In our latest feature we focus on electronic prescribing and medicines management to share successful implementations, challenges, learnings and advice from 5 organisations and projects.
There is strong evidence to suggest that electronic prescribing and medicines administration systems improve safety for patients, reduce the risk of harm and ensure high quality efficient patient care which is as safe as possible. However these projects can be difficult to deploy and many trusts still utilise a paper process.
In this feature we hear from 5 organisations to understand the technology and to hear their advice for other organisations looking to digitise in a similar way.
Contributors include: Nervecentre Software, Cambridge University Hospitals NHS Foundation Trust, Omnicell, InterSystems and Poole Hospital NHS Foundation Trust.
1) HTN spoke with Paul Volkaerts, CEO, Nervecentre Software to understand the technology:
“If e-prescribing systems are to be used by hospital teams, they must maximise familiar tools that users can access whenever they need them, wherever they are. That means making it mobile. The benefits are significant. Fundamentally, documenting prescribing information at the patient’s bedside is the safest and most efficient time to do it. The portability of mobile devices means the system not only becomes part of the uniform, it removes the need for clunky desktop systems that disrupt the patient consultation or make it difficult to administer medicines that fall outside standard drug rounds. Mobile systems allow hospital staff to capture – and access – data in real-time, anytime, empowering them with the best information to make accurate, reliable and timely decisions.
One of the biggest complaints about traditional e-prescribing is that the screens in the system don’t match what users actually do. User experience is everything – but to be effective it must be designed with the clinician, not the technology, in mind.
The next generation of e-prescribing must therefore be clinically-led and mobile-first. Delivering the best mobile experience means helping the user get to where they want to go in a single click – and that requires understanding their workflow and designing interfaces that reflect it.
Common sense tells us that e-prescribing solutions cannot operate in isolation. Prescribing decisions are both complex and multifactorial; medication can link to pathology results, physiological parameters, past medical history, current medications and contraindications. If you want to do e-prescribing well, you can’t separate these items out, they must be connected and accessible at the point of clinical care.
Next generation tools will make e-prescribing part of a fully-integrated EPR. They’ll interact with real-time vital signs and pathology data to show optimal drug chart views including full drug history, pathology results and amendable dosing and timing options. And they’ll link to the PAS to provide a complete picture of the patient. Crucially, because next generation tools will be mobile and accessible, multidisciplinary teams will have all the information they need at their fingertips, wherever they are in the hospital.
These tools will incorporate the dm+d database to enable fast and precise data input. This will empower mobile prescribing, giving doctors rapid access to the national dictionary alongside local formularies and all the necessary clinical decision support. This means clinicians can prescribe when they’re with the patient, allowing even the most complex medicines to be prescribed on a handheld device with full validation against allergies and drug interactions.
It will allow hospitals to configure alerts so that they’re automatically generated upon certain triggers. This could include alerts to pharmacy for toxic or high cost medicines, alerts to infection control when medicines are prescribed to treat contagious diseases, or alerts to nurses if medicines with unorthodox timing requirements risk becoming overdue.
Handheld devices typically include familiar functionality that can be maximised for e-prescribing. The best example of this relates to BCMA. Next generation solutions will allow GS1 barcodes to be scanned using the built-in camera on standard mobile devices – meaning that users are uninhibited by technology and can use it seamlessly as part of clinical practice. The approach will help hospitals comply with FMD, in particular with complex patients whose medicines need to be administered outside of the drugs round. Moreover, by making it easier to scan barcodes at the point of clinical care, mobile tools will – at a stroke – move the concept of closed-loop prescribing from rhetoric to reality.
Mobile technology can open the door to closed loop administration. Fundamentally, closed loop medicines administration isn’t just about traceability and scanning barcodes, it’s about ensuring that every aspect of the prescribing pathway is aligned to support the safe and timely administration of medicines. This means connecting the dots to inform agile and safe prescribing decisions, accurate and efficient flow through pharmacy and the timely administering of authenticated medicines to patients. Mobile solutions will connect those dots.”
Nervecentre’s mobile e-prescribing tools allow hospital staff to capture and access data whenever they need to, wherever they are – empowering them with the best information to make accurate, reliable and timely decisions. The tools make e-prescribing part of a fully-integrated EPR, giving clinicians real-time visibility of data that can influence complex prescribing decisions; pathology results, vital signs, medical history, drug charts, current medications and contraindications.
2) InterSystems and North Tees and Hartlepool NHS Foundation Trust
The inefficiencies and risks of paper-based medication records continue to contribute to the increasing volume of reported adverse medication errors. International studies highlight an average of 1 in 10 patients experiencing an adverse medication error whilst in hospital.
- Most common single preventable cause of adverse events in medical practice
- Major public-health burden with an estimated annual cost between € 4.5 – 21.8 billion p.a. in the EU
- Medication Error Rates in the EU c. 10%
- Medication errors account for 2m deaths p.a. (globally)
- 18.7 – 56% of all adverse drug events among hospital patients result from medication errors that would be preventable
Source: European Medicines Agency
North Tees and Hartlepool NHS Foundation Trust is an acute service that has recently deployed a hospital-wide electronic medication management (eMM) solution to transition from paper records. This has been achieved as part of a broader programme to deploy the InterSystems TrakCare EPR solution.
The eMM programme set out a series of practicable steps reflecting the scale of change the Trust could consume whilst providing the opportunity to gain experience and insight in a controlled manner for how the eMM solution could best meet the Trust’s aspirations:
- Discharge Prescribing: established solid foundations and provided a gentle introduction to ePrescribing and decision support
- In-Patient / Out-Patient: phased deployment over a six-month period to deliver eMM supporting ePrescribing, pharmacist review and medicines administration across two hospitals
- Specialist Services: eMM for services with different or more complex requirements such as ED and paediatrics
- Optimisation: on-going configuration of TrakCare making use of advanced features to support local clinical practices and targeted KPIs (e.g. evidence-based order sets and order sentences)
The Trust are already observing measurable improvements and benefits.
Mandy Skilcorn, Ward Matron, North Tees and Hartlepool NHS Foundation Trust said “Before eMM there were lots of issues with handwriting, being able to get hold of the actual chart. You can see when it was last given so you are not giving doses too early and putting the patient at risk.”
For organisations at the beginning of an eMM journey, there are some core principles which can significantly increase the likelihood of a successful outcome:
- Meaningful clinician engagement across all disciplines. Nurses, as the most intensive users of MM, should be engaged early and throughout the programme. It is not a pharmacy project
- Seek clinician champions who can ‘sell’ the vision to colleagues
- Focus on an initial set of improvements to inform decision-making throughout the programme
- Treat it as a transformation programme, not a software installation, recognising that uncertainty and unexpected challenges are to be expected for such a complex undertaking
- Select a supplier who will partner with the organisation for the long-term and will jointly invest in the successful outcome of the programme
The adoption of hospital-wide eMM is arguably the most complex and challenging deployment of a clinical software solution. However, it is one where the ROI is clear from patient experience, clinical outcomes and fiscal performance perspectives.
3) Cambridge University Hospitals NHS Foundation Trust
Cambridge University Hospitals adopted ‘Scan for Safety’ – the international best practice for the safe administration of medications, through the scanning of barcodes which has been integrated with its Trust-wide Epic electronic patient record.
Barcode medication administration enables nurses to safely administer medications and infusions by scanning both a patient’s barcode on their identity wristband and the barcode on their prescribed medications. This process is now live across all 51 of its wards, 5 critical care areas and emergency department.
HTN asked Helen Balsdon, Head of Nursing for Informatics/Chief Nursing Information Officer, Cambridge University Hospitals NHS Foundation Trust, about the project and implementation:
Helen said: “We wanted to give this project a lot of focus following the implementation of our EPR.
“There was a lot of pre-planning with this project to first understand our workflows, who does what, where and when. Then we needed to understand what the workflows could look like. There’s lots of stakeholders involved so it’s important to know the process upfront and then understand the technology.
“The roll-out was done ward by ward to begin with to really understand the different workflows. As part of the implementation we ran daily huddles to ensure there was a regular feedback loop to understand what was working and what wasn’t.
“We were really fortunate to have an engaged and pro-active team involved, it really made a difference. The teams now say they would never go back to our previous process and with the support of tech we have improved safety.”
4) Paul O’Hanlon, Managing Director, Omnicell UK & Ireland comments:
“Last year, the UK government last year announced £78m of funding for electronic prescribing and medication administration systems for 13 Trusts. The next round of funding is expected to be announced imminently. To date, the main focus for Trusts seems to be an investment in electronic prescribing systems – however they only improve patient safety to a limited degree. They don’t protect against the nurse picking the wrong drug, the wrong dose or administering medication to the wrong patient.
To help eradicate medication errors altogether, the NHS needs to adopt a system to close the loop on medication administration. This includes automated dispensing, electronic confirmation of patient identity and medication administration records. This approach allows Trusts to track everything back to the patient from the moment the medication is prescribed to when it is administered, improving patient safety throughout the entire medication management process.
Patient safety remains a key issue for the NHS. Just last month, NHS England & NHS Improvement announced their eagerly-awaited new Patient Safety Strategy – a ‘golden thread’ to run through healthcare. It includes a series of recommendations built on two core pillars – a patient safety culture supported by a patient safety system. If implemented successfully, the report believes it could save around 1000 lives and £100m in care costs every year.
The development of a Medicines Safety Programme to support medicines safety systems across the NHS is welcomed whole-heartedly by Omnicell. The programme has identified a number of national priorities for improving safety. This includes a Medicine Safety Improvement Programme (MSIP) to reduce avoidable medicine related harm globally by 50% in five years, as well as the implementation of electronic prescribing and medication administration systems. It’s great to see the report mention the importance of combined electronic prescribing and medication administration systems in improving patient safety. Omnicell has been campaigning for both systems to be used in UK hospitals as a standard of care.
As well as the human cost of medication errors, there’s also the financial costs to the NHS. The estimated cost to the NHS of avoidable adverse drug reactions is a staggering £98.5 million per year, consuming 181,626 bed days, causing 712 deaths and contributing to 1,078 deaths. Adverse drug events in England have previously been estimated to be responsible for 850,000 inpatient episodes and costing £2 billion in additional bed days.
Last year Omnicell worked with an independent pharmacy expert to produce a new report; ‘SAFE in Secondary Care’, which showed that the implementation of automated medication administration systems alongside ePMA systems would dramatically reduce the risk of medication errors. With 40% of nursing time currently spent on medication tasks, using both systems would simplify the process for nurses so they have more time to focus on face to face patient care.
Omnicell will continue to campaign and raise awareness of the importance of using both technologies to ensure the UK works to a gold standard of care across our healthcare landscape – creating a consistent and truly ‘national’ health service.”
5) Poole Hospital NHS Foundation Trust
The implementation of an EPMA solution has been managed by a joint project team between Poole Hospital NHS Foundation Trust and Royal Bournemouth & Christchurch NHS Foundation Trusts.
Poole Hospital NHS Foundation Trust started the deployment of a web based electronic prescribing system in June 2018, and the deployment is now close to being complete following a phased roll-out ward by ward.
Nick Bolton, Interim Chief Pharmacist, Poole Hospital NHS Foundation Trust “We started the project against a backdrop of challenging IT deployments, with cynicism from some clinicians towards newer IT solutions; so we wanted to ensure our teams had the full support they needed. This led us to take a phased roll-out approach and I think one of the key successes of the project is that it has been really well delivered and well managed.
‘There are positives and negatives for taking a phased roll-out over a big bang approach. It can mean you’re using a mixture of paper and electronic processes but then there are risks associated with a big bang approach in getting it right. Each Trust has unique circumstances and this approach to the project worked for us.
“It gave us the opportunity to work with our nursing, clinical and pharmacy teams to really understand their processes. You might think the methodology is right beforehand but in practice we gained valuable feedback from the teams. This feedback loop helped us to hone and refine the system, we had some really good ideas come back that we were able to implement.”
James Young, EPMA Project Lead Pharmacist “The deployment team were on the ‘shop floor’ from 7am – 11pm each day to ensure the support was there for our teams. Identifying advocates within ward teams helped the project to embed within work patterns.
“We decided to start the proof of concept in a downstream ward that had slower patient turnover. However this was not an admitting ward, so we had to transcribe new patients from paper to digital. The better place to start is an admission ward, because although it’s busy with a higher turnover, it’s safer going from digital to paper (by printing) than the other way around.
“Each Trust would have different considerations around whether to take a phased roll-out or a big bang approach, but I would say engagement is really key to ensure an effective roll-out of a system and to have passionate people around you.
“Following implementing the system many of the teams and nurses have said they would never go back to paper.”
