Selecting a dose recommendation

Once an indication is selected, Touchdose provides dosing recommendations.

Dosing recommendations derive from the medication and indication previously chosen, along with the available information about the patient. Different patient input requirements may arise based on the chosen indication. If a Touchdose requires any missing patient information to provide a dose recommendation then the user will be prompted to enter that missing information. Refer to Body weight, Body surface area, and Obesity status for specific details.

Multiple dose options

For a single indication and corresponding medication, there can be multiple dose recommendations available for the user to choose between. Each grey box outline represents a dose recommendation which can contain one or more suggested doses. See the figure below where there is one dose recommendation that contains two suggested doses that need to be decided between:

In this next example there are two separate dose recommendations as can be seen by the two grey boxes and corresponding proceed buttons:

In the first dose recommendation there is only one suggested dose and in the second dose recommendation there are two suggested doses which in this example can both be prescribed as you can give the one suggested dose and then the other.

Where there are multiple dose recommendations, users first need to decide which dose recommendation (grey box) they would like to select and, when there are multiple suggested doses they will need to select a suggested dose from within that dose recommendation. You should look at the contextual information provided by the Conjunctions to determine when multiple suggested doses from within the dose recommendation can be prescribed together but you will need to select one at a time to proceed to the final screen.

In the first illustration in this section above, there are two suggested doses separated by the "or" conjunction and so they should not both be prescribed, see Valid combinations of dosing options for more information. In the second illustration in this section above, the second dose recommendation contains two suggested doses separated by the “Then” conjunction and in that example the suggested doses can both be prescribed.

Conjunctions

Conjunctions are used to provide contextual information about the relationship between suggested doses within a dose recommendation.

Conjunctions in this context typically fall into one of three categories: "or", "then", or "and". However, they may include additional contextual information, such as "Followed by", and may also provide guidance on the recommended intervals between suggested doses, such as "after 3 hours". An illustration of a conjunction with context and an interval is as follows: "Then followed by [after 30 minutes]."

There might be instances where suggested doses lack both conjunction and contextual information. In all cases, clinicians should apply their clinical knowledge and discretion when selecting a suggested dose to prescribe or when prescribing multiple suggested doses.

Valid combinations of dosing options

Within a dose recommendation, one or more suggested doses may be prescribed. The permissibility of prescribing multiple suggested doses hinges on their relational context, as indicated by the Conjunction joining them. Suggested doses should only be concurrently prescribed if the connecting conjunction is not "or." Consider the following examples:

• "Dose A then Dose B or Dose C" implies that Dose A and Dose B, or Dose A and Dose C, can both be prescribed. However, Dose B and Dose C should not be prescribed in combination.
• "Dose A or Dose B then Dose C" implies that Dose A and Dose C, or Dose B and Dose C, can be prescribed together. Nevertheless, Dose A and Dose B should not be prescribed in combination.

It is permissive to prescribe just one suggested dose even when there is the “Then” or “And” conjunctions that separate different suggested doses. For example if you had Dose A Then Dose B you may choose to prescribe both A and B at once or prescribe just Dose A and return to prescribe Dose B when necessary.

Clinicians should apply their clinical knowledge and discretion in selecting the appropriate combination of suggested doses for prescription.

Sequence of suggested doses that make up a dose recommendation

The sequence in which the suggested doses are presented within the dose recommendation holds significance, as they contribute to forming a sequential dosing story. For example, if the system presents suggested dose 1 then suggested dose 2, suggested dose 1 should always be prescribed first. The connection between each suggested dose is explained by a conjunction that separates the doses and provides context regarding their relationship to one another. Refer to Conjunctions for further details.

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The conjunction "or" consistently pertains to the preceding suggested dose. For instance, the sequence "Dose A then Dose B or Dose C" should be understood as either administering (Dose A followed by Dose B) or administering (Dose A followed by Dose C), and does not mean administering (Dose A followed by Dose B) or (Dose C). A misinterpretation of this could lead to medication errors. Opting for only one option among A, B, or C is also an acceptable choice.

Multiple routes of administration

Sometimes, a suggested dose may group multiple routes of administration when all other dosing details—such as the dose, frequency, and any supplementary information—are the same for the two routes of administration. In such cases, the route of administration must be selected on the next screen. If the different routes required a different dose or any other variation, they would be presented as two separate suggested doses.

Refer to the Route / Method selection section for further details.

See below for an example:

Handling of divided doses

When divided doses are included in the underlying formulary, this information will be displayed to the clinician on this screen as the total dose and the number of divisions. However, the frequency and dose per division, based on the total dose and divisions, will only be presented on the next screen.

For example, if the formulary specifies "1g in two divided doses," this will be communicated to the clinician on the current screen. On the next screen, it will be presented as a frequency and dose per division, such as "500mg twice daily."

If there are a number of divided doses offered as a range, you will be required to select a frequency on the next screen, derived from the number of divisions. The dose per division will then be calculated based on the selected frequency.

Refer to the Frequency selection section for more details.

See below for an example of how divided doses is presented at this stage:

Source

All dosing information on this screen comes from a source displayed next to the medication’s name. If the source has an associated URL in the underlying formulary, clicking it will open the source content directly in the web browser.

Dose insights

Touchdose sometimes presents additional dose insights for clinician's consideration, such as Potency, Pharmacokinetics or Dose equivalence information. These considerations are positioned above the dose recommendations, beneath the heading that reads "Please consider." See the figure below for an example of a dose insight displayed in Touchdose.

It's important to emphasise that the listed dose insights are provided for the clinician's evaluation and do not reflect adjustments made by Touchdose based on the information contained in those dose insights or any other information about the patient that the system does not know (refer to Contraindications and Limitations). Clinicians are responsible for reviewing this information and making any necessary modifications or rejections to the dose recommendations suggested by Touchdose. Failing to recognise this limitation could lead to medication errors.

Furthermore, not all dose insights may be pertinent to the patient in a given context. It is the clinician's responsibility to assess these considerations and exercise clinical judgment to determine their relevance.

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The listed dose insights are meant for evaluation by clinicians and do not represent factors considered by Touchdose in its recommendations. Failure of clinicians to make necessary dose adjustments when required could lead to medication errors.

Filtering of dose insights

When possible, dose insights undergo filtering to eliminate their display when not relevant to the patient in the current context. For example if a dose insight is only applicable to certain routes of administration and based on the selected indications those routes are not contained in any of the dose recommendations then the dose insight will not be displayed. However, it's crucial to note that there might be instances where dose insights not pertinent to the selected patient are shown. For example, if Touchdose is unaware of the patient's pregnancy status, the pregnancy insight may be displayed even when the patient is not pregnant. The filtering mechanism operates based on available patient information, and any limitations in the data may result in the display of considerations that might not be applicable to the specific patient.

Sources of dose insights

For further information regarding any dose insights, users are advised to refer to the source listed next to the name of the medication. This source provides additional details that may assist users in understanding the dose insights associated with the medication.

General advice

General advice encompasses free-text additional information that is relevant to all the suggested doses within a dose recommendation. Positioned at the bottom of the dose recommendation and following a black information icon, general advice often communicates details like the maximum allowable dosage within a specified time period, such as maximum per week but can contain any free text administration or dosing information.

Importantly, Touchdose does not modify any suggested doses based on information presented in general advice. General advice provides additional information that aims to help clinicians make more informed decisions across a range of scenarios. When necessary, it is the clinician's responsibility to adjust prescriptions based on this information. This information may also help a clinician decide between different dosing options. See the figure below for an example of general advice:

The general advice example below demonstrates how maximum cumulative dose information is presented. As previously mentioned, Touchdose will not modify any recommendations based on this information; this responsibility lies with the clinician. For instance, if a patient has already received two doses of 250 mg and one dose of 125 mg, they should not receive another dose exceeding 125 mg. However, the system will still display 125-250 mg as a dosing option because Touchdose does not have access to the patient’s prior prescriptions or administered doses.

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It is crucial for clinicians to recognise that neglecting to consider general advice and, when necessary, manually implementing required changes may result in dosing errors. It is the responsibility of clinicians to review and incorporate relevant information from the general advice section to ensure accurate and safe medication prescribing, guided by their clinical judgement.

Dose and rate

Intermittent doses

Intermittent doses (e.g. 3mg) are always shown in absolute terms, e.g. as 'mg' and not in relative terms, e.g. as 'mg/kg'. Intermittent doses can either be unranged, e.g. 2 mg or ranged, e.g. 2 - 4 mg. Touchdose will convert relative intermittent doses to absolute doses, using the patient's inputs.

Continuous doses

Continuous doses can take the form of either unranged, for instance, 2 mg/kg/min, or ranged, such as 2 - 4 mg/kg/min. In contrast to intermittent doses, continuous doses will not be transformed into absolute doses. The unit for continuous doses is displayed exactly as authored in the underlying formulary, maintaining consistency with the original presentation.

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In cases where continuous doses are articulated in formularies using relative terms, clinicians frequently discuss these doses in the same relative terms. For instance, a clinician might say, "Patient X is on a continuous morphine infusion at 20 mcg/kg/hour." Touchdose reflects this practice by presenting the formulary dose in the same relative terms if it is originally expressed in such a manner. This approach aligns with the common practice of preparing continuous infusions at standard concentrations, facilitating reconciliation of infusion rates with drug delivery rates.

Optimisation of dose and unit for presentation

In the formulary, if the dose is authored as absolute or if an absolute dose minimum or maximum is applied the dose will be presented exactly as authored, e.g. 125 mg. However, in all other scenarios, doses will undergo normalisation for unit consistency and rounding, following the process described below.

Unit normalisation

For unranged doses, the presented quantity will, whenever possible, be normalised to be greater than or equal to 1 and less than 1000. For instance, a 10000mg dose will be displayed as 10g, and a 0.0001g dose will be presented as 100 micrograms.

For ranged dose quantities, the normalisation process is applied similarly, but it is based on the upper value. For example, for a dose range of 75-120 micrograms/kg, for a 10kg patient, the output dose will be 0.75mg - 1.2mg (not 750 micrograms to 1200 micrograms). This design choice accommodates electronic prescribing (EP) systems with prescribing forms that support ranged dose prescriptions but do not allow different units for the low and high values.

Dose Rounding

Touchdose employs a rounding process for calculated quantities before presentation where the quantity is rounded to three significant figures and where the third significant figure, when present, is then further rounded to the nearest 0 or 5.

For instance, a quantity like 12.346mg will be rounded to 12.5mg following this process.

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Touchdose employs high-precision rounding and does not programmatically aim to generate doses specifically tailored for administration using certain medicinal forms. For example, if the relative dose is 10 mg/kg and the patient weighs 21 kg, Touchdose will suggest a dose of 210 mg. If the medication needs to be administered orally and is only available in tablet form, the clinician will need to appropriately round the dose to match a suitable tablet size.

Therefore, it is incumbent upon the clinician to:

• Grasp the rounding precision applied to dosing suggestions provided by Touchdose.

• When deemed necessary, undertake additional rounding, taking into account the practicality of administering a rounded dose with respect to available medicinal forms.

This ensures that clinicians are aware of the rounding precision and have the flexibility to further round doses as needed for practical administration.

Formulary dose hover feature

In the Suggested Dose story, the dose and frequency is underlined, allowing users to hover over them to display a pop-up. This pop-up provides additional details from the underlying formulary, including:

• Dose
• Frequency
• Divided doses
• Dose limits
• Patient group information

These details explain how the patient-specific dose was determined.

Handling of Relative vs. Exact Doses:

If the underlying dose is not relative (i.e., not based on weight or other patient factors), the formulary dose will be the exact same as the patient-specific dose.

If the underlying dose is relative, the pop-up will display:

• The relative formulary dose
• Any minimum or maximum dose limits specified in the formulary when present

Example of the formulary dose hover feature:

This feature allows users to:

• Check any calculations that may have been performed.
• Assess whether the patient’s dose is near the boundaries of the recommended dosing range.

Smart alerts

Touchdose generates patient and case-specific Smart alerts to provide clinicians with additional insights into the specific logic applied in determining dose suggestions.

A smart alert is triggered when an alternative body weight scalar, such as ideal body weight (IBW) or adjusted body weight (AdjBW), is used to calculate a dose because the patient is obese, and the formulary recommends using that scalar in such cases.

Example alert: "Patient is obese. Formulary instruction to use AdjBW in obese patients. AdjBW (67.38 kg) has been used for dose calculation."

An example of how the Smart alert surfaces at this part of the prescribing journey can be seen below:

Note that Smart alerts can be generated as a result of other scenarios, but these will only be presented at the next stage of the prescribing journey. See the Smart alerts section on the Medication order page.

Formulary view

The availability of the formulary view depends on the content source you have selected. If available, you can access it by clicking the “Formulary” button (circled in the figure below). Currently, this feature is not available for BNF content but is accessible for all other content sources.

The formulary view displays the underlying formulary information across all patient groups in a non-patient-specific format for the selected indication. This allows you to see the details of any calculations performed and compare dosing across different patient groups. The patient groups relevant to your patient will be slightly highlighted to help you identify them easily. Additionally, some free-text information applicable to all patient groups may appear at the bottom of the view.

Refer to the figure below for an example of the formulary view and the location of the “Formulary” button:

Renal caution banner

If the caution renal flag is present, as outlined in Derived Patient Parameters, an additional banner will appear on this screen. This banner clearly indicates that the patient may have renal dysfunction, which Touchdose has not considered in its dose recommendations. As a result, manual dose adjustments may be required.

Tags

Tags can be used to add additional information to medications and indications. Every tag returned for this screen is displayed. Tags that apply to the medication are shown next to the medication — for example flagging a controlled drug or a prescribing restriction — and tags that apply to the selected indication are shown alongside it, for example indicating the recommended line of therapy or relevant guidance.

See a screenshot below for how tags appear in the system for Abatacept as an example:

If a tag includes additional detail, clicking on it will display that information. In some cases, this view may also include a link to further information; if so, a button will be shown that allows you to open the link in a new tab.

In other scenarios, a tag may contain only a link and no additional detail. In this case, clicking the tag will immediately open the external URL, and an icon will indicate that it will take you outside the system.

Finally, if a tag has no additional detail and no associated link, it will be displayed as a non-clickable label.

Other information and navigational elements

Patient header

At the top of the list of indications, there is a Patient header that contains all the patient information known by the system.

Navigational elements

See the bullet points below for where to find the following features and information:

• A menu button that contains the following sub items when clicked:

  • The instructions for use document / manual

  • A training video that explains how to use Touchdose

  • Information about the device and formulary

  • Feedback form that allows you to send any feedback you would like

The menu button is found in the top right corner of the patient header to the right of the Dosium logo.

• Navigation to previous pages
  • Above the selected medication name.
  • In an in-order launch, the medication is fixed for the duration of the prescribing flow; the breadcrumbs do not allow navigation back to a medication selection step.
  • See the figure below for where the page navigation buttons can be found: