Medicines at the interface

Growing concerns about the risks associated with medicines had prompted the development of a national electronic medication record, according to Dr Amin-Farid Aly (Project Manager, Drug Safety at Drug Commission of the German Medical Association). Describing the deficits in the current medication use process, he said that prescribing errors occur in up to 7% of prescriptions and dispensing errors in up to 3%. Further errors occur because of non-adherence and failure to carry out annual medication safety checks or monitor responses adequately. As a result of these and other deficits, about 5% of hospital admissions arise from medication-related problems.

More than 20 stakeholder bodies, including medical, nursing and pharmacy organisations, healthcare insurance providers and patient support bodies, have worked together to create a workable electronic medication record. One key development is the layout and content of the record. Dr Aly explained how the record needed to be printable for patients, but allow for electronic access for healthcare professionals. For each medicine the following information is listed – approved name, brand name, strength and dosage form.

Dosing instructions are noted by time of day – morning, midday, evening and night-time; additional instructions (for example, with water, before food, etc) and the reason for the prescription (for example, blood pressure, stomach, leg cramps) are also recorded. Short courses of treatment, such as antibiotics, and ‘as-required’ medicines are recorded separately from regular medication. Over-the-counter (OTC) treatments are also listed separately.

The information is presented in readable form but it is also shown on the same page as a 2D barcode for electronic reading and transfer. It is accessible electronically for hospital doctors, GPs, hospital pharmacists and community pharmacists. Patients will be given a printed version whenever a change is made.

The electronic medication record is not a permanent document and is not a prescription, emphasised Dr Aly. It can be a valuable means of communicating structured information about current treatment to doctors, pharmacists and nurses, provided that information has been entered accurately and is kept up-to-date.

At present, doctors are responsible for inputting most of the information (through electronic links with patient records). Pharmacists are expected to enter information about OTC medicines.

As part of the implementation process, a pilot study has examined the practicality of using an internet-version of the electronic medication record (see Resources). A password-protected secure internet portal was established for the study. The study included 600 patients in five hospitals who were each taking a minimum of three regular medicines.

Hospital pharmacists took detailed medication histories on admission. At discharge, the initial medication record was created in consultation with the responsible doctor, and a printed copy was given to the patient when their treatment was explained to them by the pharmacist.

For the following six months, patients were given an updated version of their medication record by their GP or community pharmacist each time their medication was altered.

By January 2016, 1266 medication records had been created for 405 patients (both ambulatory and in-patients). For 151 patients, the records had been updated on one or more occasions. Some 259 community pharmacists and 186 GPs were involved in the care of the ambulant patients.

The majority (71%) of patients said that this was the first time they had received a medication record that listed all of their medicines. A total of 93% of respondents said it was important that both the GP and the pharmacist were able to update the record at any time. More than 95% scored the chart as legible and readily comprehensible. A similar proportion reported that the indications and additional instructions were important information, and this was new information for more than 65% of patients. More than 80% said that useful advice was given during the consultation when the record was first provided.

The authors concluded that the use of the internet version of the medication record was a simple and reliable way to convey information between disciplines and sectors. From the viewpoints of patients and providers, it represents a satisfactory basis for the provision of information and advice.

Different professions have differing perspectives on the criteria for ‘high-risk’ status, explained Dr Yvonne Hopf (Teacher-practitioner, Ludwig-Maximilian University Hospital, Munich). Factors such as age over 70 years, more than seven regular medicines, more than one high-risk medicine, more than three comorbidities and dementia or inability to manage medicines are generally agreed; doctors usually add organ damage and allergies and nurses would add social problems and pressure sores, she continued.

Turning to interfaces, she said that there are numerous internal interfaces in the healthcare system and handovers are common, so effective communication is critical. One recent publication had estimated that no fewer than 46 doctors could be involved in a patient’s care in a 48-hour period. One useful method for assessing a patient’s status is the national early warning score (NEWS) that was developed in the UK.

This organises information that is readily available – respiratory rate, oxygen saturation, temperature, systolic blood pressure, pulse rate and level of consciousness in such a way that even a junior nurse can make a sensible decision “instead of just recording blindly”, explained Dr Hopf. For example, a NEWS score of zero would call for the minimum 12-hourly monitoring whereas a score of 7 or more calls for immediate senior medical assessment (see Resources).

Poor communication is estimated to account for up to 84% of treatment delays and poor patient outcomes. It can be insufficient or incomplete information or badly organised information, including too much information leading to ‘cognitive overload’, she added. She recommended the ISBAR scheme, which is similar to military communication protocols.

According to this scheme, I stands for identification (Who am I and what is my role? Who is the patient?), S stands for situation (Why is the patient being transferred?), and B stands for background (What is the background or context?). Lastly, A and R stand for assessment (What is my opinion of the problem?) and recommendations (What would I recommend and what are the risks?)

Medicines’ reconciliation when patients are admitted and discharged from hospital is another important way to minimise medication-related problems. It can be hampered by lack of training and resistance to change but can be helped by support from management and local champions.

In summary, Dr Hopf reminded the audience that interprofessional teamworking is often the best way to tackle complex internal interfaces and “bottom-up solutions are always preferred”.