NHSN Inpatient Medication Administration Reports (NHSN-Medication-Administration-FHIR) (HL7 Implementation Guide for FHIR Release 4) (PSS in Confluence)

Medication data are integral to informing the quality, safety, and costs of U.S. healthcare, supporting federal, state, and local public health, and guiding clinical decision-making in patient care. In inpatient workflows, medication administration—as captured by electronic medication administration (eMAR) records - is considered the gold standard for accurately measuring in-hospital medication exposure, including identifying the exact medications patients have received, in what formulations, doses, and for what duration of time. Published data indicate that alternate data sources for medication exposure, such as pharmacy 'order' (or billing) data and medication 'lists' are inaccurate representations of in-hospital medication exposure. Pharmacy order/billing data are discordant with medication administration data due to variability in when billing events occur relative to actual medication administration (1,2). For example, order/billing can occur upon order entry or upon dispensing, neither of which reflects actual medication administration to the patient. Despite an order/billing event, actual administration to the patient can be held, missed, or discontinued (prior to a discontinuation order reaching the pharmacy). Medication 'lists', such as those generated during medication reconciliation, remain a relatively new concept in clinical workflows and are based on processes that are highly variable across U.S hospitals with regard to their accuracy and comprehensiveness (3). Medication lists can also have a high level of discordance with actual administration of medications (4,5). The need for medication administration information has never been clearer as during the COVID-19 pandemic, where identification of the medications that acutely ill hospitalized patients with COVID-19 had received was integral to understanding clinical management of this new public health threat and directing public health resources, including scarce medications. The continued reliance on the “medication list” resource instead of the 'medication administration' resource is a severe limitation in achieving accurate representation of medication exposure in U.S. healthcare data through FHIR resources.?

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1. Courter JD, Parker SK, Thurm C, Kronman MP, Weissman SJ, Shah SS, Hersh AL, Brogan TV, Patel SJ, Smith MJ, Lee BR, Newland JG, Gerber JS. Accuracy of administrative data for antimicrobial administration in hospitalized children.?J Pediatric Infect Dis Soc?2018;7(3):261-63.??

2. Schwartz DN, Evans RS, Camins BC, Khan YN, Lloyd JF, Shehab N, Stevenson K. Deriving measures of intensive care unit antimicrobial use from computerized pharmacy data: methods, validation, and overcoming barriers.?Infect Control Hosp Epidemiol?2011;32(5):472-80.???

3. Pevnick JM, Shane R, Schnipper JL. The problem with medication reconciliation. BMJ Qual Saf 2016; 25(9):726-30.

4. Rose AJ, Fisher SH, Passche-Orlow MK. Beyond medication reconciliation. The correct medication list.?JAMA?2017;317(20):2057-8.?

5. Gupta A, Yek C, Hendler RS. Phenytoin toxicity.?JAMA?2017;317(23):2445-6.?