Can drug orders continue indefinitely until explicitly stopped?


At one of our implementations, they would be ordering drugs by not specifying any end date. What they intend to achieve is basically that that drug order has to be active until it is explicitly stopped by a care provider.

Right now though, since the duration field is mandatory for a drug order, every drug order expires when the duration ends. Hence the system would not be able to cater to the above mentioned scenario.

So what is the possible solution for this?

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It is commonplace to only expire medications when a specific duration is given (e.g., a two week course of antibiotic) and never expire medications when the duration is not specified our unclear, supporting chronic medications (e.g., meds for blood pressure, chronic pain, cholesterol, etc.). So, we fully expect many drug orders to not have a duration and never expire.

Both the duration fields (drug_order.duration & drug_order.duration_units) and the auto-expire field (orders.auto_expire_date) are optional.

Where are these fields mandatory? Was that requirement added within our REST API? If so, it is a mistake.


I clearly see why duration may not be required, e.g. when is prescribed for chronic condition. So a question that we are grappling with in Bahmni, then should Bahmni have a validation for duration? Wondering how common is it, that doctors do not provide the duration and in such cases how is it communicated to the patient?

I just remembered one point which may be playing into this: outpatient orders are required to specify a quantity and a number of refills (because otherwise a pharmacy wouldn’t know how to fill the prescription), but this is not required for impatient orders.

Perhaps Bahmni is automatically calculating the quantity based on the duration, and this gives the impression that duration is required.

@burke or @jteich can speak to how to represent a prescription for a chronic condition, they still must be filled at a pharmacy.

Generally speaking, these forever drug orders are very common in some areas (HIV, MDRTB, and chronic care, in my experience).

It would be unusual for providers to be simply ordering “METOPROLOL” for a patient without specifying how much the patient should be given (quantity) and/or whether they can get more before seeing the doctor again (refills). These may imply a duration, but for chronic meds they simply indicate how much to give the patient now. For example, for a patient taking METOPROLOL for the rest of their life, the doctor would still order “METOPROLOL one daily #90 with 3 refills” to give the patient a year’s supply three months at a time. The quantity & refill requirement for outpatient reflects that fact – i.e., you cannot write a prescription without specifying how much the patient should get and how many times it can be refilled.

Order templates (when we get them) could autopopulate quantity=1 and refills=0 for one-time treatments. If someone just wants to document meds in the system without actually giving the patient a prescription, then they (or the system) could populate both of these with zero – but that would be an application-level decision, not something we would do in the platform.

I am assuming that is agreed that duration should not be mandatory.

About Total Quantity When we are speaking to the clients on this particular project, they do not want to provide total quantity or refills. My understanding is that they want to put patients on the medicine with dosage details, start date and route. At one place where the system would be rolled out the patient would be under DOTS and that is also said to one of the reasons the total quantity of the prescription is irrelevant for them.

So Burke, you are suggesting that we populate total quantity with 0 for such cases? Thanks

Correct. If the code is requiring this, it’s a bug.

Burke just went on vacation for 2 weeks, so I’ll answer as best I can:

The quantity and numRefills are details that the ordering doctor communicates to the pharmacy that is going to fulfill the order, so that the pharmacy knows how many pills to give the patient.

In the DOTS scenario the patient is not going to pick up this prescription at the pharmacy, so it is appropriate to store these as quantity=0 (and hide this in the application).

For later: generally I think this argues for dropping the validation that we require quantity for all outpatient orders, unless @burke wants to argue that outpatient DOT therapy is a separate care setting or something like that.