e-Prescribing and robotic dispensing: part III

This is the third article in a series on using technology in a hospital pharmacy. The first article described the efficiencies of linking electronic prescribing (EP) and robotic dispensing (RD) as we have experienced them at Sunderland. The second article looked at using unique bar codes on boxes to improve the distribution of fluids

around the hospital, and in doing so integrated fluid distribution much more closely with ward processes. This article looks at the impact at ward level of EP-RD, and the effect it has on pharmacy professionalism.

The efficiencies described in the first article released pharmacy time to be deployed in other areas. The pharmacy at Sunderland has a strong ward presence, but it became evident that what pharmacists think about the technology and its impact on their working lives is not well described in the literature. A study was carried out to further assess pharmacists’ views on this matter. It is also described in reference 1.

In Canada, Motulsky et al.(2) looked at the impact of technology on the professionalisation of community pharmacy, and concluded that the adoption of technology increased professionalisation. They defined increased professionalisation as pharmacy practice centred on clinical activities within pharmacy services. There is confusion in the literature regarding what constitutes EP, which distorts any attempts at benefit analysis. Abdel-Qader et al.(1) performed a qualitative survey on three hospitals in North West England using EP, and published the results of attitudes of doctors and pharmacists to the technology. The survey results were not unexpected when the levels of EP technology were assessed because two of the hospitals were using dual paper and electronic systems at the same time.

A questionnaire was developed in line with standard texts on thematic analysis from themes identified by a focus group and circulated to pharmacists to assess how they regarded the impact of technology on their own practice. Scores ranged from 1 to 5 per question, with 5 being ‘strongly agree’ with the question. Twenty-six out of 35 pharmacists responded (75%), making the aggregate ambivalent (neutral) score for each question 78. A score above or below this indicated agreement of disagreement with the question. The questions and responses are shown in Table 1.

A focus group identified six themes, and questions about these were asked of the pharmacists. The six themes were: information, ward relationships, policy enforcement, efficiency, EP versus Kardex (medicine chart) and empowerment (defined as the ability to do what pharmacists felt was professionally beneficial to patients, that is limits to their professionalism).

The main finding was that EP as applied at Sunderland provides ward-based pharmacists with a wealth of information to support them in their role. This was supported in many comments. One interviewee said, “the doctors feel as if we are omnipresent”, such is the information available. What follows from access to this clinical information is a feeling of empowerment. This process of empowerment has a positive effect on ward relationships.

Most pharmacists appreciated the information to hand with EP. Besides medication prescribed, it included pathology laboratory data, nursing notes and also a ‘notice board’ screen on which to write important comments (Clostridium difficile/methicillin-resistant Staphylococcus aureus status, etc.) All of these can be utilised from a laptop computer when in discussion with patients. Access to information did support pharmacists as they learned to better apply their clinical and personal expertise. This was reflected in the band 8 pharmacists ‘no’ answers in this section, whereby experience makes them less dependent on other information sources. There was a comment about the poor quality of the discharge medication summary report (discharge letter), and the full potential of the EP system not being used. The comment was not negative, but reflected a higher expectation of what can be developed from the EP system when good quality information is available to support pharmacists and reflect EP system development needs.

Most pharmacists felt that EP enhanced ward relationships, as evidenced by questions 10 and 11. Several mentioned policy enforcement using EP was much better. The key to this is understanding how medicine policies at Sunderland are enforced using EP. Individual drug files are controlled by pharmacy. If a drug is not on the drug files, it cannot be prescribed. This controls the hospital formulary easily and, in this respect, the ‘policeman’ function of the hospital formulary by pharmacists is removed. This means that the pharmacist does not have to enforce the formulary at ward level, and therefore avoids a confrontational aspect of working with doctors. This permits the development of a more positive relationship with ward staff. All agreed that EP supports the clinical pharmacist at ward level. All pharmacists answered yes to question 16, meaning pharmacist clinical training was considered critical. On the whole, pharmacists thought EP helped policy enforcement.

Linking EP directly to the robotic system means that dispensing errors are designed out in this system. The confidence with which pharmacists use ‘instantaneous dispensing’ reflects this point (that is, trigger dispensing and labelling of a prescription from ward level). Dispensing errors are not perceived as a concern, which was reflected in the survey. The only point where it is considered in the survey is in terms of comments about robot reliability. There is an expectation of 100% reliability of the dispensing robot. If there is a problem (for example, with the automated labeller), it slows down matters from ‘instantaneous dispensing’. This affects the pace of work carried out by ward-based pharmacists and technicians. Network capacity also becomes a concern. One pharmacist commented that the system slows down around 3pm to 4pm, and this reflects increased network traffic on the EP system at these times. Most pharmacists thought the systems at Sunderland more efficient, including weekend work. Curiously, band 8 pharmacists did not consider the systems helpful during weekends. However, the chief pharmacist commented how the technology supported weekend working and staff cover (the pharmacy at Sunderland is open 80 hours per week). Some respondents felt that the EP system could do more, but that the level of efficiency from the robot was nearing the limit of possibilities.

Overall, pharmacists felt EP was superior to the Kardex. Two band 8 pharmacists qualified their views by saying that the EP system is much neater than a Kardex if the Kardex is heavily used, and has lots of medication stopped on it. However, although most found this a positive thing, three mentioned that there were aspects of a Kardex that might be better for discussing medication matters with patients. These reflect the closer, better ‘eye contact’ discussions. The amount of relevant information readily available using EP was considered to be superior to the Kardex.

Most pharmacists felt that the processes empowered pharmacists at ward level (that is, they could do more for their patients than without EP-RD). The RD and EP meant less time was needed from pharmacists in dispensaries. This feeling of empowerment was positive. One experienced pharmacist said “EP lets the pharmacist cover more ground than traditional methods.” This comment links with the same pharmacist noting the systems seem to increase recruitment potential within the UK. Most staff felt empowered on the wards, that the system met with their preferred style of working, that the systems enhanced ward relationships and was a more efficient way of working. This links to the responses to ward relationships and policy enforcement. Kahalen and Gaither3 observed the way the organisation behaves to give empowerment to employees affects the commitment of pharmacists in such behaviours as commitment, loyalty and job turnover in a positive way. This is in line with Kanter’s theory.(4)

One aspect of enhanced ward-based relationships is in the subtle shift of prescribing on the ward. Within the Sunderland system, new junior doctors are less familiar with EP than are the pharmacy staff. The junior doctors do more actual prescribing than consultant colleagues, so there is a need for the presence of the pharmacist to help them navigate their way around the EP system. This creates a positive environment to professional relationships at ward level with nursing and medical staff. (See reference 3 and compare with Smith and Preston,(5) who identified barriers to effective team working in an NHS trust hospital.) Our survey identified that it took a pharmacist around three months to be fully competent within the EP-RD system. New medical staff receive nothing like this level of support, so part of the survey results may reflect insufficient induction training for other hospital staff.

It was considered that the level and degree of integration of the pharmacy service at ward level was based on the efficiency of implementing and integrated EP system with a RD system. One major feature from the qualitative survey was acknowledgement by pharmacists that the level of ward work (based on each of 36 wards receiving 0.75 whole time equivalent [WTE] pharmacist time and 0.5 WTE technician time) would not be possible without the technology. Readers not familiar with dispensing at Sunderland need to be aware and grasp the notion that over 60% of dispensed items are initiated from outside the pharmacy.

Staff based in the dispensary have no input to the items picked and labelled automatically from commands at ward level. Dispensary staff merely put them into the right box for onward distribution. A major virtue of the technology was that it reduced the amount of mundane work that pharmacists and technical staff are required to do, and allows more time for pharmacy staff on wards. The positive view on relationships at ward level with doctors and nurses indicates pharmacy staff are not only present on the ward, but integrating into the ward teams. The empowerment section indicates pharmacists also considered that they are doing the appropriate tasks for their pharmaceutical skills. The significance of the EP-RD impact at ward level by a suitably trained pharmacy workforce is that it is ‘visible’ to ward staff, and ‘sells’ the pharmacy service to the hospital. By adding value to the pharmaceutical processes, and meeting the patient’s pharmaceutical needs, it implies these services would continue to prosper even in a budget constrained environment.

As pharmacists are empowered to integrate with ward teams, they experience many more patient experiences and, as a result, they frequently encounter more complex professional matters. This accelerates their experiential learning, and will from time to time throw up concerns about ‘the rules’ and the patient context, and challenge them to think more about the first principle in the code of ethics about doing what is best for the patient. These factors focus the mind on what would be defendable actions if a rule was transgressed. It is in this context that pharmacists will be better able to make correct decisions for patients and that ‘professionalism’ increases.