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Medication Usage Dates for Improved Reporting

Available with the v3.5.5 release of Chronic Pain Tracker, you now have the ability to define a Start Date and End Date for each custom Medication item in the Medication Tracker. Although this feature is optional, we do encourage our users to take advantage of it where applicable.

The feature has been added for two key reasons. First, it helps avoid mistakes at the time of entry creation, and second, it improves the accuracy of medication usage reporting. Let’s take a look at how to enable this feature and also how these benefits are achieved.

Defining Medication Usage Dates

To apply a Start or End Usage Date to your Medication items, you’ll need to open the Tracker List editing table for the Medication Tracker object. You can access this table either by (1) Going to the Settings tab, selecting Diary Preferences -> Medication Taken -> Edit Medication List, OR (2) Starting a new Diary Entry, adding the Medication Taken tracker to the entry, and selecting the “Edit Table Entries” from the medication table.

Once you have opened the Medication List, you can select the medication you wish to edit. In the example shown here, we’re going to edit the usage dates for “Dilaudid 4mg”. Once selected, you will see the details for this medication item. By default the Start/End dates will show as “Not Defined”.

Medication List Medication Details showing Usage Dates as Not Defined
Medication Tracker ListMedication Item Showing Start/End Dates as Not Defined

By tapping on the Start Date row, you will be presented with options for setting the date value. As you can see in this image, you have the option to (1) Manually Set the Date, (2) Automatically Set the Date, (3) Clear the Date, or (4) Cancel the Change. If you choose to Manually Set the Date, you will be presented with a Date Picker as shown in the second image below. Adjust the Month, Day & Year values to the appropriate date.

If you choose to use the Automatic option, the app will determine the Start/End Usage Date by looking up the First/Last time you used that particular medication and use that date as the new value. This usually will be sufficient, so we recommend using the automatic selection option first, and if necessary using the manual option to fine tune the date value.

If you set a date incorrectly (eg. setting an End Usage Date for the medication, but you are actually still taking it), you can use the Clear the Date option to reset the date to the “Not Defined” value.

MedicationAvailabilityStartDateEntryOptions MedicationAvailabilityStartDateManualSelection
Options for Setting the Start/End Date ValuesUsing the Date Picker to Set a Start Date Value

Once you’ve set the Start/End dates as desired, you will tap on the Done button in the upper left corner and then you’ll need to save the changes (green checkmark in upper right) to the Medication List.

For CPT users that have Device-to-Device Sync Enabled

We have identified a bug with v3.5.5 that prevents the proper saving of Tracker List changes when device-to-device sync is enabled. Although the changes appear to be saved, if you re-open the tracker list item, you’ll see the same previous values in place for that item. This bug is being addressed in the next update, but until then, you can do the following to avoid this problem.

Before you make any Tracker List changes, go to Settings tab -> Cloud Services -> Device Sync Services. Scroll to the bottom of the screen and tap on Turn Off Sync Services for Device to disabled the sync processing. Then you can make your Tracker List changes. Once those are complete, you can re-enable the Sync services. We do suggest going through the process of Uploading your Master DB to the cloud repository and Downloading the Master DB to your secondary devices after this step to ensure that all devices are starting from the same synchronized baseline.

Improved Medication Input with Usage Dates

One of the benefits of assigning usage dates to your medication items is that CPT can now help you avoid errors when creating new diary entries. This is done by giving you a warning message if you try to enter the usage of a medication for a diary entry that is before or after the associated usage date range.

For example, consider the situation where you have indicated that your “Dilaudid 4mg” medication was used from Nov 22, 2011 to Jan 10, 2014 via the new Start/End Dates. You then begin a new diary entry input for Feb 3, 2014. If you select the “Dilaudid 4mg” during that entry, you will receive a warning like the one shown below. This warning indicates that you are trying to indicate medication usage outside the defined timeframe.

MedicationAvailabilityEntryWarning
Warning Shown During Diary Entry When Selecting a Medication Beyond Its Availability Date Range

Improved Medication Reporting with Usage Dates

The more significant benefit of setting the usage dates comes when we look at CPT’s reporting features – specifically the Medication Tracker Summary Report. There are 4 standard graphs created per medication item in the current Summary Report format. Of these 4, the first graph, “Daily Medication Qty Totals per Day”, is the one where this change is most obvious.

The impact comes from the way we evaluate usage of the medication item. This is most easily explained by using the example of a breakthrough pain medication that is used a variable number of times per day – as needed for pain. There are some days where the pain is high and you may use the medication 3 or 4 times; maybe other days it will be moderate and it’s used only once or twice. Still other days, the good days, and you may not use the medication at all. It’s this last situation where the usage dates come into play.

Graph 1 - Daily Qty Totals when Start/End Dates are Not Defined Graph 2 - Daily Qty Total when Start/End Defined
Graph 1 – Daily Qty Totals when Start/End Dates are Not DefinedGraph 2 – Daily Qty Total when Start/End Defined

Graph 1 above shows a situation where usage dates are not defined for the “Dilaudid 4mg” medication item. You can see that there is consistent usage of the medication for the first half of the period, but then it drops to zero for each day. You can also see that there is a Medication Change milestone indicator at the point where the usage stops.

Looking at this you could assume that this was a situation where you were continuing to have the Dilaudid 4mg available for use but didn’t need it once you added some other medication to your treatment strategy (Scenario A). Or, perhaps this was a situation where you were using Dilaudid 4mg for the first part of the period, but then stopped using it in favor of a different medication (Scenario B). Although these situations are similar, they are unique and you’d probably want to report on them differently.

Graph 1 matches well to Scenario A since we continue to plot data points for the days after the medication change, and the moving average plot (green line) continues for the full width of the plot accounting for the reduced usage levels in the period after the medication change. The overall period average qty used indicated by the horizontal line labeled 1.1 tablets per day also reflects the average usage of Dilaudid 4mg during the period.

But for Scenario B when the usage of Dilaudid 4mg was discontinued after Jan 10, we would prefer a different view of the data, and that’s where Graph 2 is relevant. Here, we have the Jan 10, 2014 End Date defined in the Medication item. So now you can see that the Daily Qty data points past Jan 10 are shown, but they are grayed out indicating that the medication was not available during those days. You can also see that the moving average plot stops at the Jan 10 date since this was the last day the medication was available for use. And finally, the overall period average qty used is calculated only for the days when the medication was available and shows a 2.3 tablet per day use of the Dilaudid.

We believe the inclusion of Start/End Dates for the Medication items will allow you to generate more accurate summary data like those shown here. Both scenarios are realistic and therefore we saw a need to enable both to be reflected in the summary analysis and graphs. Enabling the definition of Start/End Dates now gives you the ability to deal with both of those situations.

Sorting your Medication Items

As of CPT v3.5.5 (released Feb 20, 2014), you have the ability to define a manual sort order for your list of Medication Items. This can be helpful if you have a large number of items in the Medication table and want to move current meds towards the top of the list.

Using this feature is quite easy. To begin, open the Medication Tracker List by either:

  • go to the Settings tab -> Diary Preferences -> Medication Taken – Edit Medication List, OR
  • create/edit a diary entry, add the Medication Tracker and select “Edit Table Entries” at the bottom of the list

With the Medication list open, you’ll see that each table entry will include a sort order control on the far right side of the row. It’s the icon with the three stacked gray bars. To change the position of an item in the table, tap/hold on the icon and drag the item up or down in the list. Once it’s in the location you want, just let go of the item and it will pop into place.

Once you have manually changed the sort order of the table, the items will remember their new positions and will display in this order for all new diary entries. As you add new Medication items, you can continue to adjust the sort order as needed.

scrnMedicationTrackerListSortOrderControls

Testing Medication Effectiveness in Relieving Pain

The Challenge of Evaluating Pain Relief Efficacy

Let’s face it, most people dealing with Chronic Pain take some type of pain relief medication – often multiple types. But do you know if they are really working? And when your doctor suggests trying a new medication to see if it is more effective than your current drug – how can you tell?

Unfortunately, most of the time you can’t objectively say whether one drug is working better than another, or even if either of the drugs is having a real impact on your pain levels. To get truly subjective data on the matter generally requires a laboratory like environment with rigorous data collection processes to ensure that medication intake and pain relief impact is captured on a regular basis. This is just not a realistic situation for most chronic pain folks.

Capturing the Data

However, using the latest analytical tools within Chronic Pain Tracker, you CAN document and analyze this type of data. You and your doctor can now see the statistics describing the reality of your medication and pain interaction over the past month(s), so that you can both make better informed decisions about how to best treat your condition. How does this work? Well, let’s take a look…

When we want to look at medication effectiveness, there are two main sets of data we need to capture:

  • Medication History – what was taken, how much was taken, and when was it taken
  • Pain Intensity – how badly are you hurting and when

 

Both of these data sets are easily recorded using Chronic Pain Tracker. Users are able to create their own customized lists of medications being taken which can record the name, dosage, and date/time of the med being taken. Similarly, recording a current pain level is as easy as selecting from the visual pain indicator scale.

Medication Analysis Window

Another important factor that needs to be considered is the time frame over which the drug is supposed to be effective. For example, many breakthrough pain meds should start to work within about 30 min and last 4-6 hours. Other types of meds may be effective for up to 12 or even 24 hours. And, if you’re dealing with something like a Fentanyl Patch, it may be several days that you need to evaluate.

Medication Entry WindowYou can now specify this effectiveness window period (hours) within the definition of your medication in CPT. You simply enter the number of hours over which you want to analyze the drug’s effectiveness. This value can vary for each medication entry and can be adjusted at any time. The screen image to the right shows the location of this field.

Now, considering the timeframe, it will be important to track your pain levels at the start of taking the medication and then several times over the course of the analysis window period. For example, let’s say that it is 1:00PM and you have just taken a Vicodin. So you create a Diary Entry that records the taking of 1 Vicodin pill and your current pain level (eg. 7). if the analysis window for the drug is 8 hours, then you should plan on creating additional Diary Entries at perhaps 1, 2, 4, 6, and 8 hours after the initial entry where the medication was recorded. There are no hard and fast rules on how many data points you need to capture each time, but its better to err on the side of too much data rather than too little.

The Summary Report Analysis

The magic of the process begins to happen when you run a Summary Report for a particular time period. Let’s say you’ve been testing out Vicodin for the last month and want to get an idea of how it has been working for you. So after following the steps above throughout the month, you’re now ready to produce the Summary Report to review with your doctor.

Summary Report - Medication Taken - Pain Reduction AnalysisBefore explaining what goes on behind the scenes, let’s jump straight to the end result – the Pain Reduction Efficacy graph shown in the Medication Tracker section of the report. You can see a sample of this report on the left. In a normal Summary Report, you would see one of these graphs for each medication listed. This one happens to be a sample for Vicodin 10mg over a 14 day period.

The graph is structured with Time (hours) as its x-axis. The Time represented is the time since the particular medication was taken. So you can see that it starts with 0 hours on the left and goes up to whatever number you plugged into for the Analysis Window – in this case 6 hours.

The vertical axis represents that relative increase/decrease of pain levels over the time period. Each time you take the medication and provide a starting pain level, the app will look for additional Diary Entries that fall within the analysis window timeframe and will check whether your pain level went up or down compared to the starting pain level. This is represented as a percentage value on the vertical axis. The actual data points are shown as the color diamonds on the chart. A green diamond is one where the pain level dropped from the starting point, a yellow represents no change in pain level, and a red shows an increased pain level since taking the medication.

The individual data points are connected by thin gray lines which are shown as a way to see the progression of pain levels for that particular medication cycle. You will also see several diamonds with a thick black border around them. These represent entries where an additional dosage of the same medication was taken. If you start to see clusters of these bordered markers earlier in the analysis window, it may indicate that your medication is wearing off earlier than it should be, and is a good time to raise the question with your doctor.

The thicker blue line shown on the graph is the aggregated pain reduction impact for the medication during the analysis timeframe. This is a great tool for seeing the average effect of the medication on your pain levels. The sample shown illustrates the effect we would expect to see with a medication like Vicodin. After a short period of being digested, the medication begins reducing pain levels over the course of hours 1 to 4. By about hour 5 or 6, pain levels have again returned to their original level and you’re seeing signs that the patient has taken another dose at that point (the bordered diamonds).

Medication Pain Reduction - Sample 2Not all of your graphs are going to follow this idealized curve, there are just too many variables that impact the efficacy of your medications. For example, if you pain normally gets worse towards the end of the day, then a medication taken mid-afternoon will probably show more of a steady-state pain level until it starts to wear off and pain levels rise.

Let’s take a look at a couple other samples based on real world data captured from one of our users. In this first graph, we’re looking at the short acting pain reliever Dilaudid with an analysis window set to 8 hours. As mentioned before, we don’t see the idealized curve from the Vicodin sample above, but that doesn’t mean there isn’t valuable information here.

If we look in the area (A)  on the plot, we see that around hours 3 to 4 there is a large number of bordered markers which indicate that the patient is taking additional doses at those points. This suggests the relief from the medication is not lasting more than 4 hours for this patient. This is further verified with the area (B) where when the patient did go further into the analysis period without taking more medication, the pain levels began to steadily rise over time.

Medication Pain Reduction - Sample 3

The next sample has a longer analysis window (12 hours) for the drug Robaxin. Again, we don’t see the idealized curve, but we can draw some valid conclusions from the graph. In area (A), we’re seeing a short-term increase in pain levels. However, there are very few data points within the first 4 hours of the drug being taken, so we may conclude that the increased pain levels are only due to a lack of data points in the area.

Unlike area (A), when we look at area (B), we see lots of data points which should suggest a more representative view of the drug impact on pain levels. In this period we’re seeing a gradual uptick in pain levels starting at about the six or seven hour mark. Given this increase and the quality of the data here, this probably suggests that the drug is working for roughly the first 6 hours for the patient, but not really beyond that point. It also looks like area (C) is demonstrating that the patient is taking more Robaxin at roughly the 10 hour point. Given the findings in area (B), it may make sense to move the next dose a bit closer say at the seven or eight-hour mark.

Again, you shouldn’t rely on a graph alone to make medical decisions. You should always review the graphs along with your other history factors with your doctor before making any medical decisions. However, we believe that the tools in Chronic Pain Tracker, like the Pain Reduction Analysis, can be an invaluable tool for you to use in your continued care. We hope you find these tools beneficial.

Understanding all those report graphs

Have you wondered about some of those graphs that appear on the Summary Report? Couldn’t quite interpret where or how the data you’re seeing was generated? If so, then we’ve got a great new page for you.

Check out this Report Graphs: In-depth discussion that will take you through each of the many graphs appearing in the Summary & Analysis Report format.

 

Summary Report: Medication Details

Summary Report: Medication Details

Even if you have a pretty good handle on the many graphs CPT offers, we do suggest you take a look at the section talking about the Medication Tracker graphs. We’ve added a new graph in v3.0.4 which is about to be released which does a Pain Reduction assessment to test the effectiveness of your medications in reducing pain levels.

This type of a Medication Graph has been requested by many users and now you’ve got it. Please take a moment and read this information to learn how to understand it so that you can share the info with your doctor.