contracted working hours of doctors, for reasons of patient safety, and changes to medical career planning. As a result of this, there is increasing willingness within health provider organisations to delegate routine tasks that have traditionally been performed by junior doctors, to other healthcare professionals. While there is good rationale for this, in terms of appropriate use of “ skill mix ” , some physicians feel that patient care is compromised, and that their professional identity is threatened.
Moreover, some studies have suggested that the continuing professional develop- ment needs of those health professionals engaged in providing new services have not been fully understood and addressed. 1
EP Systems: Support for Professional Practice
It is clear that, in twenty-first century healthcare systems, health professionals are facing various professional and political challenges, and that professional roles are changing. Nevertheless, healthcare professionals are still committed to providing optimum patient care, according to best standards of practice, and in the light of an adequate evidence base. On this basis, there is a clear potential for electronic prescribing systems to support and enhance clinical practice, both in terms of optimising current practice, and supporting and developing new roles and services.
A number of papers have discussed the capacity of EP systems to support and enhance professional practice, within the health professions.
Pharmacy-led evaluations of EP systems have recognised the potential of EP systems to support ward-based clinical pharmacy activities and interventions.
Marriott et al. 2 undertook a study in the UK comparing the number and type of pharmacist interventions at Queens Hospital, Burton on Trent (BH), where a fully integrated patient data and prescribing management system has been implemented, as discussed previously, 3 and at Good Hope Hospital, Sutton Coldfield (GHH), where a traditional paper-based system was in place. Over a period of 2 months in 2003, a larger number of clinical interventions were made at BH – 2,512 interven- tions (equivalent to 0.2 interventions per finished consultant episode (FCE)) com- pared to 763 interventions (0.05 interventions per FCE) at GHH. Furthermore, the types of intervention were different between the two hospitals. Thirteen per cent of the pharmacist interventions at GHH, the paper-based hospital, were concerning drug interactions, use of non-formulary medicines, route changes and prescription legibility, but there were no interventions of this type at BH, the hospital with the EP system,. However, at BH, 26% of interventions were concerning medicines information and patient monitoring, whereas there were no interventions of this type at GHH.
Since the workload and case-mix of the two hospitals was similar, and the patient demographic profile similar, the authors concluded that the EP system facilitated more clinical pharmacy interventions. Considering also the different profile of interventions between the two hospitals, there may be three factors involved:
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(a) The EP system, with its decision support tools, automates the prescribing proc- ess, and therefore eliminates errors associated with choice of drug, prescription legibility, etc.
(b) Because various types of intervention relating to the actual prescribing and sup- ply procedure are reduced, pharmacists have more working time available to devote to near-patient clinical activities – monitoring new treatments, assessing side effects and providing advice to other healthcare professionals – which will in turn give rise to other types of intervention.
(c) The EP system presents a larger amount of clinical data in a systematic manner and therefore facilitates the identification of hitherto unrecognised intervention issues by clinical pharmacists.
Traditionally, data on pharmacist interventions has been collected to justify the existence of clinical pharmacy services. However, clinical pharmacy services are now well established and there is a need to take the evidence-base a step further to see how clinical pharmacy interventions actually affect clinical governance and patient care. However, this requires a robust data-capture procedure, and paper- based monitoring systems have usually been too laborious and haphazard to pro- vide a validated and benchmarked dataset on pharmacist interventions. A project has been conducted in five NHS Hospital Trusts in Wales, UK 4 where a personal digital assistant (PDA) database has been used to report pharmacist interven- tions. Pharmacists across the Trusts entered intervention data over a 2-week pilot period, resulting in the collection of data on 1,531 interventions, from 38 hospital wards. The PDA clinical intervention system was a quick and convenient way to collect intervention data. Furthermore, the dataset was use- ful for identifying inconsistencies between different Trusts at the enterprise level, and comparing the practice of pharmacists in different clinical special- ties. An EP system would provide the potential for the clinical intervention record, logging interventions by all professionals, to be held alongside, and integrated with, the prescribing record. The introduction of tools to specifi- cally support the work of clinical pharmacists is an important aspect of EP system design; the UK Connecting for Health e-prescribing programme is looking to design a pharmaceutical care record as part of the CfH e-prescribing functionality.
American hospital pharmacists have long recognised the potential of electronic prescribing and computerised decision support systems to support clinical prac- tice in pharmacy. In her discussion on the potential for computerised physician order entry (CPOE) to enhance pharmacy practice, Shane 5 indicated that, in 2002, a number of health providers in the US had already implemented central- ised and decentralised automation to increase the efficiency of the prescribing process and medicine supply process, and therefore enable pharmacists to con- centrate more on pharmaceutical care. Indeed, since financial pressures faced by health providers would focus managers ’ attentions on pharmacist headcount once CPOE was implemented, there was a pressing need for the pharmacist’s role to be redefined.
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EP Systems: Support for Professional Practice 99
Shane indicated that US health system pharmacists had traditionally focussed their attentions on medication management during acute disease – during a patient’s hospital stay – and that lack of time and information had precluded any attempt to manage a patient’s chronic disease medication requirements on a long-term basis. However, EP systems can now make chronic disease manage- ment possible, and this will have implications for the role of the pharmacist, and the pharmacist’s required professional competencies, and therefore continuing professional development needs.
This requirement represents a particular economic burden in the US, where there are large and disparate ethnic groups of people with chronic diseases, many of whom are not receptive to health education messages, are poor and are reliant on State medical insurance (Medicaid/Medicare). Nevertheless, those with chronic diseases undoubtedly represent an equally significant challenge to the health economies of the UK, continental Europe, and Australia. EP systems have the potential to address issues relating to chronic care, and change the professional practice of healthcare professionals accordingly.
As discussed previously, the nursing profession has undergone significant changes. Nursing has historically been a vocational occupation, subservient to medicine. Increasingly, though, nurses take on a variety of enhanced profes- sional roles, and have increasing clinical autonomy. In many countries, nurses have recognised clinical specialties, manage specific clinic services and have prescribing responsibilities (which will be discussed further in the following chapter). While it has been recognised that nurses are a key stakeholder in the implementation of an EP system, 6,7 and their attitudes to the introduction of an EP system can be influencial in its acceptance, there is little documentation on the role of electronic systems in helping nurses develop their professional roles.
It is recognised, however, that EP systems can benefit nurses in their routine duties. The introduction of the closed-loop process electronic prescribing sys- tem at a London Hospital, 8 where medicines administration working practices were revised following the introduction of bar code patient identification and automated ward dispensing cabinets ( “ magic cupboards ” ), caused the medicine administration round time to be decreased from 50 to 40 min. There was a cor- responding increase in nursing time spent on medication related issues outside of drug administration rounds, but this might reflect appropriate redeployment of skills as a result of automation. In a systematic review of the impact of elec- tronic health records on time spent on documentation by nurses and physicians, 9 it was found that the use of bedside terminals and desktop PCs at the nurses ’ station reduced nurse documentation time by 24.5% and 23.5%, respectively, during the course of a shift. However, this decrease in nursing time was offset by a considerable increase in physician time per shift, when physicians used desktop PCs for CPOE.
The main area of interface for nursing staff with an EP system is the medicines administration functionality. It is important, therefore, that this part of the EP system is designed to be as user-friendly as possible for nursing staff doing their
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drug administration round on a busy ward. A key element of this is that the medi- cines administration screen looks as much like a traditional drug chart as possible. 10 Another important element is that the medicines administration screen is designed in such a way that all of the drug administration instructions and annotations are clear, unambiguous and easy to read.
Nurse specialists will have involvement in activities such as clinic management, medicines review and clinical audit; all of these could be facilitated by specialist advanced functionality within EP systems. These are discussed in detail in later sections of this chapter. The role that EP systems can play to help support nurses in supplementary and independent prescribing roles is discussed fully in Chapter 7.
The potential impact of EP systems on physician practice has been extensively discussed in the literature. Many of the benefits of electronic systems to physi- cians concern the use of decision support systems to assist with the prescribing process, and the ability of CPOE systems to reduce medication errors within hospitals. 11,12 Both of these benefits should reduce the likelihood of a doctor fac- ing litigation as a result of a medication error, and automate the routine processes of therapeutics, in order that clinicians can concentrate on the intuitive, human aspects of medicine. EP systems have also been shown to reduce financial costs and hospital stay time 13,14 which would be a benefit to clinicians with responsibil- ity for budget management in their clinical area. However, as noted previously, it is likely that these organisational benefits are specific to the healthcare context in which they were elucidated.
Nevertheless, not all changes facilitated by EP systems are positive. Some studies point to the way in which CPOE increases physician prescribing time,9,13 due to the design of the prescribing workflow. Also, it has been noted that decision support systems may not always be effective because they do not fit appropriately into the prescribing workflow, or do not flag up latent physician monitoring needs. 15
Nevertheless, the electronic capture of the prescribing history by an EP system, together with the possibility of interfaces between the EP system and other systems and devices opens up a range of potential applications that might benefit medical practice. These might include automated data downloading for clinical audit and management reporting, remote clinics and the use of hand-held devices for domi- ciliary visits, clinical trial data collection and prescribing support.
It has been suggested that EP systems can change the dynamics of a patient’s consultation with a prescriber (doctor or other healthcare professional). 16 Historically, the prescriber has “ led ” the consultation, imparting information to the patient, who has been in a passive role. With a comprehensive EP system, where the system can be used to retrieve medicines information, as well as prescribe the medicine, however, there is the potential for the prescriber and the patient to view the same screen. The prescriber can therefore talk the patient through the benefits and risks of the medicine to be pre- scribed, and the rationale for prescribing, using medicines information material retrieved from the EP system, or hospital intranet, while at the same time setting up the prescription for the patient. This is illustrated in Fig. 6.1 .
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