teaser
Rod Beard
B Pharm MSc MBA MProf
MR Pharm S
Principal Pharmacist, City
Hospitals Sunderland
Medicines are ubiquitous in hospitals and an electronic prescribing (EP) project has to be an organisational one, because of the degree of change management required for effective implementation. Researchers have outlined the number of medication errors a typical NHS hospital in the UK might have each.[1]
One of the issues that arises when trying to encourage management to implement such projects is the perceived cost-benefit when compared to other conflicting priorities. However, tentative evidence-from a 1000-bed hospital in Sunderland, Northern England, with eight years of EP experience- suggests that the better integrated and implemented the system the greater the corporate benefit. Preliminary data suggests this may not be an inconsiderable amount of the trust budget.[2]
Definition of integrated
In the context of EP, integrated means a reduction in the number of times data need to be re-keyed into the system. It is obvious that if a task does not have to be repeated there is an efficiency saving. Therefore, the more comprehensive the level of integration, the greater the potential for efficiency. This means information should flow between the various modules of the hospital IT systems (including pharmacy, pathology, radiology, electronic prescribing, drug administration and patient administration systems). In the system at Sunderland, when the doctor prescribes electronically for an in-patient, the directions also go on to the label of the medicines.
This removal of double handling/typing of information saves around 800,000 re-keys each year at Sunderland in pharmacy. This allows re-direction of resources out of the pharmacy to assist with problems on the wards.[3] However, this potential to improve efficiency is realised only if the system is highly integrated.
Significant changes in working arrangements need to be made to re-deploy staff at ward level. It is important to appreciate that EP is not magic, but it is a platform for change management. Some hospitals use stand-alone EP prescribing modules that do not fully integrate with the rest of the hospital IT systems, considerably reducing the potential for efficiencies.
Ideal system features
The greater the amount of data that is captured in the day-to-day processes, the greater the move towards complete integration. It is illogical to believe that partial capture of information can yield equivalent benefits. The way the organisation handles data (well or badly) shapes its efficiency and EP imposes discipline to focus and direct data handling of consistent quality, reducing unnecessary expenditure. The crucial point is that the cost savings accrue across the organisation because of improvement in the quality of the medicine processes.
Therefore, ideally, we need:
- No requirement for any paper information which has the potential to be missed. For prescriptions this is dangerous. Ideally, the system will deal with inpatients and out-patients. Chemotherapy and clinical trials are particularly challenging areas to link into an EP system.
- A clear transaction link to the patient for all records.
- The potential to make information available to all users – based on a hierarchy of permissions.
- The uniqueness of each transaction to be logged and auditable. This means a corporate approach to information individual departmental systems will lose benefit at a corporate level.
- The patient is linked individually into the medication process. (not using ward stocks).[4]
- Linkage of information on medicines to trigger warnings for weight-adjusted doses, allergies, contraindications, or interactions.
- Potential for interfaces to link to departmental equipment. For pathology, this might be linked to analysers, for pharmacy, perhaps a dispensing robot.
- The system should provide the clinical coding and financial information required. Ideally this should be done as close to the bedside as possible.
- The system should provide real-time reporting and file integration.
Formulary management
If the EP is set up to pick from a list of drugs, it follows that there is an opportunity to change clinicians’ prescribing behaviour- if a drug is not on the list to be selected, then it is unavailable to prescribe. It is .possible to have a permissions-based formulary, so that senior medical staff can select from the full drug inventory. However, this means that the particular consultant wishing to prescribe such a medicine must do it- the prescribing of restricted medicines cannot be delegated.
The formulary does not rely on goodwill for observance. This means the formulary runs optimally with minimum deviations. The advantage over a ward pharmacy service in maintaining formulary adherence is that it runs 24 hours per day- there are no ‘missed dose’consequences of a restricted drug being inappropriately prescribed. Missed doses are easily recorded
in an integrated EP system.
Convenience
The fact that information flows across the organisation, and is ‘on tap’ wherever it is required saves a lot of time previously wasted seeking information, or moving to a ward to prescribe. Moving information carries a cost that can be reduced by integration of IT systems.
Change management
With an EP system, a locum has to be trained and have log-on codes before being permitted to work within the hospital. This means locums have to be scheduled appropriately and the personnel and training departments have to cater for locum staff. Since ‘on-demand’ training is not possible, the management of staff absence is more disciplined. Locum staff are no longer a substitute for good planning for leave of absence.
Risk management
Research has identified that poor knowledge of medicines outside the individual’s speciality is a potential cause for medication errors.[5] Medicines can be flagged by a British National Formulary (BNF) code, within allergy lists, to give a warning if prescribed. It can be permitted to allow prescribing, and screen a warning flag and confirmation of the prescriber’s intention. Therefore, if an error is made, it is not because of a default. This can apply similarly in paediatrics, where the dose is automatically checked against the weight.
The links across the various files to make risk management part of the system work reflects the level of integration of the software. This level of real-time interaction is an important feature in an ideal system.
Therapeutic optimisation
The fact that these systems work 24 hours a day means that therapeutic variation is reduced, meaning that overall, the organisation uses medicines more consistently. This potentially reduces length of stay, and thereby allows increase in patient throughput. Increased throughput means increased revenue for the organisation. EP is not the only means by which this can be achieved, but it can enhance whatever systems are in place by the sheer efficiency of the integration of information.
Comprehensiveness of information
Clinical codes- such as The International Statistical Classification of Diseases and Related Health Problems (ICD10), pathology tests, medicines and other aspects of treatment- mean that all the data can be used to become important information. The information can be used for finance, governance, monitoring or research.
Accurate information
Under the UK payment by results funding, some drugs are funded as individual treatments rather than part of a care package. It requires that the patient and the drugs can be mapped in the hospital IT systems to trigger reimbursement from the appropriate primary care organisation. The discipline of EP forces information to be recorded, therefore, financial reports are more accurate, ensuring all payments are triggered.
Making the case
The potential for EP to facilitate improvements in the overall hospital medicine processes is significant, depending on what precisely is being implemented. The benefits are not confined to reduction of medication errors alone, and if the desired outcomes are thought through, then there is a wider organisational benefit that makes the business case for implementation more attractive.
References
1. Karnon J, McIntosh A, Dean J, Bath P, Hutchinson A. A prospective hazard and improvement analytic approach to predicting the effectiveness of medication error interventions. Safety Science 2007;5(4):523-539.
2. Beard RJ. Professional Masters thesis: University of Sunderland 2009.
3. Woods A, McElnay JC, Fleming GF, Hogg A, Scott MG. Pharm Journal 2003 217. A hospital-based integrated medicines management model.
4. Longo DR, Hewett JE, Bin MD, Schubert S. Journal of American Medical Association 2005;294(22):2858-2865; The long road to patient safety: A status report on patient safety systems.
5. Bates DW, Gawande AA; NEJM 2003;348(25):252-2534 Improving safety with information technology.
