Trusts urged to move faster with e-prescribing

Tags: A Acute ASSIST Data E-Prescribing England iS NPSA Patient safety Safety Sales

16 Aug 2006

Trusts are being urged to move forward faster with e-prescribing and the use of robotics to automate hospital pharmacies by the leader of the Healthcare Commission’s medicines management review.

Review lead, Julia Sonander, was speaking to E-Health Insider following publication of comparative assessments on medicines management for all 173 acute hospital trusts in England. Eighteen hospital trusts got the highest rating of 'excellent' while 12 got the lowest of 'weak.' Seventy trusts got a rating of 'good' while 73 were 'fair'.

Referring to the use of e-prescribing systems she said: “We want to move forward with this faster than we have. Progress has been slow on this and on robotics. A lot of people are waiting for Connecting for Health…which is a shame.”

The National Patient Safety Agency’s National Reporting and Learning System data quoted by the Healthcare Commission, which regulates trusts, shows that 41,220, or 9% of all incidents reported from the acute sector in England and Wales, were related to medication in the year ending July 2006.

The NPSA reports that the vast majority of these incidents (95%) caused no or low harm to the patient.

The Healthcare Commission's review posed several questions to trusts to assess their progress on the use of IT but the 21 published indicators do not include a specific reference to IT. The indicators cover a range of issues, from the percentage of patients who had had a comprehensive medicines review to whether patients had a complete medicines record for their stay in hospital.

Sonander explained that the commission saw technologies such as e-prescribing and pharmacy robotics as enablers rather than indicators in themselves. However, she added: “What we know is that some of the issues raised in the indicators could be addressed by moving forward with e-prescribing.”

For example, she said, e-prescribing could help with getting prescriptions right first time and freeing up pharmacists to do more of the educational and review work now considered to be good practice. Getting doses right, ensuring prescriptions were complete and legible and picking up errors such as drugs prescribed daily instead of weekly were other examples she cited.

Sonander acknowledged that e-prescribing could do more when linked to an electronic patient record, such as adding checks on a patient’s allergies, but she emphasised that there were gains to be made before this became possible.

She added one caution: “The one thing we have got to be careful of that it [e-prescribing] does not introduce errors. Trusts must ensure it comes into being with a reasonable safety case.”

A national report, outlining in full all of the findings from the medicines management review, will be published later in the year.

Keith Kirtland, sales and marketing director at clinical decision support specialists, First DataBank Europe agreed with the Healthcare Commission’s verdict that more needs to be done to discuss side effects and adverse drug reactions with patients. However, he said there was an infinite number of drugs available and the comprehensive knowledge of these cannot be digested or kept up to date by every provider in every care setting.

Kirtland commented: “The real tragedy of these figures is that there are electronic systems with integrated clinical decision support available here and now which are able to help prevent medication errors. With the ever-increasing pressure on clinicians it is essential that the systems that are available to assist in this key area of patient safety are made available to them at the earliest opportunity."

Medicines management software specialists, Ascribe, sent E-Health Insider an analysis of trusts' ratings which show 72% of trusts rated 'excellent' were using its software, along with 34% of those rated 'good', 29% rated 'fair' and 17% rated 'weak'. Chairman and chief executive, Stephen Critchlow, said the two users with 'weak' ratings had bought the firm's software recently to improve their medicines management.

Readers Comments

Waiting for CfH a

16 Aug 06 09:28

Perhaps someone from the DH can clarify here? Is the Healthcare Commission (a regulatory arms length body of the DH) officially saying that CfH (a DH agency) is making such slow progress that Trusts ought to press on regardless? And is this advice valid for all the other delayed CfH offerings, I wonder?

As far as I can see, the real shame is that NPfIT put the brakes on local procurements when it started. Now we seem to have come full circle!

the future includes e-Prescribing

john.aird@uhl-tr.nhs.uk

16 Aug 06 10:14

e-Prescribing is enormously complex and difficult to implement, but has substantial clinical risk management and financial savings potential. Our trust was certainly proposing to pilot e-Prescribing as part of our EPR pre NPfIT, but I can understand the caution that currently seems to pervade. However, the increasing introduction of Pharmacy robotics and similar associated initiatives will add to the pressure for e-Prescribing system. Unless we can address this demand I fear that departmental “back-door” solutions will materialise.

Eeeh Prescribing !

sean@eprarms.com

16 Aug 06 14:08

What is a surprise is that this is a surprise to anyone. Didn't we all already know all about the benefits of electronic prescribing and how essential it was to reduce risk and improve patient safety? Isn't this why Frank Burns (rather ambitiously) put ePrescribing in the EPR model level 3/4 to be implemented by 2005 (!) We seem to have lost some of our corporate memery and are coming eventually to the conclusions reached back in 1998 albeit it with a different delivery mechanism. Failure to appreciate and understand the pre-cursor to CfH's NPfIT will result in unecessary delays. Debate at will !

Back to 1998!

16 Aug 06 14:39

Despairing at CfH's track record, no doubt, many Trusts are indeed reverting to the 1998 strategic approach (as outlined in Information for Health) by defecting from the Programme and doing their own procurements. The Healthcare Commission seems to have noticed that Frank Burns' "local implementation to national standards" approach is the way to begin to deliver patient benefits sooner rather than later.

Carrying this approach to its logical conclusion, one might perhaps dispense with CfH altogether, beef-up the NHS Information Standards Board (giving it some teeth in the process or even making it a part of the HC), and then let the local NHS get on with it!

Pilot sites using e-prescribing?

16 Aug 06 15:33

I presume Cerner and iSoft are developing their own e-prescribing solution running with FirstDataBank decision support software. Using dm+d/Snomed codes it should be possible to link relatively seamlessly into the hospital pharmacy system without rekeying of data. Does anyone know if Cerner or iSoft have any e-prescribing pilot sites up and running and if so what feedback can you give to the rest of us?

Prescribing and Pharmacy (sigh)

16 Aug 06 19:05

"Using dm+d/Snomed codes it should be possible to link relatively seamlessly into the hospital pharmacy system without rekeying of data."

......a gross over simplification of the relationship between Pharmacy and Prescribing business processes (which are different things). The prescriber should not be expected to have to pick pack sizes for example - a hospital pharmacy may well keep a number of different pack sizes of the same preparation - and might take the decision at the point of dispensing to provide something else - that's in no way simple……

There’s also the issue of 'complex prescribing', infusions etc etc

Rekeying of data re-introduces risk (including clinical risk) – which should be avoided.

To be frank - I've been involved with Pharmacy and Prescribing for a long time now – and for a number of high profile healthcare software suppliers - including some involved with CfH. These news articles just keep restating what we already know - and have known for many years. In my opinion there just isn't the will to implement prescribing in secondary care, and the systems suppliers just don’t seem to be able to see the wood for the trees - wrong people making the wrong strategic decisions.

As far as Cerner and iSOFT providing prescribing systems - don’t make me laugh – I don’t believe that the will to deliver is there.

Ideally Pharmacy and Prescribing systems should interface with PAS so that contraindication screening (e.g. pregnancy) can be provided – it’s not just drug-drug interactions we should be screening for.

The expertise and **experience** needed are out there - and have been for sometime - they just have consistently not been listened to – and I for one have given up – I just don’t think anyone is serious about it.

SNOMED & dm+d codes (another sigh)

17 Aug 06 09:33

Often cited as some sort of panacoea for NHS IT. Have they been tested? Is anyone using them on the sort of scale that the Programme would require (assuming it delivers, of course). And are they any better than Read Codes?

Prescribing has been piloted in i.CM

colin.sweeney@kingsch.nhs.uk

17 Aug 06 12:30

We have been using i.CM to prescribe take home drugs for a number of years and along with a couple of other iSOFT sites have piloted inpatient prescribing and medicines administration using i.CM. The users, especially the nurses, liked the system with the major benefits being around legibility and drug chart availability. One other benefit from a pharmacy and Trust point of view is that you can actually analyse prescribing patterns and what drugs are actually being administered - much easier than trying to pore through hundreds of paper drug charts.

The major reason we haven't rolled it out is that there is a bug in the software, which we are told is fixed in the next release (have to say I've heard that before). If it is fixed then we will roll the system out.

What shouldn't be underestimated is the amount of resource required to train and support the users initially (which includes having staff on site training and supporting the night staff).

Also for prescribing to work mobile computing and wireless networks are a must.

"Just do it" don't cut it

17 Aug 06 13:22

Sadly the executive summary level (mis)comprehension is that "GPs have been doing ePrescribing for years so why don't hospitals?"

There is a leap in complexity from outpatient prescribing to inpatient prescribing. There is another huge leap to electronically documenting the actual administration of medications to inpatients. Neither can the interface / support for pharmacy dispensing and stock control systems be taken for granted just because dm+d codes are to be used as the '(sigh)' poster emphasizes.

This is not primarily a question of better computers, programming languages, messaging standards or coding systems. These may each make e-prescribing marginally easier but technology capable of supporting it within single institutions has been available since at least the mid-nineties.

Implementing 'full-Monty' paper free inpatient prescribing, dispensing and administration is not just replicating the fearsomely versatile hospital paper drug chart. Rather it is redesigning the many 'human' processes around the paper form to use its electronic replacement while concealing underlying complexity from users. This a monumental challenge for systems analysts, interface designers and providers of electronic formularies.

No one has yet signed off the 'perfect' high level functional spec which can be seamlessly transformed into working software by incomprehending 'droids'.

The handful of centres (Worldwide) piloting full inpatient prescribing have succeeded only by the closest possible collaborations between software developers and clinicians through exhaustive repeated loops of iterative design. NPfIT and the LSP structures interposed between system suppliers and end-users have IMHO not so far nurtured such deadline deprecating collaborative environments.

Pilot sites using e-prescribing (cont'd...)

neil.kirby@srht.nhs.uk

17 Aug 06 13:36

There is (albeit limited and with varying degrees of success) prescribing experience in the UK with iSoft's iCM product - some of it local - but all of which, however, was or is outside the NPfIT. Many thanks also to the poster who so eloquently described the issues regarding oversimplification of the Prescribing vs. Pharmacy business processes.

How can we all agree and yet be wrong?

rf@medicineit.com

17 Aug 06 15:01

Bravo Neil & the 'sigh' correspondent!!

I was heavily involved with one of the secondary care providers and tried, as Neil correctly indicates as essential, to bring the UK user community closer to the developers. Alas, I fear Neil is equally correct in his assessment that the will is not there to listen - not from the developers per se, but from their managers. As the Wirral often explained - 'You can teach healthcare staff about IT but you cannot teach IT staff about healthcare'.

In my case, we go back to the age old problem of differences between the US and the UK and in e-prescribing there are important differences that require significant engineering to resolve. However, the national specifications are not detailed enough to support the few who are experienced in these things. When the Americans see how much work is proposed from the UK side of the pond to achieve the ICRS requirements, they start to say things like 'that's not what the requirement says'. It is all very frustrating, deeply dissappointing, and probably common to many EHR components - not just e-prescribing.

This is not about striving for the perfect system - just something that does justice to the huge effort employed by the staff of the NHS to get these systems to work!

IDX found these problems and Cerner will find them too. I'm assuming iSoft have found the issues and working to manage them despite all the negative publicity at the moment.

I just hope the NHS user community don't get steam-rolled into taking what is on offer and that they stand-up and demand the systems that the patients and this massively expensive project deserve.

Burton, Salford, Sunderland, Wirral, Winchester et al. please come to the rescue!!

What do people think of systems like JAC and Ascribe? Are these more appropriate solutions?

e-Prescribing - stand alone or part of EPR

john.aird@uhl-tr.nhs.uk

17 Aug 06 16:08

I would suggest that ideally e-P should be an integrated component of an EPR with "integrated care pathways" and "rules based ordering" at its heart. So that a clinician can order (and be advised on) "investigations and treatment" from the same screen. But as that does not seem likely for the immediate future, so perhaps the interfaced specialist pharmacy systems (ordering to stock control) are the more pragmnatic solution.

Been there; done it; gave up!!!!

graeme.stafford@talk21.com

17 Aug 06 22:29

I tried so very hard to introduce e-prescribing and it basically ruined my career. Anyone who remembers my efforts will be glad to know I am now working happily as a Pharmacy Locum!!!!! I advise anyone else who is invovled in this impossible scheme to do the same.

Discharge and Out-patient e-prescribing

18 Aug 06 13:01

e-prescribing for hospital discharge and out-patient prescribing is "relatively" striaghtforward. Acute trusts could have these up and running within 9-12 months with enough commitment. The lessons learned will be invaluable for the more complex step to full inpatient e-prescribing. I suggest that trusts should crack on with a "tactical" OBS and invitations to tender. Your local GP's will be delighted with an electronic discharge medication summary and it may even help with the traumatic payment by results (PbR) negotiations.

Changing the requirements?

19 Aug 06 15:14

>>However, the national specifications are not detailed enough to support the few who are experienced in these things. When the Americans see how much work is proposed from the UK side of the pond to achieve the ICRS requirements, they start to say things like 'that's not what the requirement says'. <<

I suppose there is a possibility that the consultation document issued this week for a national specification for ePrescribing (http://www.connectingforhealth.nhs.uk/eprescribing/docs/functional_requirements_eprescribing.pdf) may provide the opportunity to revise the requirements. But doubtless all the LSPs and their suppliers will be busy re-calculating their contract terms to take account of such changes.

On first glance, the document does a good job of laying out what the NHS will need from a system, but others are right in saying that current offerings from LSPs may fall a long way short.

Clarification will also be needed where the national spec will fit with systems currently in design (or should that be configuration?). Would a system that doesn't meet the "essential" elements of the requirements be acceptable as an interim solution?

Succesfull E-Prescribing examples

21 Aug 06 08:31

Following the increased awareness for E-prescribing: there are two examples on the European continent availble where the concept is working in a large live environment. The Hospital in Aalborg (Denmark) is using E-prescribtion succesfully. In the Zentralklinikum in Suhl (Germany), E-prescribtion is implemented in combination with automatic robots. Please contact me for more information at Hilbers@t.is

Eeeeh Prescribing

sean@eprarms.com

21 Aug 06 09:57

During my (short) time as a system supplier, Northgate had a French partner, Stylus, who had successfully implemented wall to wall clinical systems in a large number of hospitals in France and Belgium. I visited one such hospital in Marseilles way back in 2001 and witnessed electronic prescribing across the whole hospital. But unless there is a will and commitment to deliver this across the entire patch over here, you will find enthusiastic but often solitary individuals who will try and some will get burned or worse still burnt out. This thread has reinforced the support for ePrescribing and yet also reinforced the commonly held view that it IS difficult. Changing the requirements may help but, as mentioned, may give the LSP's an excuse for non-delivery on current spec. To return to the stimulant for this thread, the bottom line is that ePrescribing will deliver the REAL benefits we are anticipating from CfH. Forget about the seamless national electronic record for the time being: Reduce clinical risk and improve safety locally. That is where the REAL benefit will be seen. Sean (Brennan)

e-prescribing implementer burn-out

Stephen@goundrey-smith.freeserve.co.uk

29 Aug 06 23:39

I am in a similar position to Graeme Stafford (above) - indeed, having worked for the same IT supplier and on the same e-prescribing system - and I too am now working largely as a locum pharmacist. However, I plan to look at the draft EP spec from CfH that is up for consulation - to see if we've moved any further forward !!??