For our feature series on electronic prescribing and medicines administration (EPMA), we talked to Gary Mooney, clinical solution executive at InterSystems.
Gary has been with InterSystems for ten years and has a background in academic medicine and digital clinical solutions. Starting his career in academic medicine with a focus on medical education, clinical decision-making and medicines safety, Gary went on to a secondment with the Department of Health to write strategy around the use of digital technology for national evidence bases and public health. Whilst there, he also managed a digital team delivering against the policy agenda for the Our Healthier Nation White Paper.
He also spent time through a travelling Lectureship with a School of Medicine in South Africa to help with the adoption of digital technologies to support undergraduate medical education, before moving into commerce, where his focus was again on medicines management and patient safety, along with developing and delivering EPMA, pharmacy, and clinical EPR solutions in the UK and overseas.
EPMA in the NHS
Asked about his experience working on EPMA roll-outs, Gary said: “When I started with InterSystems I was working for the global product team, so I got exposure across international territories. Looking at my experiences in the UK specifically, I’ve worked closely with North Tees and Hartlepool NHS Foundation Trust. They were one of our early adopters of our clinical EPR TrakCare and our medicines management solution.”
Describing North Tees and Hartlepool as an “absolutely fabulous organisation to work with”, Gary described how they deployed TrakCare across all clinical areas including general, inpatient, outpatient and the emergency department. “More recently, they’ve started getting into the more complex and high-risk areas of medicine, such as neonatal ICU. From a medicines perspective, they’ve now got that ideal position where they have one single medication record for the patient. So regardless of where they go – whether they come through the door at ED, whether they spend time on the ward or in theatre – their medicines history follows them.”
Considering the impact of this on patient outcomes, Gary added: “That really starts to reduce well established medications risk relating to transitions of care, tackling those siloes of medicines information that don’t get communicated in a timely way between care teams”.
From an organisational perspective, Gary noted that North Tees and Hartlepool had one of the best cases of clinical engagement he has experienced in the NHS. “That doesn’t just mean doctors – it also means having nursing teams, clinical pharmacy, technicians and medics actively engaged from the beginning, supported by a very capable digital team”.
Gary shared another recent example of his work, deploying a medicines management solution at a forensic mental health facility in Ireland. “They have patients who are very poorly and they tend to have different needs to the patients you find in an acute hospital, and it’s a different outlook too in terms of things like risk of harm and length of stay. So that’s been great in terms of learning about that different care setting and how the InterSystems TrakCare solution supports that care setting. The good thing about that is the variation – it helps us understand the different use cases of medicines management technologies, and how we can make it safer and more effective.”
Recent developments in EPMA
We asked Gary what changes he has witnessed in EPMA development over the last five years. “You can see distinct cycles in medicines management solutions evolution, and we’ve seen continual maturing,” he noted. “I think the biggest change I’ve seen over the past five years is that in years gone by, there weren’t many enterprise EPRs that could offer a comprehensive medicines management solution. A lot of the earlier initiatives in the NHS focused on adopting best-of-breed standalone solutions. They have been functionally very capable, but still deliver challenges in that you still have the disjointed medicines information from the clinical record, and you need to be able to make safe and appropriate decisions around medicines and broader treatment.”
There has been an “ever-increasing awareness that medicines need to be part of a unified clinical system,” Gary said. “They need to be alongside blood results, observations and clinical notes, to allow those elements to combine to inform care decisions.”
Focus on improving transitions of care has been a driving force behind these changes, Gary suggested. “Research has continually and consistently shown that a lot of medication errors happen during transitions of care, whether the patient is coming into the hospital or whether they are transitioning from ED to a ward, for example. What do we do with the drugs that they already have, what is the plan to continue? It’s a key question around step-up and step-down of care, too. Having that seamless, continuous flow of medicines information is really key.”
Gary picked up on the importance of interoperability here. Alongside the step-up and step-down transitions of care within an acute hospital, he said, “It’s about being able to share and receive that information with other services. At the point of coming into the hospital, staff need to see what a patient might have already been given by other care services. They could be a cancer patient who we haven’t seen in this particular hospital before, but they have been admitted and they are very poorly; we need to be able to see, very quickly, their pre-existing conditions, what medicines they have been given, what chemotherapy have they taken. Or the patient could have received particular medications for a mental health condition but they are presenting with something else. We need to know the full story.”
Interoperability has brought about changes for EPMA with the evolution of the FHIR standard (Fast Healthcare Interoperability Resources), in terms of being able to very precisely prescribe, code and share medicines information across services. “That’s a change that we have had to handle over the past few years, getting a FHIR repository built into our solution as a default capability so that it’s ready to support those transitions of care.”
Key challenges and impacts
Gary commented that one of the key challenges is end-user usability.
“We’ve seen, over the last five years, increasing time demands on a decreasing staff ratio,” he said. “The last thing clinicians need or want is to be using a computer all the time. Whilst they’re using the computer, they’re not engaging clinically with their patient.”
Gary described how InterSystems had a “major rethink” with regards to how to improve usability and adoption of their solutions, with the aim of making them “a seamless element of people’s day-to-day jobs”. This resulted in “a major overhaul in terms of our user interface, workflows and functionality. That was really focused on looking in more detail at what the software looks like and how easy it is for staff to navigate, so that it’s quicker and intuitive to use. It’s about enabling staff attention to go to their patients, rather than on the solutions.”
With regards to impacts of EPMA solutions on staff and patients, Gary said that he has experienced benefits in top-level categories such as clinical outcomes, patient safety, service efficiency, financial performance and patient experience.
“When we are deploying our solutions, we very much have a focus on the benefits and outcomes – that’s the reason why we’re doing it, and that’s the reason our customer is doing it. It’s not about installing technology, it’s about asking what improvements we can make for patients and for the service. To do that, we’ve got to get the data. We need data before we implement, and we need data after we implement.”
Gary shared another example from North Tees. “We got some feedback from the trust before they had even finished rolling out the solution – they were about nine months into the project, so they hadn’t got to the specialist areas yet. They said that around 20,000 hours of nursing time had been saved, because they had clearer, more consistent communication. Rather than sifting through paper drug charts to see which patients needed medications and the dosages required, the system was telling them this information, reducing the time spent chasing it, and also reducing the risk of errors. The nursing staff were able to spend more time with the patients and they saw about an 80 percent reduction in errors.”
Something that impacts not only the clinical outcomes but also the patient experience, Gary added, is the way that the tech supports dosage monitoring. “For example, if you take a simple, not uncommon scenario where the patient is experiencing pain; being able to monitor their dosages to manage and maintain their level of pain is really important,” he said. “With the pressures that nurses face, and the demands on their time, it’s unfortunately easy for those dosages to slip. The patient could have gone for a scan when the nurse planned to go and give them their next dose, for example, and on the paper chart there is nothing there to say that the patient has missed a dose. All of those things are catered for within TrakCare. We saw a significant reduction in missed doses, which is great in terms of managing and treating that patient’s condition, but also in terms of making their experience the best that it can be.”
In addition, due to the integrated data centre for the patient’s journey, Gary noted the ability for the organisation to perform analytics. “You can look at the outcomes of a particular medication,” he noted, “and you can fine-tune their use, which you can’t do on paper.”
Another impact Gary raised was that of the environmental contributions of the electronic systems, supporting organisations to minimise paper. “Organisations such as North Tees have been able to share a direct contribution in terms of their carbon footprint,” he said. “In turn, that also reduces cost, when you think about all the pieces of paper and printing that are required.”
We then moved on to ask Gary what his advice would be if he could talk to someone in a similar position to himself, ten years ago, at the start of his journey with EPMA solutions for InterSystems.
“It would be to really focus on the end-users, getting that really detailed empathy and understanding of their needs. Although there is a lot of overlap in the NHS surrounding the types of needs, there are specific differences, and it’s about understanding those nuances and helping organisations to meet their needs,” he said.
What about what Gary hopes to see for EPMA, five years in the future?
“This reflects something that I also work on from a research perspective with InterSystems, and that’s pharmacogenomics,” he said. “I’m really hoping that we start to see this in routine use across the NHS in the coming years. Essentially, it’s looking to get a ‘right first time’ approach for medications by selecting the right medication and appropriate dose to reflect a patient’s personal genomic profile that determines how they metabolise specific medications. Emerging research continues to highlight how certain variations in genes determine the safety and efficacy of medications for individual patient and whether they will metabolise the medication too quickly or too slowly.”
Gary continued: “In the NHS, at any given time we have around seven 800 bed hospitals’ worth of patients who are in hospital today because their medicines have caused unexpected side-effects. If we applied the genomic test, we would be able to say, ‘This medicine isn’t appropriate for the patient’, or we be better equipped to recognise when we need to adjust the dose for a particular individual.”
There are established use case examples for this, he noted, such as cancer care, but there are lots of different applications. For example, Gary raised the issue of pain management again; specifically, codeine, and the way that the human body metabolises it so that it turns into morphine. “There’s a specific gene variation that determines how you metabolise this drug. Some patients have a genetic variation which means that they don’t absorb the morphine as well, which results in poor pain management or escalated dosing which can introduce other risk factors. For patients unable to clearly articulate their level of pain, for example patients with certain neurological conditions, such scenarios become even pertinent to be able to effectively manage pain.”
Another use case could be found in neonatal intensive care, where very young children can have genomic variations that cause them to metabolise gentamycin and vancomycin differently. Gary noted that for some children, complications with these drugs can lead to lifelong effects such as deafness. “Currently, there’s a lot of monitoring and daily blood tests to keep a check on drug levels for neonates,” he said. The genomic test, by contrast, could ensure that babies get the appropriate medication and dose in the first place, to reduce that risk.
“It’s about proactive testing to make sure that we get it right first time; we improve patient experience; better clinical outcomes; and significant reduction on pressures for the NHS. I’m really hoping that the future holds more of this. We’re working through out strategy for it – so I’m excited by the opportunity for these new technologies to become frontline tools for our clinical services.”
Many thanks to Gary for taking the time to join us.