This month our feature focus switches to Electronic and Medicines Prescribing Administration (EPMA). We’ll be sharing a range of articles, expert comment and interviews around medicines management, which you can keep up to date on through our dedicated channel.
Here, Gary Mooney, Clinical Solution Executive at InterSystems, shares his EPMA experiences, advice for Integrated Care Systems (ICSs), and the benefits of using platforms like TrakCare. Find out more, below…
Hi Gary, tell us about your career path and role with InterSystems
I started my career in academic medicine – I was a lecturer in a medical school and ran a research and development unit, which had started to look at early use of digital health technologies and clinical decision making.
From there, I went to work for the Department of Health to set up a team to start to deliver policy objectives, particularly around public health, using digital technologies. I then moved into the commercial sector – working with several ‘best of breed’ suppliers for pharmacy and EPMA, and then Electronic Patient Record (EPR) suppliers. But my focus has always been around clinical solutions and using digital technologies to support clinical practice.
I joined InterSystems eight years ago – I think they’ll probably let me stay now but, in InterSystems terms, I’m still a newbie! My focus when I joined was working with the global product teams, with a particular emphasis around medicines management, helping to further develop the product and make sure it was a full-featured part of the broader clinical EPR [and] a solution that met TrakCare customer needs, which is delivered across 26 regions internationally. We needed an EPMA solution that met the broader needs of those international territories.
My job title now is Clinical Solution Executive so, I work across the business from the pre-sales perspective, supporting the pre-sales and sales teams with customer engagement, and then supporting businesses through procurement into the initial discovery phase. It involves learning about our future customer’s service, why they work that way, and trying to get to a position where we can clearly articulate how they can best use our TrakCare solution [and] broader healthcare solution stack, to meet their objectives. That support then continues through the deployment phase and post-go live. It’s about working with customers on optimisation and further adoption plans, as well.
Do you have any use cases to share with us?
A good example is North Tees and Hartlepool Hospitals NHS Foundation Trust – they’re around a 650-bed service in the North East of England and they’ve been on a journey with TrakCare, our EPR. They had quite a pragmatic approach to the deployment of their enterprise solution and had an incremental journey. They’ve been very aware as to the amount of change they can consume at any one time and have prioritised the different capabilities of TrakCare and how to adopt it.
One of the most significant and rewarding phases for them was the TrakCare EPMA solution. Currently, they have that across both hospitals and across all specialities. That includes general services – outpatients and ED – right through to the areas where it is more unusual to see EPMA, such as in neonatal intensive care.
Their adoption of the EPMA solution has also been incremental. So, they’ve started with the general services, which represent the bulk of activity on a day-to-day basis – and then they’ve rolled into the more clinically complex and demanding. They’ve done a fantastic job with a very capable team led by clinicians. That’s been a key feature of their success. They’ve got the CCIO front and centre, and the nursing and pharmacy teams are heavily engaged.
What the team have been clear about is that EPMA isn’t a pharmacy project. Obviously, the pharmacy [team] are a key stakeholder and they have a lot of experience, knowledge, and governance around medicines. But the prime users of EPMA are the nurses, then the doctors, and then pharmacy.
They aimed for increments of better and have delivered some fantastic results. Even within the first months of using it they were seeing an 80 per cent reduction in adverse medication incidents, and over the first 12 months of use they saved an excess of 20,000 hours of nursing time. That didn’t mean they needed less nurses, what it meant was that nursing time was invested back into direct care and it reduced a lot of that administration, as well as reducing missed and late doses. That’s a key performance indicator for acute NHS trusts now.
Tell us more about the reduction of missed medications
We’re seeing a lot more medications now tailored to the needs of the individual and that can include the timing of medicines. For example, for a patient with Parkinson’s, if they’d been taking medications at home, what would too frequently happen is that they would take medicines five times a day at specific times to control the symptoms – but when they go into hospital, there will be ward times that will be different. This means patients’ symptoms could re-emerge and that can have a knock-on effect in how long they must stay in, when they can have physio etc.
So, what can seem like something simple – such as the time you have your medicine – could have a quite significant impact on the quality of experience the patient has in the hospital. [Hospitals can use] TrakCare as support for personalised medicines times and to make the nurses aware of when individual patients’ medicines are due and if they are time critical.
It works the other way round as well – say a patient gets diagnosed with a neurological condition while in hospital, they start taking those medicines, and then when they go home it’s important that they continue the medicines at the same times. It may be that they go into supportive care or need the help of community nursing teams, or primary care, to manage the condition. So, it’s about the onward communication, as well – it’s a key feature of a modern medicines management platform, being able to receive information from community and primary care and being able to share it with other services. That can help reduce the risk of re-admissions if they’re not complying with medicines as required, or if the GP doesn’t have visibility.
What are the other benefits of EPMA?
There are a range of headline benefits that are usually associated with EPMA, such as the reduction in adverse events around allergy interactions, dosing etc. We’re seeing a lot more coming out about personalised medicines, as well, and having the EPMA as that integral part of a patient record. When I’m looking at a patient’s record – either to give a dose of a medication, to prescribe or alter a medication – I have the patient’s latest blood results or other observations at my fingertips, as well as clinical notes that have been taken, so I have a very rich picture and am not dealing with medications as a separate thing outside of that record. So, yes, there’s a wide range of benefits that customers are starting to see with a unified medicines management platform.
The other big issue is around infection control, with things like sepsis, where you have the timing of antibiotics. When the patient is in the more sensitive phase of treatment or deteriorating, and you’ve got to get antibiotics into the patient, dose and administration is important and they usually fall outside of the usual drug round times. This is where you do need a fully integrated management platform for management of serious and life-threatening infection – because you need to see what the patient’s observations are…to know whether the treatment is effective or needs to be changed, to look at the blood results coming back to see inflammation markers and blood levels etc, and to have all that in real-time.
More people die from sepsis than some of the main cancers, it’s incredibly frequent, and the morbidity levels from sepsis is shocking. The more information and intelligence we can put in the hands of clinicians, who are making decisions [the better] …that’s important.
[It helps] the efficiency of much-stretched acute services, as well. The quicker we can get the patients well and back home, or wherever they are cared for, the better for everybody really.
What we can see with medicines management platforms such as TrakCare is that they are able to pick up those subtle conditions. So, say this patient has normal potassium levels but we can see it’s on a downward trend, and we also know this patient has been prescribed a non-potassium-sparing diuretic. It can give early visibility that we might be heading for a problem here with this patient – so it enables you to be proactive and anticipate, for example, if you need to switch this patient to a diuretic that leaves the potassium in the body. Rather than waiting until the patient becomes ill, you can head it off at the pass.
What’s the hardest part of implementing an EPMA?
The technical perspective is relatively straight-forward – if you have an InterSystems experience – because our solution is built from a full technology stack. So, we provide the data platform, IRIS for Health, the database technology, and we have HealthShare, which deals with all the interoperability and integration. Then we have TrakCare, which is the EPR, and medicines management is part of that.
They are technical challenges but, overall, in terms of an EPMA deployment, it’s not the technical aspect, really. It’s the customers’ ability to adopt them and having the focus on a clinical transformation project. It’s [about] establishing that clinical leadership and pragmatic approach, appreciating how much change can be consumed at any one time. [Also] about having that plan of priorities as an individual customer, a risk profile, and really driving the programme to remove or mitigate those risks, and a plan for afterwards. That’s the biggest challenge.
It’s about starting and getting something done in a reasonable timeframe – something that’s going to have tangible benefits and then having an adoption optimisation programme thereafter. The biggest challenge, from a customer’s perspective, is around change management. To assist customers with that we use a persona analysis… a detailed analysis of the groups of users that will use TrakCare on a day-to-day basis. What’s their role in the organisation? What are the things that are important to them, or concern them? That really helps, as you talk in a language that individual healthcare professionals understand, and it resonates with their roles.
Are you having more interest from ICSs? How do you tell them to get started?
From an ICS perspective, the key is interoperability – being able to readily share information in a standard format. The complexity that surrounds medications, in being able to describe not just precisely and consistently the drug but the frequency, the dosing, the duration…how do you reliably and safely share that information?
Interoperability is key for an ICS in being able to share by crossing over with other services from acute care, tertiary services, primary care, social care etc. I’d encourage them to look at platforms that have that proven interoperability. An important part is also performance visibility. With analytics type views, you’re looking at key performance indicators of what’s happening within the service. Historically, those have been retrospective…but near real-time visibility of performance is key for ICS, so they can see across their region. That leads into more advanced technology, that we’ll see in the coming years, such as artificial intelligence and machine learning.
What do you expect to see over the next 12 months?
I think what we’re going to see is a move towards proven enterprise, robust technology platforms, but with clinical solutions with proven interoperability – so they can receive information in real-time from external parties and share information.
This will enable a GP to see what’s happening with a patient before they even leave hospital or allow care teams to join-up services and be prepared for community nursing activities. Medicines management is a key part of not just intervention within hospitals, but also in ensuring a patient doesn’t go back into hospital.
So, interoperability and communication across care services is going to come more and more to the fore, led by the ICSs. Being able to coordinate and schedule services proactively will help patients get out of hospitals earlier and reduce the risk of them having to go back in.