In this feature we dive into the world of EPMA (electronic prescribing and medicines administration). To find about the technology, we spoke with Paul Volkaerts, CEO of Nervecentre. We also managed to chat with Gang Xu, Consultant Nephrologist and Graeme Hall, Chief Pharmacist at University Hospitals of Leicester (UHL), to discuss their recent go-live with the Nervecentre EPMA module on their renal wards.
First up, we talk with Paul Volkaerts about the go-live, as well as the approach, learnings, where they are with the roll-out and what else is coming up next…
Speaking about the technology directly, Paul said: “EPMA is such an important piece of software to a hospital trust. As a software provider we have dedicated a lot of time and resource to try and perfect our perfect EPMA system. With the roll-out stage being just as crucial, the EPMA deployment at University Hospitals of Leicester was a pivotal moment for both organisations.
“This was our world-first airing of this piece of software and the staff took to it immediately, and the feedback was extremely positive. The training was minimal, as the software is intuitive and user-friendly, which is what we target; our thinking is ‘when was the last time anyone was trained on Facebook?’. You shouldn’t need to be heavily trained on any mobile software.
“Since go-live, the success measures have also shown that clinical staff at UHL have administered over 50,000 doses using the system in 10 weeks – 95% of that was on mobile, as opposed to PC based.
“Safety is paramount to all EPMA products. This is one of the reasons we wanted to incorporate closed loop medicine administration from the outset, but there are other areas too that we wanted to focus on to drive safety improvements, such as ensuring all medicines are included within the EPMA.
“When hospitals are live with an EPMA system, it’s common that some complex drug pathways have to remain on paper, such as haemodialysis and subcutaneous insulin, but that shouldn’t be the case – the Nervecentre system is able to handle the most complex medications – often the most dangerous ones – in a safe and clear way.”
To explore the programme further, we also asked Graeme and Gang a few questions about the go-live, what happened and what’s next…
What approach did you take to go-live?
Graeme: “We took the approach to identify a pilot area, and we chose the renal speciality at our Leicester General site and went live on the 30th September on our renal wards.
“The idea really was to get some experience and learnings from the renal wards and then, after a review period, to roll-out across the hospitals.”
Gang: “An important part of our approach to mention is that we currently have an EPMA system in place. We’re not entirely moving from paper to digital. We have been using both but, from a clinical point of view, we had to log-in to five or six different systems to do a ward round. For clinical observations, I could see that having it integrated in one system and not having to use another log-in, remember another password and so on worked better.
“Our initial discussions focused on where we should pilot; should it be it somewhere straightforward, where there is not much clinical risk? Or where complicated prescriptions are going on? Or do we take another approach?
“The approach we decided [on] was to pilot on a ward [that was] more complicated. We discussed areas such as for dialysis patients, patients going to theatre to have acute renal transplantation, outpatients, inpatients – where we have lots of stuff going on – and ED at one point [also] got mentioned as a place to trial.
“The reason why we as a group decided to try it somewhere more complicated was because the decision was this system needed to work wherever it was. There would be no point trialling it somewhere easy, where the patients get prescribed free drugs, to find out it’s great but then further down the line find out it doesn’t work in more complex areas.
“There were lots of decisions and governance. It was my role to decide where it was appropriate to trial this system and where we can get the most benefit. But [also to] balance that up with risks.
“We meta-tested literally every scenario that we have in the hospital – theatre, medical [and] inpatient/outpatient transfers, which was a small enough unit so that if we did have a major issue, we could rollback quickly. So, that’s probably the reason for going with renal and when we decided that in my mind, it guided us to what we wanted to do.
“Right from the outset we looked at making haemodialysis prescriptions electronic, thinking about how we could use smart lists. From my point of view, that was the exciting part of this project. It was about setting the scene and trying to do something useful, which has carried on really. We are trying to leverage the system in as many ways as possible.”
Graeme: “Because we already had an EPMA system, it was absolutely critical that we took a leap forward with Nervecentre, in terms of the capability of the EPMA and its integration into the rest of the Nervecentre EPR. It is key that the system is integrated into the other areas that we already use it for e.g. handover nurse assessments, E-OBS, bed flow. Just deploying it as part of that would give us an advantage.
“Right from the early days we started looking at quite complex issues such as haemodialysis paper. Gang worked really closely with the Nervecentre pharmacists to build that type of order set within the EPMA system, so we could get that into the electronic environment.
“Previously we used paper where the drug is prescribed electronically but then we use supplementary charts, as some things are quite complex to capture electronically.
“We now prescribe and administer subcutaneous insulin directly into Nervecentre, where prior to Nervecentre we would use a supplementary paper chart for this, with a note in the EPMA to indicate that the patient was on insulin. We now put all the dosages for insulin on the system and they get changed depending on blood sugars, and the blood sugars are obviously visible because they are part of the E-OBS module. That now means that, of course, our diabetes outreach team can see all the prescribing of insulin and the doses against blood sugars, so they can monitor at a distance how we are doing with patients for diabetes in the hospital on the renal ward. That has been a positive development for us and very much one that Gang has been involved in – working and pushing those boundaries.
“We signed a long-term contract with Nervecentre to develop the project to meet our needs and we are pushing that envelope really quite early.”
What happened on the go-live date?
Graeme: “It went really, really smoothly!”
Gang: “We planned it quite a lot, we had a lot of discussions again around clinical governance and risk. In a way, having to deploy a new electronic system on a ward which is already running an electronic system…that was always going to be challenging. Then on top of that our staff on renal would be using their third electronic prescription system in probably around five years.
“There needed to be quite clear buy-in by the clinical team, not just to be something they would try for a few weeks which wasn’t going to work. There was an initial plan of how we would do the transcription process and then that was discussed – we then took that to the clinical team where the matron said that wouldn’t work for us – took it back and changed it and went back to them again with the new process. Graham spoke to some other trusts about this too.”
Graeme: “Derby hospital were moving from one e-prescribing system to another, and we spoke to a number of London hospitals.
“You have to do the changeover quickly; get the prescriptions from one system and onto another system by the time of a major drug round. The plan was to start early in the morning, you would have the morning drug round done on the system you were moving away from, then you would aim to get the 12:00pm drug round on the new system. You have to transcribe those prescriptions across, and we deployed medical staff and pharmacy staff to prescribe on the new system and then for the pharmacists to check the new system – that process in a renal environment was lengthy because the patients were on a significant number of medications. So that was a tough morning really!”
Gang: “We learned from that and we tried to capture what did and didn’t go well with that actual deployment and we rolled it out on another ward. The first time we rolled it out was organised chaos, whereas the second time was smoother.
“It took a lot of planning and I think what we learnt was you have to talk to the staff on the ground. From a larger trust-wide deployment, we are not saying ‘this is how you do it’, but we are saying ‘this is how we did it’, ‘these are the resources you need’ and ‘it is up to your matrons and your clinical staff to decide how they want to do it’. The type of granularity and detail for implementing such a system, you’re not going to know unless you go to frontline staff who can come and say, “hold on, for our service this is just not going to work”. Our challenge now is to try to get that level of buy-in across the Trust.”
Graeme: “One of the big learnings for me is that when you are thinking about this, it is much more efficient to have the transcription process done by the staff who know that patient group.”
Gang: “We have tried to set the tone where this is not just a one-off project where we are trying to hit terms in a contract and be done with it and move on to another contract. This is part of a bigger transformational change in the trust, where we are using this as a tool for better clinical care.
“We are now trying to link this into quality improvement, so we now have a system that shows us patient observations, pulls in blood tests and medication results. We know about insulin, missing critical drugs, and for a fairly short period of time you could think of hundreds of things you could do with this system. The next stage is to deploy this trust-wide.
“The other big learning for me is that it’s about process and understanding clinical process; some of the issues we’ve come across have been because we haven’t taken into account just how people on the front-line work. Your beautiful process on paper looks like it should work, but in reality, it doesn’t. It isn’t about the product but understanding how the process fits in.”
Graeme: “If we are really going to go for transformation, what you don’t want to do is just to use the system to replicate what you already do. We do not see this as the deployment of an IT system but about the intelligence you gain from a system to use as a smarter way to work.
“Our hospital is under a huge amount of pressure. COVID-19 aside, the flow of patients is increasing all the time and we need to track that on a mobile device. We are looking to deploy to the rest of the hospital in the first quarter of 2021. Ordering of results from pathology will be feeding through in early 2021, which will give us a fuller picture from prescribing. We will also be thinking about how we will use this tool that we now have to really change the way we work.”