Clinical decision support in secondary care

Electronic patient records and the 2010 deadline for electronic prescribing in secondary care are cornerstones of the National Programme for IT. Intrinsic to a good electronic prescribing system is the use of an interactive drug knowledge base which provides clinical decision support when a healthcare professional makes a prescribing or dispensing decision.

Systems of this kind have been used in primary care for many years, but their use in secondary care has not been nearly as widespread. Keith Kirtland, sales and marketing director at First DataBank Europe (FDBE), writes about the company’s role in this high-profile market.

Clinical decision support today

The advent of the electronic patient record is the first stage in offering hospitals the chance to utilise interactive drug knowledge bases to improve the quality of care and to save more lives. Working in the background as the silent partner, the emphasis is on prevention - supporting and enabling best practice for those occasions when the clinician may not have treated a particular condition or prescribed a particular drug or combination of drugs previously; or when the clinician is dealing with the unexpected, such as prescribing for a condition when he/she is not aware of all the details of a patient’s medical history.

We have already successfully implemented our decision support in a number of secondary care locations. At Doncaster Royal Infirmary, an audit of the effect of the JAC electronic prescribing system and associated clinical decision support revealed that the system can reduce potential adverse drug events by up to 60%. At Shrewsbury and Telford Hospitals NHS Trust, in the absence of an electronic prescribing system, we collaborated closely with their pharmacy and IT departments in their development of a successful interim solution. This has enabled them to prioritise work more efficiently in the pharmacy, speed up the patient discharge process and provide accurate, complete and legible discharge prescriptions.

From our experience, it is clear that clinical decision support is more widespread in primary care. This is in part attributable to the fact that electronic prescribing, along with clinical decision support, has evolved gradually, at a pace that was dictated by the needs of GPs. Secondary care is lagging significantly behind primary care, with current estimates showing that the number of hospitals that have successfully implemented electronic prescribing is still very low.

Challenges in secondary care

Less widespread adoption in secondary care is in some part understandable as some of the key characteristics and the challenges in an acute hospital setting are very different to that of general practice. A hospital is a massively complex and time-critical environment with prescribing being distributed between many clinicians. Prescribing occurs 24 hours a day, seven days a week, with more rapidly changing patient conditions. For example, the route of administration of a drug may be altered perioperatively or during intensive care, requiring careful consideration of the bioavailability or stability of drugs. Total parenteral nutrition or cytotoxic drug regimens present particular challenges of their own, in addition to any other medication or treatment that the patient may be receiving.

Electronic prescribing in secondary care incorporates the recording of drug administration or omission which is a very complex process in itself. The decision support required at the point of administration will differ from the point of prescribing, for example how to administer the drug, which intravenous drugs to avoid mixing together or the dilution and diluent required to safely administer a prescribed dose. Many more rules to prescribing and administration are required in secondary care, for example, ‘hold administration if pulse less than’, or ‘do not administer until order has been verified’.

Another difference between primary and secondary care is the ownership of the prescription. A consultant or junior doctor might write the original prescription, this may then be annotated or corrected by a pharmacist to clarify details for the nurse who has to administer the drug. Adjustment of doses may be initiated by another member of the team. The original prescriber may not see that prescription again before the patient is discharged. These sorts of medication changes happen as a matter of routine, throughout the hospital every day.

These complexities mean there is an even greater need for electronic systems that support the sharing of patient information between a distributed team of clinicians and across different specialities within a hospital. With a greater range of conditions, medicines and prescribing routes, there is a greater potential for error than in primary care and therefore a much more critical role for clinical decision support to play. Given the vast amount of information and pace at which products come onto the marketplace, it is just not possible for any one person to always be up to date with absolutely everything.

Local drug formularies are beneficial in terms of ensuring a consistent approach to prescribing the most cost effective medication across local health communities. However, their use does introduce an interesting challenge for prescribers, in that whilst they become very familiar with the medicines used in their speciality, or within their formulary, they may require additional support when prescribing outside these boundaries, for example, when a patient moves from one formulary district to another. Additionally, more junior health care professionals or those on training schemes regularly move between wards and specialities. The drugs that they are familiar with in one field do not necessarily translate to another, even within the same organisation. Given these differences, clinical decision support provides a consistent reference source and offers an additional layer of support, flagging potentially harmful drug interactions and contraindications – helping to prevent medication causing harm in a patient.

Current successes

Although take-up of electronic prescribing and clinical decision support is slower in secondary care, there are hospitals that are taking advantage of the systems and the functionality that is already available today to great effect.

Our experience at Doncaster Royal Infirmary demonstrates the value of decision support very clearly. An initial audit of decision support identified how many times a warning or alert made a prescriber reconsider their decision. On 74 occasions (1 in every 97 orders) the prescriber did not complete their initial prescribing intention. A further audit of the effect of electronic prescribing and associated clinical decision support also showed that the system can reduce potentially adverse drug reactions by up to 60%. In an environment where the clinician is faced with greater accountability, information overload and increasing performance pressures, we have found that this type of electronic decision support has been welcomed.

Shrewsbury and Telford Hospitals NHS Trust have developed their own eSCRIPT transcribing system, as an interim solution to ease the eventual transition to electronic prescribing and which incorporates FDBE’s clinical decision support. Electronic patient records are set up on arrival and are connected to inventory and stock control systems. Prescriptions are sent to the dispensary using wireless LAN technology for approval and fulfilment by the pharmacist. Doctors can access patient records from the ward, check patients’ drug histories and current medication and see whether urgent orders have been processed. The feedback on the impact that this kind of end-to-end system has made has been entirely positive.

The future of clinical decision support

Obviously there is always room for improvement. With our team of clinicians working closely with the national programme, we are aware of the challenges and are working on developing solutions to address them. One key area is the requirement to provide only relevant alerts and to not overload and interrupt clinicians within their workflow.

Customisation by clinical specialism and by clinician is key. We recognise that different units have different needs. Pre-programmed order sets for different clinical specialities within a hospital may be used to improve the consistency and safety of prescribing. Customisation by the individual could also be very useful as this would eliminate repeated interruptions in a setting where a specialist clinician is deliberately using a combination of drugs which would normally fire an alert message.

The experience we gain from working with hospitals such as Doncaster and Shrewsbury is continually ploughed back into our product. We have integrated the NHS dm+d (Dictionary of Medicines and Devices) and SNOMED CT (Systemised Nomenclature of Medicine Clinical Terms) into the latest version of the Multilex Drug Data File, FDBE’s core product and the UK's leading drug knowledge base. This is a step further towards achieving the vision of joined-up healthcare by supporting standardisation.

Future product developments include the addition of role or setting based information filtering and the use of increased contextual inputs to guide the relevance of alerts to certain users and scenarios. In addition, FDBE is developing a secondary care prescribing module to provide common order dosage regimens and a mechanism to support the use of multiple medications to meet a single condition protocol, all of which will enable the provision of a greater quality of care by our customers.

The universal adoption of the electronic patient record as the means of storing patient data in the NHS is a gradual process. The holy grail of fully digital healthcare may be some way away, but there are real patients, with real health problems who need to be cared for in the meantime. Our clinical decision support is available now and is already providing invaluable support to clinicians, enhancing the quality of care and improving patient safety today.