voor het eten innemen, met als startdatum 4 juni 2018.
Op 12 augustus blijkt na controle dat er geen sprake meer is van bloedarmoede en de arts stopt de medicatie. De patiënt wil registreren dat ze gestopt is met de medicatie en registreert dit zelf op 15 augustus.

Situatie 4
Geneesmiddel	FERROFUMARAAT 100MG TABLET
Gebruiksindicator	Nee
Volgens afspraak indicator	Ja
Stoptype	Definitief
Ingangsdatum	12 augustus 2018
Einddatum	-
Doseerinstructie	nvt

Situatie 5: Medicatie is/wordt in de gebruiksperiode gebruikt maar onbekend of dit volgens afspraak is of er is geen afspraak (zelfzorgmedicatie)
Patiënt heeft de griep en hij neemt tegen de koorts en pijn paracetamol 500 mg van de plaatselijke drogist. Hij neemt inmiddels al vier dagen 4 tot 6 tabletten per dag en denkt dit nog drie dagen te zullen doen. Hij registreert dit op 12 augustus als medicatiegebruik.

Situatie 5
Geneesmiddel	Paracetamol 500mg
Gebruiksindicator	Ja
Volgens afspraak indicator	-
Stoptype	nvt
Ingangsdatum	9 augustus 2018
Duur	7 dagen
Doseerinstructie	4 tot 6 tabletten per dag

7.9 Implementatie geïndividualiseerde distributievorm (GDV)-velden

7.9.1 Achtergrond

Steeds meer patiënten ontvangen hun medicatie via geïndividualiseerde distributievormen (GDV), waarbij de apotheker overzicht en ordening voor de patiënt aanbrengt in diens geneesmiddelen door deze gereed te maken in afzonderlijke compartimenteenheden. Deze aflevervorm heeft met name een vlucht genomen toen de Geneesmiddelenwet in 2007 bepaalde dat in zorginstellingen zonder apotheek de medicatie voor de patiënten op naam gesteld dient te zijn.

Voor zorgverleners is het van belang om te weten of een patiënt een gebruikmaakt van GDV. In 2018 is geanalyseerd (onder regie van Z-Index, met zorgverleners) wat de knelpunten en wensen zijn rondom het vastleggen dat een patiënt gebruikmaakt van GDV. Daaruit is globaal naar voren gekomen dat het wenselijk is om zowel op medicatieniveau als op patiëntniveau te kunnen zien of een patiënt gebruik maakt van GDV. Voor de details zie volgende paragraaf.

Onderstaande aanwijzingen geven een handreiking hoe het Medicatieproces deze wensen kan ondersteunen.

7.9.2 Wensen zorgverleners

In 2018 is met de gebruikersraden van Z-Index geïnventariseerd wat de wensen rondom het vastleggen en uitwisselen van GDV is. Hieronder het overzicht van deze wensen.

Wie

Alle zorgpartijen (van voorschrijver t/m toediener)

Wat

Vastleggen/uitwisselen dat iemand gebruik maakt van GDV
Vastleggen waaróm iemand GDV patiënt is
Vastleggen/uitwisselen bij medicatie dat dit in de GDV moet
Vastleggen/uitwisselen wat de duur van een rol is
Uitwisselen of wijziging per direct is of bij volgende rolwissel

Waarom

Bepaalt welke apotheek aflevert
Apotheek moet weten of wijziging voor lopende rol geldt of niet
Van belang voor stoppen van eerdere medicatie bij starten van GDV
Evaluatie van GDV-patiënten voor zorgverzekeraar
Overige logistieke processen richting thuiszorg/mantelzorg

Wanneer

Bij starten van medicatie, in apotheek al voor aanschrijven recept
Bij overdracht 1e/2e lijn
Bij wijzigen (incl. stoppen) van medicatie
Bij wijzigen ICA-gegevens

Waar

Bij het werken in het dossier van de patiënt dient inzichtelijk te zijn dat dit kenmerk bij betreffende patiënt van toepassing is. Per soort zorgverlener kan dit een verschillende plaats zijn (patiëntendossier, medicatiedossier). De wens van openbaar apothekers is dat ze dit kenmerk altijd bij de patiënt inzichtelijk hebben.
Op medicatieoverzicht

7.9.3 Data-elementen Medicatieproces

De bouwstenen voor het Medicatieproces kennen de volgende velden die een rol spelen bij het vastleggen van GDV.

Bouwsteen	Data-element nr	Omschrijving	Soort inhoud
Medicatieafspraak	23283	Aanvullende informatie	Aanvullende informatie bevat een lijst van bijzonderheden over de gemaakte afspraak die van belang zijn voor de medicatiebewaking en invulling door de apotheker. Bijvoorbeeld: ‘wijziging in GDS per direct’.
Verstrekkingsverzoek	22759	Aanvullende wensen	Logistieke aanwijzingen van belang voor de invulling van het verstrekkingsverzoek door de apotheker. Bijvoorbeeld: ‘niet opnemen in GDS’
Verstrekking	20927	Distributievorm	Distributievorm. Bijvoorbeeld: GDS
	20924	Verbruiksduur	Voorraad voor deze duur
	22500	Aanschrijfdatum	De aanschrijfdatum is het tijdstip waarop een apotheker een voorgenomen uitgifte vastlegt
	20272	Datum	Het tijdstip van uitgifte. De datumtijd waarop het geneesmiddel ter hand gesteld wordt

7.9.4 Toepassing data-elementen ter ondersteuning gewenste functionaliteit voor GDV-patiënten

7.9.4.1 Vastleggen dát iemand gebruik maakt van GDV

Bij het werken in het dossier van de patiënt is het van belang om te zien dat iemand gebruik maakt van GDV. Dat geldt zowel voor de apotheek die de GDV levert, als andere zorgverleners van de patiënt. Daarom is het van belang dat dit gegeven kan worden gecommuniceerd naar en getoond aan andere zorgverleners.
Zolang er nog geen patiëntkenmerk is waarmee GDV vastgelegd kan worden, kan ervoor gekozen worden dit gegeven af te leiden uit de GDV-gegevens die bij de medicatie zijn vastgelegd. Een mogelijk handvat hiervoor is het feit dat medicatie in de distributiemodule is opgenomen tezamen met het veld Distributievorm in de verstrekking.

Stap 1: indien medicatie in de distributiemodule is opgenomen: vul het veld Distributievorm in de verstrekking met ‘GDS’.
Stap 2: op basis van het veld Distributievorm afleiden dat een patiënt gebruikmaakt van GDV. Het feit dat een patiënt enige verstrekking heeft waarbij het veld Distributievorm met ‘GDS’ is gevuld, geeft aan dat de patiënt gebruik maakt van GDV. Deze verstrekking kan een eigen verstrekking zijn, of een verstrekking ontvangen van een andere apotheek (voor zover deze gegevens worden binnengehaald en zodanig worden vastgelegd dat de inhoud van het veld Distributievorm herbruikbaar is). Het gegeven dat een patiënt gebruikmaakt van GDV, kan vervolgens getoond worden bij het werken in het medicatiedossier c.q. het patiëntendossier. In overleg met eindgebruikers dient nader bepaald te worden waar en hoe dit getoond wordt.

7.9.4.2 Vastleggen waaróm iemand gebruik maakt van GDV

Gebruikers hebben aangegeven dat het wenselijk is om te kunnen vastleggen waarom iemand gebruik maakt van GDV. Op dit moment zijn hier geen structurele velden voor beschikbaar.

7.9.4.3 Bij medicatie vastleggen dat dit in de GDV moet

Voorschrijvers willen kunnen aangeven of een middel al dan niet via GDV verstrekt dient te worden. Dit kan als volgt:

Verstrekkingsverzoek, veld Aanvullende wensen. De codelijst voor dit veld bevat het item ‘niet in GDS’. Deze codelijst is thesaurus 2051 van bestand 902 in de G-Standaard.

7.9.4.4 Vastleggen/uitwisselen wat de duur van een medicatierol is

De duur van de medicatierol kan worden bepaald op basis van de ‘verbruiksduur’ van de verstrekking: de ‘verbruiksduur’ geeft aan wat de loopduur van een medicatierol is.

7.9.4.5 Vastleggen/uitwisselen of een wijziging in de medicatie per direct moet of niet

Het is wenselijk dat een voorschrijver kan aangeven of wijzigingen in de medicatie per direct doorgevoerd moeten worden of dat deze kunnen wachten tot de volgende rolwissel. De handvatten hiervoor zijn als volgt:

Medicatieafspraak, veld Aanvullende informatie. De codelijst voor dit veld bevat twee items die betrekking hebben op wijzigingen in de GDV, namelijk ‘Wijziging in GDS per direct’ en ‘Wijziging in GDS per rolwissel’. Deze codelijst is thesaurus 2050 van bestand 902 in de G-Standaard.
Daarbij is het van belang dat de voorschrijver inzicht heeft in de duur van de rol en hoe lang het nog duurt voordat de huidige medicatierol op is. Dit is te herleiden uit:
- De verstrekking, veld Verbruiksduur, zie hierboven. Hiervoor dient het voorschrijfsysteem wel de beschikking te hebben over de verstrekkingsgegevens van eerdere verstrekkingen.
- Verstrekking, veld Aanschrijfdatum of Datum (of als niet dit veld gevuld is maar het veld Aanschrijfdatum, dan het veld Aanschrijfdatum; als beide zijn gevuld heeft Datum de voorkeur). Op basis van deze datum en de verbruiksduur, kan berekend worden per welke datum de huidige medicatierol is verbruikt.

8 Beschouwingen

8.1 Ongeadresseerd voorschrijven (ambulant)

In deze paragraaf wordt de term “prescriptie” gebruikt om het bericht waarmee een patiënt een geneesmiddel bij een verstrekker mag afhalen aan te duiden. Een prescriptie bevat een medicatieafspraak en een verstrekkingsverzoek.

In Nederland is het tot op heden gebruikelijk om prescripties digitaal te versturen naar een ontvangende apotheek in plaats van het ophalen van prescripties. Daarvoor is nodig, dat de apotheek al van te voren bekend is.
Dit heeft het risico, dat poliklinische recepten uit gemak altijd naar de poliklinische apotheek gaat en dat de patiënt niet meer bij de vertrouwde vaste apotheek kan halen.

Deze paragraaf is een beschouwing of er meer flexibiliteit in de logistieke afhandeling van prescripties te bereiken is, zonder de huidige voordelen teniet te doen. Deze paragraaf kan beschouwd worden als een lange termijn visie waar wij naar toe willen werken.

8.1.1 Uitgangspunten

In de afweging hoe wij flexibiliteit in de afhandeling kunnen bewerkstelligen zijn uitgangspunten geformuleerd. Deze zijn:

De patiënt heeft de keuzevrijheid van afhandeling.
De huidige verwerking van verzenden van prescripties blijft mogelijk.
Het systeem moet zoveel mogelijk dezelfde functionaliteit hergebruiken.
Een prescriptie mag maar éénmaal verstrekt worden.

Omdat de hieronder beschreven methodiek gebruik maakt van de bestaande methode van verzenden van prescripties, gelden dezelfde juridische regels over de geldigheid van de prescripties. Alle discussies over elektronische handtekeningen gelden evenzeer voor de huidige methode van communicatie van prescripties.

8.1.2 Uitwerking

Een patiënt kan kiezen uit 3 keuzemogelijkheden:

Een prescriptie wordt altijd naar een vaste apotheker verzonden.
De patiënt geeft per keer op waar de prescriptie naar toe verzonden wordt.
De patiënt geeft niets op en komt bij een apotheek die een prescriptie opvraagt en afhandelt.

Voor opties 1 en 2 is een patiënt portaal nodig, waarin de patiënt zijn voorkeur aangeeft. Bij optie 2 mag een patiënt een voorkeurapotheek definiëren, die boven aan in het selectiescherm zal staan als de patiënt gevraagd wordt, waarheen de prescriptie gestuurd moet worden. Als een patiënt niets opgeeft kan optie 3 de enige werkwijze zijn.

De methodiek maakt deels gebruik van een concept dat “publish en subscribe” heet.

Het is van belang, dat de apotheker aan zijn vaste klanten uitlegt hoe het principe werkt.

8.1.3 Werkproces

Een arts besluit een prescriptie te doen aan een patiënt. Dit kan bij een consult of zelfs bij aanvraag van herhaalreceptuur zijn. De arts registreert de prescriptie in zijn voorschrijfsysteem ( EVS). De arts hoeft zich niet te bekommeren om de apotheek, dat doet de patiënt immers via het portaal.

Na akkoord van de prescriptie wordt een centrale prescriptie-index bijgewerkt. Dit gebeurt automatisch door het EVS, die een aanmelding stuurt naar deze prescriptie register. In deze beschouwing wordt de prescriptie-index als een apart register beschouwd met de gegevenssoort “voorschriften”. Later kan altijd nog geëvalueerd worden of dit niet samengevoegd kan worden. In eerste instantie wordt ook gedacht aan een atomaire registratie in het register. Later kan overwogen worden of een categorale registratie niet toereikend is.

Het is belangrijk om te begrijpen, dat er op dit moment alleen nog maar gemeld wordt, dat een prescriptie klaar staat. De prescriptie is immers nog altijd bij het EVS in een database vorm met status “staat klaar”. Er is dus nog geen prescriptie bericht.

Het register systeem weet uit de voorkeurinstelling van de patiënt wat er met de aanmelding moet gebeuren:

Bij de keuze vaste apotheker van de patient wordt een signaal naar de ingevulde abonneehouder van de patiënt gestuurd met de melding, dat een prescriptie opgehaald kan worden.
Bij deze keuze stuurt het register systeem een signaal (bijv. SMS) naar de patiënt. Vervolgens wacht het register systeem totdat de patiënt via een app op de smartphone of via het patiëntportaal ingeeft naar welke apotheek het signaal verzonden moet worden.
Bij deze optie doet het register systeem niets. De patiënt heeft geen vaste abonneehouder.

8.1.4 Verwerking in de apotheek

Een ontvangende apotheek herkent aan het doorgestuurde signaal (gegevenssoort), dat dit om een openstaande prescriptie gaat. In het signaal is ook bekend wie de patiënt is en wie de bron is van de prescriptie.

Bij een patiënt die voor optie 3 gekozen heeft, begint het proces pas hierna. De patiënt identificeert zich en meldt aan de apotheker, dat een prescriptie bij een bepaalde instelling klaar staat. De apotheker zoekt eventueel in het prescriptieregister om welk EVS het gaat.

Het apotheek systeem vraagt dan aan het EVS bronsysteem om de verzending van de prescriptie van de betreffende patiënt. Aangezien dit ook een verzoek is zonder medische inhoud, zou dit zelfs met een laag vertrouwensniveau verzocht kunnen worden.

8.1.5 Verzending door het EVS

Als een EVS een verzoek ontvangt voor “verzending van openstaande prescriptie” dan controleert het EVS of de prescriptie inderdaad nog open staat. Hiermee wordt voorkomen, dat een prescriptie meerdere keren wordt opgevraagd. Het adres van de apotheek wordt ingevuld en het voorbereide prescriptie bericht wordt dan eindelijk aangemaakt. Het prescriptie bericht wordt verzonden naar de betreffende apotheek.

Als de prescriptie al eerder opgevraagd is geweest, dan wordt een foutmelding naar de opvragende apotheek verzonden met de mededeling dat de prescriptie niet meer opvraagbaar is.

Het verzenden van een prescriptie is feitelijk het standaard proces, dat nu al gebruikelijk is bij het pushen van prescripties. Dit heeft het voordeel dat de ontvangende apotheek alleen één manier hoeft te onderhouden voor het verwerken van ontvangende prescripties. Hier wordt nogmaals opgemerkt, dat dezelfde juridische regels van toepassing blijven.

Na de verzending wordt door het EVS tevens een bericht naar het prescriptie register verzonden om de registratie van de openstaande prescriptie te verwijderen. Hiermee wordt dan duidelijk gemaakt, dat de betreffende prescriptie niet meer op te vragen is.

9 Bijlage referenties

9.1 Algemene referenties

Auteur(s)	Titel	Versie	Datum (raadplegen)	Bron	Organisatie
NHG, KNMP, Z-index	Bouwstenen van het medicatieproces	2014	Augustus 2015	https://www.nhg.org/bouwstenen	NHG, KNMP, Z-index
ActiZ, KNMP, NVZA e.a.	Veilige principes in de medicatieketen	2014	Augustus 2015	http://www.knmp.nl/patiëntenzorg/samenwerking/brochure-veilige-principes-in-de-medicatieketen	ActiZ, KNMP, NVZA e.a.
Diversen	Richtlijn Overdracht van medicatiegegevens in de keten	25-4-2008	Augustus 2015	Website KNMP	Diversen
Paul Geels	Beoordeling Eigen beheer van Medicatie (BEM) in verzorgingshuizen, Instituut voor Verantwoord Medicijngebruik	Februari 2009		http://www.instellingsapotheek.nl/downloads/rapporten/beoordeling_eigen_beheer_van_medicatie_in_verzorgingshuizen.pdf	Instituut voor Verantwoord Medicijngebruik
ActiZ	Veiligheid in de medicatieketen	Maart 2012		https://www.knmp.nl/downloads/brochure-veiligheid-in-de-medicatieketen.pdf	ActiZ, Diversen
KNMG	Richtlijn electronisch voorschrijven	September 2013		Website KNMG	KNMG

9.2 Kwalificatiescripts

Kwalificatiescripts zijn gepubliceerd op de wiki pagina "Kwalificatie".

10 Bijlage: Documenthistorie

Versie	Datum	Omschrijving
0.95	15 juli 2016	Versie t.b.v. pilot
0.96	1 december 2016	Paragraaf 2.4 Proces: toedienen aangepast en als gevolg daarvan ook H6: toegevoegd Sturen/ontvangen toediengegevens.
0.97	22 december 2016	Paragraaf 2.4, 4.3.1 opmerkingen review verwerkt. Paragraaf 4.2.11 aanscherping in tekst.
9.0.2	18 juni 2017	Omzetting document naar wiki.
9.0.4	september 2017	Verwerkt Ontwerpbeslissingen in functioneel ontwerp. Daarmee zijn de ontwerpbeslissingen vervallen. Het huidige FO is vanaf nu leidend. Par. 1.3.1. Definities bouwstenen aangepast en afkorting voor medicatieverstrekking gewijzigd van vs naar mve. Par. 1.3.3. Medicamenteuze behandeling nu op basis van PRK, stuk herschreven en ontstaan mbh en omgang met parallelle ma toegevoegd. Par. 1.3.4. Nieuw datamodelplaaje, diverse relatie toegevoegd en aangepast op basis van ontwerpbeslissingen. Par. 1.5 Begrippenlijst verwijderd. H.2 Plaatje medicatieproces aangepast: mo toegevoegd bij actief beschikbaarstellen door gebruiker; lijnen in swimlane van toediener/gebruiker aangepast. H4.1 Nieuwe use cases toegevoegd: Niet verstrekken voor, Verschillende PRKs onder dezelfde medicamenteuze behandeling, Staken van medicatie door derden, Achteraf vastleggen medicatieafspraak, Parallelle medicatieafspraken. H4.2 Nieuwe use case: Stop-toedieningsafspraak; gewijzigde use case: Aanschrijfdatum, verstrekken en niet afhalen. H5: Onderscheiden van medicatieprofiel en medicatieoverzicht beschreven; afleidingsregels aangepast op basis van de nieuwe ontwerpbeslissingen. Waar logisch verwijzingen vanuit Art-decor naar FO H7 aangebracht. Diverse grammaticale en kleine tekstuele wijzigingen.
9.0.5	januari 2018	Terminologie: Stop-ma gewijzigd naar staken-ma conform eerdere projectafspraken. Par. 1.3.4 Aanvulling dat ma ook mag verwijzen naar bouwsteen onder andere medicamenteuze behandeling. Par. 4.1.22 Ontslag aangepast omdat bij ontslag eerder gestaakte ambulante medicatie opnieuw gestart kan worden. Par. 4.1.26 Staken van medicatie door derden aangepast. Par. 4.1.27 Twee PRK's onder één medicamenteuze behandeling. Par. 2.2.5.3 Staken medicatieafspraak aangepast ter verduidelijking van impact op reeds ingevoerde toekomstige medicatieafspraken. Voetnoot 3 Voorlopige en definitieve medicatieopdracht verduidelijkt en use case medicatieopdracht (par. 4.1.31) toegevoegd. Par. 4.1.30 Use case Eenmalig gebruik toegevoegd. Paragraaf 2.2.4, 2.2.5.2, 2.2.5.4, 4.1.16, 4.1.22 aangepast voor substitutie.Bij substitutie wordt een medicamenteuze behandeling niet tijdelijk onderbroken maar daadwerkelijk gestaakt. Het substituut wordt onder een nieuwe medicamenteuze behandeling gestart. Paragraaf 4.1.33 Ontbreken digitale medicatieafspraak bij opname toegevoegd. H5 Medicatieoverzicht aangepast met verwijzing naar nieuwe inhoudelijke pagina met functionele uitwerking. Paragraaf 7.10 Medicatiegebruik: gebruikindicator, volgens afspraak indicator en stoptype toegevoegd. H6 Bouwstenen van medicatieoverzicht gewijzigd naar ma, ta en mgb. Figuur 2 Kleuren in datamodel conform figuur 1. Diverse afkortingen verklaard.
9.0.6	mei 2018	Aanvulling op voorstel verstrekkingsverzoek en toevoeging van antwoord-voorstel verstrekkingsverzoek Hoofdstuk 6 tabel 4 toevoeging van linkjes naar ART-DECOR transacties Verwijderd: hoofdstuk over LSP Par. 7.10 tabel uitgebreid met gebruiksperiode en doseerinstructie Aanscherpingen in diverse teksten Toevoeging van kenmerk 'bouwsteen van iemand anders' voor MA, TA, MGB in medicatieoverzicht
9.0.7	december 2018	Par 1.3.3. MBH op HPK niveau in geval van 'niet geneesmiddelen' zonder een PRK niveau Par 1.3.3. MBH voor geneesmiddelen zonder PRK (magistralen, infusen etc) Par 2.2.5.5. Wijzigen medicatie: Technisch stop-ma: afspraak datum voor stop-ma en nieuwe ma moeten hetzelfde zijn. Wijziging op MA die reeds gestopt is toegelicht (geen extra staken-ma nodig) Par 2.2.6. Toegevoegd: VV onder MA van iemand anders Par 4.2.15. Uitleg GDS leverancier levert ander HPK Par 7.10: Medicatiegebruik gebruikindicator, volgens afspraak indicator, stoptype, gebruiksperiode en doseerinstructie: tabel aangepast en voorbeelden toegevoegd Par 4.1.34: Eigen artikelen uitleg toegevoegd Hoofdstuk 5: voorbeeld medicatieoverzicht ingevoegd in deze wiki pagina ipv een losse wiki pagina (om zoeken binnen het FO te vereenvoudigen). Diverse tekstuele aanscherpingen/verbeteringen
9.0.7	juli 2019	Voorbeelden voor specifieke infrastructuren verwijderd.
9.1.0	29 januari 2020	Tekstuele aanpassingen staken/stoppen Par 7.11 toegevoegd: Implementatie geïndividualiseerde distributievorm (GDV)-velden BITS MP-85, BITS MP-93, BITS MP-122 Use cases toegevoegd (Gebruik registreren op basis van verstrekking, Verstrekkingsverzoek met aantal herhalingen, Voorschrijven van niet geneesmiddelen) Hoofdstuk 4: plaatjes bij use cases toegevoegd Nierfunctiewaarde in het voorschrift BITS MP-48 Medicatieoverzicht: Par 5.7 toegevoegd 'Velden die niet getoond hoeven te worden' Diverse tekstuele aanscherpingen/verbeteringen o.a. BITS MP-131 Paragraaf 'Ongeadresseerd voorschrijven' verplaatst naar hoofdstuk 'Beschouwingen' BITS MP-151 Proces van aanmaken concept-TA verwijderd BITS MP-128 Par 4.1.8: Toelichting 'Medische noodzaak' BITS MP-129 Par 4.1.35: Use case toegevoegd

11 Bijlage: Figuren en tabellen

Figuur 1 Bouwstenen - overzicht
Figuur 2 Bouwstenen - samenhang
Figuur 3 Activiteitendiagram - Medicatieproces algemeen
Figuur 4 Processtappen en transacties - medicatieverificatie
Figuur 5 Processtappen en transacties - voorschrijven
Figuur 6 Processtappen en transacties - ter hand stellen
Figuur 7 Processtappen en transacties - toedienen
Figuur 8 Processtappen en transacties - gebruiken
Figuur 9 Voorbeeld effectieve periode
Figuur 10 Overzicht systemen en systeemrollen
Figuur 11 Interactiediagram Ongeadresseerd voorschrijven

Tabel 1 Bouwstenen – beschrijving
Tabel 2 Informeren versus (Actief) beschikbaarstellen
Tabel 3 Overzicht systeemrollen
Tabel 4 Overzicht transactiegroepen
Tabel 5 Typen klinische medicatie relevant voor extramurale zorgverleners

12 Bijlage: Diagram Medicatieproces algemeen

Terug naar hoofdstuk Medicatieproces

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↑ This document only uses the term medicatieafspraak, which therefore also indicates the clinical equivalent provisional medication order
↑ The verstrekkingsverzoek building block is not applicable in the clinical setting. Dispensing medication is handled in different ways in the clinical setting. Replenishment of, for example, a department’s supply is not considered medicatieverstrekking, but rather an extension of the pharmacist’s stock. Medicatieverstrekking only takes place when the link between the medication and patient has been made. In clinical situations, administration often takes place immediately afterwards.
↑ ^3,0 ^3,1 A provisional medication order, as it is used in hospitals, is both the request from the physician to the administrator to administer medication to the patient as a verstrekkingsverzoek to the pharmacist to ensure that the medication is available for the administrator. This last part corresponds to the medicatieafspraak and the verstrekkingsverzoek from the first line. In addition, the hospital pharmacist usually carries out a validation of the administration request (this creates the final medication order which is called an toedieningsafspraak here). The provisional medication order is therefore not the same as a proposal from, for example, from a nurse on the basis of a protocol that has not yet been approved by a physician.
↑ Use may have been preceded by medicatietoediening. Registration of use, for example after medicatietoediening of rabies vaccinations or infusion is not obvious.
↑ From one-time to a certain period. The building block ‘Medicatieverbruik’ has not been detailed any further in this information standard.
↑ In practice several medicatieafspraken (with different PRKs) are often combined into a single product instead of a single medicatieafspraak with underlying the composition.
↑ The patient may also verify his own medication. He then records ‘gebruik/use’, see paragraph 2.5.4.1.
↑ This is about patients from a nursing home or a mental health institution who are going to the outpatient clinic of a hospital.
↑  This includes all healthcare providers who are authorised to prescribe: not only physicians, but also nurse practitioners and physician assistants, for example
↑  Information systems keep an audit trail. In case of a change, the existing MA is discontinued (new record) and a new MA with the change is then created (new record). By using the records of the audit trail, no major adaptations are needed for discontinuing a MA in most systems.
↑  Correcting/cancelling administration agreementtoedieningsafspraaks happens in the same way. XIS is a generic term for a random (health care) information system. PHR=personal health records.
↑  XIS is a generic term for a random (health care) information system. PHR=personal health records.
↑  The patient may also request a repeat directly from the prescriber: see paragraph 2.5.6.
↑  In this document, the administration list means both the digital and the paper version, unless otherwise indicated. Sublist and checklist are synonyms.
↑  XIS is a generic term for a random (health care) information system. PHR=personal health records.
↑ XIS is een generieke term voor een willekeurig (zorg)informatiesysteem. PGO=Persoonlijke GezondheidsOmgeving.
↑ XIS is een generieke term voor een willekeurig (zorg)informatiesysteem. PGO=Persoonlijke GezondheidsOmgeving.
↑ See also paragraaf 4.1.3.
↑ Eenzelfde situatie doet zich voor wanneer de apotheker een fax ontvangt.

[1] This document only uses the term medicatieafspraak, which therefore also indicates the clinical equivalent provisional medication order

[2] The verstrekkingsverzoek building block is not applicable in the clinical setting. Dispensing medication is handled in different ways in the clinical setting. Replenishment of, for example, a department’s supply is not considered medicatieverstrekking, but rather an extension of the pharmacist’s stock. Medicatieverstrekking only takes place when the link between the medication and patient has been made. In clinical situations, administration often takes place immediately afterwards.

[MO-3] 3,0 ^3,1 A provisional medication order, as it is used in hospitals, is both the request from the physician to the administrator to administer medication to the patient as a verstrekkingsverzoek to the pharmacist to ensure that the medication is available for the administrator. This last part corresponds to the medicatieafspraak and the verstrekkingsverzoek from the first line. In addition, the hospital pharmacist usually carries out a validation of the administration request (this creates the final medication order which is called an toedieningsafspraak here). The provisional medication order is therefore not the same as a proposal from, for example, from a nurse on the basis of a protocol that has not yet been approved by a physician.

[4] Use may have been preceded by medicatietoediening. Registration of use, for example after medicatietoediening of rabies vaccinations or infusion is not obvious.

[5] From one-time to a certain period. The building block ‘Medicatieverbruik’ has not been detailed any further in this information standard.

[6] In practice several medicatieafspraken (with different PRKs) are often combined into a single product instead of a single medicatieafspraak with underlying the composition.

[7] The patient may also verify his own medication. He then records ‘gebruik/use’, see paragraph 2.5.4.1.

[8] This is about patients from a nursing home or a mental health institution who are going to the outpatient clinic of a hospital.

[9]  This includes all healthcare providers who are authorised to prescribe: not only physicians, but also nurse practitioners and physician assistants, for example

[10]  Information systems keep an audit trail. In case of a change, the existing MA is discontinued (new record) and a new MA with the change is then created (new record). By using the records of the audit trail, no major adaptations are needed for discontinuing a MA in most systems.

[11]  Correcting/cancelling administration agreementtoedieningsafspraaks happens in the same way. XIS is a generic term for a random (health care) information system. PHR=personal health records.

[12]  XIS is a generic term for a random (health care) information system. PHR=personal health records.

[13]  The patient may also request a repeat directly from the prescriber: see paragraph 2.5.6.

[14]  In this document, the administration list means both the digital and the paper version, unless otherwise indicated. Sublist and checklist are synonyms.

[15]  XIS is a generic term for a random (health care) information system. PHR=personal health records.

[16] XIS is een generieke term voor een willekeurig (zorg)informatiesysteem. PGO=Persoonlijke GezondheidsOmgeving.

[17] XIS is een generieke term voor een willekeurig (zorg)informatiesysteem. PGO=Persoonlijke GezondheidsOmgeving.

[18] See also paragraaf 4.1.3.

[19] Eenzelfde situatie doet zich voor wanneer de apotheker een fax ontvangt.

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mp:V9.1.0 Ontwerp medicatieproces ENG