Optimising electronic documentation of medication in Hungary: Itemised, complete, historical, and standardised event recording

Hospital care is a highly complex process, requiring comprehensive documentation of all aspects of the patient journey in electronic health records. A critical component of this care is the accurate tracking of patient medications. International standards are not consistently incorporated into the electronic medication systems currently in use worldwide, and their interoperability remains an unresolved issue. We recognised the need to develop a set of standardised data elements that ensure consistent and accurate documentation. Although the medication systems studied exhibit various strengths and weaknesses and can satisfactorily document certain aspects of the medication process, none achieve the necessary level of optimal documentation. Our paper presents a new perspective on medication recording by identifying the electronic data requirements for all events in an itemized, complete, historical, and standardized manner. To address this gap, we collected, defined, and introduced the essential data elements required for the comprehensive documentation of medication sub-processes for the first time in our study. The Fast Health Interoperability Resources (FHIR) data exchange standard was employed for designing these data requirements. Our research identified and categorised 138 data elements essential for describing the complete medication process, including medication description, requests, dispensation, and administration. These data elements were divided into fundamental and supplementary categories. We developed a survey form to assess medication systems. In a pilot study, we tested the quality of 5 medication systems, currently in operation in Hungary. Our analysis assessed the accuracy of the electronic recording of medication and the correspondence of the recorded data elements with international standards. None of the systems demonstrated the ability to document medication accurately or capture all fundamental data elements. The best-performing system managed to record 63 % of all fundamental data elements, while the worst-performing system managed only to document 30 %. The names and the values of data elements in these systems did not comply with international standards either. The primary clinical pharmaceutical usefulness of this study was to enhance the digital documentation of medication in hospitals to meet comprehensive data recording requirements, ensure greater compliance, and improve their suitability for enriching clinical health data files, enabling real-world studies, pharmacovigilance analyses, and the identification of drug repositioning opportunities.