At HTN Now: November, we were joined by a team from CareFlow Medicines Management (CMM) and Barnsley Hospital NHS Foundation Trust consisting of CMM’s Head of Programme Helen Mutton and Barnsley NHS FT’s Deputy Director of IT Richard Billam and Clinical Digital Lead Bethany Pearson.
Starting off the session, Helen shared some information and background as to why electronic prescribing is important: “I think we can all agree by this point, we understand that electronic prescribing is the way forward for the NHS. It keeps patients safe, it allows them not to lose card exes, it ensures that you can read the handwriting, it makes sure that no one’s allergic to something that’s being prescribed.”
Now, Helen continued, with hospitals and trusts and health boards behind the change, “it’s time to start looking at the project, how they can work harder and move it at pace and fulfil their desire to get themselves live on electronic prescribing, but also see the benefits faster and keep patients safe overall.”
The EPMA timeline
Next, Helen shared some information about the EPMA (electronic prescribing and medicines administration) timeline. A year ago, System C bought CareFlow Medicines Management. “They decided to utilise us as their electronic prescribing tool of choice,” she said. Soon after, Helen was asked to go and work with the Barnsley team who needed to go live with electronic prescribing in a short time period.
Helen’s strategy to accomplish this involved calling on market leaders and customers who had rolled out electronic prescribing at pace, to make the most of their expertise.
A key fact about those customers is that “they put an extraordinary amount of time into the project upfront,” Helen noted, spending six to ten months getting ready for the rollout. Once the rollout happened, they moved fast.
Barnsley “took the lessons learned from other sites,” Helen continued. “They understood that it was a proven, safe product that is live in over 60 hospitals across the UK, and they knew that they weren’t going to be coming across any real patient safety issues because it is in live use.”
In terms of the implementation timeline, October 2021 saw introductions, project planning, a new project manager joining the team and the installation of the solution.
In November, “train the trainer” took place which meant that super users “got up to speed, so that they could undertake implementing this in their live. environment”.
In January, there was product testing and awareness days were held. “It was very important to us not to make this feel like anything was being done to anybody,” Helen emphasised. “We wanted to take them on the journey with us with us.”
By February, Barnsley was ready for onsite support and by March, they were “celebrating the success of electronic prescribing”. This led to the project being called “EPMA in 80 days”.
EPMA background
At this point, Richard took to the floor to explain the EPMA journey.
In 2018, the trust had planned to implement EPMA solutions alongside their EPR system at the time, but this was put on hold with the decision to move to a different EPR. In April 2021, they started to implement System C’s prior EPMA solution.
However, in October 2021, System C purchased WellSky EPMA and recommended implementing that instead. Richard commented that it was a “real commitment” from the CMM and System C teams to support this, “to build all the integration we’d got with the previous product.” Crucially, Barnsley had secured funding which relied on them having electronic prescribing, so it was very important that the implementation met Barnsley’s existing timelines.
Benefits of switching to CMM included maintaining full integration with PAS, which was managed by the supplier; medication would appear on the discharge summary; it was a well-known product in use at two local trusts; and CMM had all the functionalities that Barnsley were looking for, including outpatients, complex infusions, paediatrics and more.
A key challenge was time. “The timeline didn’t change – we had the same objective but less than half the time to deploy it,” Richard pointed out. In addition, “We had absolutely no awareness of this product at all. We were completely reliant on CMM’s expertise and we had to get up to speed very quickly. It was also a period in which we saw significant changes in our own team.”
Another challenge was the need for agile working, but Richard noted that this “actually proved to be a real benefit.”
The rollout
To start the rollout process, a pilot took place on two wards across two weeks to “get a really good view of how it worked and to give an opportunity for all these issues to come out.”
In terms of the trust-wide rollout, they planned for three wards to go live per week until the end of March, targeting larger wards to ensure that they would hit their 80 percent target if they faced any issues.
Richard noted that they put “an inordinate amount of time into mapping out staffing levels, patient numbers, dates – all sorts.” He noted that he wasn’t sure that it was all high-value, but “it did give us a really good plan of how we were going to rollout.”
The pilot “definitely highlighted things that we could improve,” Richard said “We looked at how people used the system in the real world and that informed how we trained it, how we communicated. It helped us to build the tools for managing patients through the cutover process, so we made sure that we’re tracking it all the way through.”
Lessons learned from the pilot included that different wards have different working practices, so adaptations are needed for training materials, and the two week period was too long; the system was embedded within three days and frustration grew in the second week.
The rollout across the trust faced no major issues, though Richard commented that the pharmacy team felt the brunt of the change when their existing paper processes came up against EPMA processes. He noted that you could see the impact of having EPMA and non-EPMA wards; moving patients in between them resulted in short-term paper reports which could cause problems.
“We sat down together as a whole team and looked at everything, and we thought, ‘There’s an amount of pain that we are going to go through here,” Richard shared. “We thought that we could either take that pain over a 10 or 12 week period and slow down, or we could go faster and have the same amount of pain but experience it in a short period, which is ultimately what we did.”
Planning and support
Bethany took up the presentation here to discuss planning and support, as that is the stage at which she became involved with the rollout.
“Looking at how we prepared the hospital and the staff for actual implementation of EPMA, we looked at how we could support and provide resources to staff,” she said. “Our support resources were clinical systems, our EPMA pharmacist team, myself as digital nursing support. We also worked closely with the University of Sheffield and Sheffield Hallam University; they provided student nurses and student medics and that was quite innovative. It was a two-way support system – we helped them with change management projects and being involved in digital healthcare, and they helped us with supporting staff and supporting the rollout.”
In addition, there were transcription resources available on the day. “We put an SOS out across the hospital to ask for people to support with transcription,” Bethany shared. “We got support from medics, from pharmacists, pharmacist techs, the patient safety team and the acute response team. They weren’t necessarily prescribers but that was fine, they had medical knowledge or clinical experience and they weren’t actually prescribing. They were just transcribing, and the medications are authorised afterwards.”
When they were taking a ward live, they visited each ward beforehand multiple times. “We would meet the ward and tell them the expected that we would be arriving and gave them an overview of what was going to be happening.” In addition, Bethany’s team would check all the IT equipment and the IT team would make a ward visit too.
About a week before their go-live, when they had the exact date, the ward would receive confirmation of this.
“When we arrived on day one, we would arrive for the handover from 7am and introduce ourselves,” Bethany said. This served the double purpose of helping staff know who to approach for help, but also meant that Bethany’s team could identify any high-risk patients on critical medication.
“We wanted to be ready for the first drug round,” Bethany continued, “so after the staff had done the first medication round at 8am on the paper drug cards, we aimed to be ready by the next drug round at lunchtime, having everybody transcribed over by then.
“We provided elbow support for the staff throughout the day, up until the last medication had been given at night. We identified those members of staff that might need a bit of extra support and sat down with them before we left, and then we came back again the next morning at 7am so that we knew everyone was OK.”
Engagement
On engagement across the hospital, Bethany said, “It is a challenge, and there isn’t one route to ensure that you have spoken to every member of staff, that everyone is aware and on board. Essentially, we took our engagement to them. We attended senior nursing forums, we attended all governance meetings. Myself and our CNIO had one-to-one meetings with every lead nurse in the hospital and asked them to identify any staff that they felt would be an ally and could provide training and support to others, or maybe people who might need extra support themselves.”
Messaging went out in the consultant newsletter so that they could communicate with consultants, and as Helen mentioned, the CMM Open Day was used to raise awareness.
When it came to training, Bethany and her team developed training packages. “We developed a £50 incentive on Page Tiger for everybody that attended the training – that was mainly because we knew that they would not be able to do it whilst they were on shifts. They would have to do it in their own time.”
Along with visits to ward areas, dummy drug rounds were performed. “Those were invaluable,” Bethany commented. “They gave us really strong lessons as to how nurses actually administer medications, what times medications are prescribed, how pre-charting works.”
In addition, the team attended junior doctor teaching sessions to provide further training.
Common issues
Bethany picked out some of the challenges that she faced, noting, “Finding drug cards was a challenge – that’s one of the reasons that we wanted to move over to EPMA.”
Nursing and medical staff, however, can be keen to hold onto drug cards. “That’s what they knew and it was safe,” she commented. “But we needed to get those medications off them. Once we got them, there was also the challenge of keeping hold of them – we had a couple of ward areas with particularly sick patients who needed access to those paper drug cards.”
Bethany added that transcription resource was another common issue. “We massively underestimated the length of time that transcription would take, particularly in some areas such as care of elderly where they’ve got three or four paper drug cards, a long list of medications with many interactions. I would advise people to get extra transcription resources.”
There were other issues with IT equipment which needed minor tweaks; for example, they found that track pads on laptops did not work when staff were wearing gloves or PPE so they needed to be able to use a mouse, and WiFi connectivity had to be checked to ensure it was all working properly.
Another issue lay in needing to ensure that people had set up their user accounts, with some people slipping through the net despite prior work in this area.
“With regards to protocols, the system is very intuitive and prescribing a medication is very simple,” said Bethany. “But sometimes they can need extra support, for example warfarin protocols; you can prescribe warfarin as a one-off but it’s better to use it as a protocol, so work went into ensuring that we were promoting the use of those protocols.”
Objectives, testing and rollout
The objectives for the EPMA rollout were clear to Barnsley. “Whenever we spoke to people, we had a real joined-up approach and they got the same vision from everybody and the same timeline from everybody,” Richard said.
“When we talked to staff, we talked about the reasons why we are doing it – not the financial savings or anything to do with the back end, saving drugs and reporting. It was all about what happens to them,” shared Richard. “We know that EPMA systems are safer than paper ones, and everybody cares about their patients. It’s a no-brainer. You won’t have to chase paper charts around, you’ll be able to access it any time, you can access it from anywhere, multiple people can see it at the same time, you can see previous care episodes without having to go and retrieve notes.
“From a Barnsley point of view, there’s a real sense of pride as well,” Richard added. “We were an outlier. Getting us up to speed with EPMA was a good driver, locally.”
He noted that there was a “definite leap of faith” involved in the project, from their reliance on CMM and System C’s knowledge to the necessary differences in the trust’s reporting and business intelligence dashboards. “These things were outside our skillsets and we had a lot of catching up to do,” he said.
“But whenever we did have issues, it was never a CMM, System C or trust issue,” he added. “We just treated it as an issue that we would work together on because this is our vision, this is how we want to deliver it, and this is when we want to deliver it by.”
In terms of testing, Richard noted that they adopted a much more agile approach of doing continual testing and integration testing.
“We’d get that bit of new functionality or some new integration, do a unit test on that to make sure it works, then run things end-to-end as well,” he said. “That helped us with product knowledge, it helped us with confidence, and we got a real grip on the system. I would definitely encourage that type of approach.”
He highlighted that they also undertook real-world testing. “We’d get out there on the ward, take trolleys around, and get people to do administration on their paper charts,” he said. “Then we’d show them how you would do that electronically.”
For the rollout, Richard shared how Barnsley worked closely with the network that they had built up through previous EPR and EDMS rollouts to “get them involved, engaged, sell them the vision – and get them to go and sell it to their teams. We found lots of new allies.”
Ultimately, Richard said, “We always kept focused on what we were going to deliver. We questioned how this change or enhancement helps us meet go-live objectives. If it didn’t, we packed that up as a request. If it got raised again, we wouldn’t have to go and revisit it because we’ve already dealt with it. We packaged it in a way that meant we could deliver it at a later date… having a phase two plan was really important.” He noted that this helped to give people confidence that their ideas and requests were being heard.
“Similarly, in terms of risks and issues, we had an open log that everybody could see and add to,” Richard added. “We encouraged people to put their thoughts in there, it allowed people to voice things that they wouldn’t necessarily do in public forums. We looked at those from the perspective of whether it was a new risk or issue being brought up by EPMA, or an existing concern that people were taking the chance to raise because there’s an opportunity. We questioned whether it was a system problem; if it was, that would probably lead to some development. Could we update our processes, either in the short-term or long-term? Again, we used that as an opportunity to recruit support.”
Team impact and lessons learnt
Richard pointed out that it is important to recognise the impact on the team; prescribers, for example, should see “huge improvements” from being able to access the system any time in any place, though they will need to develop their understanding of naming and dosing conventions.
For nurses, the system is very intuitive and designed to replicate the paper drug chart they are used to using, so training is minimal but floor walking support is “critical”.
For pharmacists, EPMA may mean a significant change to ways of working and early access to the system is key. “I think the key here is getting pharmacists involved in that end-to-end process,” Richard said. “Not just around testing CMM, but testing their entire process from end-to-end and how CMM sits in the middle of that.”
Finally, Richard summarised the key lessons that he and his team learned:
- Build your own formulary, you’ll learn as you go.
- If you can, build the whole formulary to remove supplementary charts.
- CMM is easy for prescribers and nurses; don’t overthink training.
- Change for pharmacy processes is significant so engage with them early.
- Provide extensive floor walking support when wards go live.
- Transcription is hard so you’ll need lots of people to help.
- There is little benefit from extended pilots.
- Rollout as fast as you can because staff do not tend to like the MAC paper charts that are used when switching between EPMA and non-EPMA wards.
- Define reports and build them early as part of end-to-end testing.
- Stay focused; don’t get distracted by existing issues or feature requests.
- Accept agility; run things in parallel; don’t create “dead stop” activities.
At this point, Richard, Bethany and Helen took questions from the audience; this can be viewed from 44:52 on the video below.
Many thanks to Helen, Richard and Bethany for joining us!
