Clinical professionals of all disciplines face a two-fold task in their daily practice in a healthcare environment. On the one hand, they have a duty of care towards their patients, and an obligation to ensure that patients are treated in a way that ful fi ls legal requirements and ethical requirements , and most closely represents accepted best practice for their profession. On the other hand, there are operational pressures from the healthcare organisation to treat patients as quickly and ef fi ciently as pos- sible and to achieve statistical benchmarks and service level targets . Furthermore, these two objectives can sometimes seem to be in opposition; best care of the patient by the practitioner may be at the expense of meeting organisational targets. However, there is a greater chance of both objectives being achieved if work fl ow for the prac- titioner – both the prescriber of a medicine and the person administering the medi- cine – is streamlined by the appropriate use of electronic systems.
For many healthcare systems, designed for use in a busy working environment, the design of the user interface is important. For an application such as electronic prescribing, where there is a need to present complex prescribing information in a way that enables appropriate professional decision making, and to input com- prehensive medicine order information in a straightforward and timely manner, user interface design is critical. An appropriate user interface is one of the key factors contributing to the reduction of medication errors by EP systems.
The obvious bene fi t of EP system is a legible and complete prescription , facili- tated by the electronic display of that information. Thus, an EP system can ensure that, for every prescription, the following details will be included:
• Medicine
• Form / Formulation
• Strength
• Dose
• Route
• Frequency
• Duration (if applicable)
Any speci fi c prescribing or administration instructions
•
The legibility and completeness of prescriptions is bene fi cial to the working practices of all system users involved in the prescribing, dispensing and administra- tion of medicines. Two UK implementations of EP systems have commented on the positive impact of EP on the legibility and completeness of the prescribing record
79 Workflow Management for Clinical Users of EP Systems
[ 12, 40 ] . The legibility and completeness of an electronic prescription are depen- dent on other factors.
Firstly, the legibility of prescription information on an electronic system in the clinical environment cannot be assumed; it will depend on (a) the design of the screens and forms used to display the data, (b) fonts and styles of text used, (c) graphics and colours used on the screens. The adoption of chart designs and form templates that were already in use in the hospital, as happened in Burton on Trent, UK [ 71 ] , will facilitate staff familiarization with the system and, as well as having a positive effect on the reduction of prescribing errors and medicine administration errors , will increase staff con fi dence in the system and the ef fi ciency with which the EP system is used.
Secondly, the completeness of the displayed prescribing history will depend on the completeness of the prescription data captured in the fi rst place. To facilitate adequate prescribing data capture , the database structure should have suf fi cient granularity, and the medicines data should be suf fi ciently comprehensive to handle a wide range of complex prescribing scenarios. This is because, in general terms, many prescriptions generated in secondary care are more complex and varied than those in primary care.
For example, a secondary care EP system would need to include:
(a) a comprehensive range of routes (including routes to support enteral feeding ) (b) a comprehensive range of formulation types,
(c) reducing/increasing dose regimens (e.g. prednisolone reducing dose),
(d) loading doses and associated maintenance doses of the same drug (e.g.
gentamicin),
(e) alternate routes of administration for the same drug dose (e.g. metoclopramide 10 mg po/pr/im),
(f) complex administration instructions (e.g. co-trimoxazole 960 mg on Monday, Wednesday and Friday). The provision of adequate functionality to allow cap- ture of complex drug orders is important because, in two reports [ 11, 72 ] , it was found that errors of omission increased after EP implementation, because pre- scribers found themselves unable to enter certain types of prescription due to the design of the system and the con fi guration of the drug data.
Other issues associated with data capture concern the use of screen prompts and the use of freetext fi elds. Firstly, it has been demonstrated that functions to prompt the user to fi ll in each line of the form in the prescribing work fl ow help to minimize missing information and maximize patient safety [ 73 ] . Secondly, in an analysis of 2,914 electronic prescriptions with free text fi elds, it was found that there were inter- nal data discrepancies in 16.1 % of prescriptions, leading to adverse events in 83.8 % of cases and severe adverse events in 16.8 % of cases [ 74 ] . Many of the discrepan- cies were between structured and free text fi elds, and the study authors indicated that designers should use free text fi elds with care in the prescribing work fl ow.
In addition to the clear display of a prescribing history for a patient, another important issue in facilitating an ef fi cient work fl ow for the user is the ease of opera- tion of the system. For any EP system, there is a balance between the completeness
of data capture during the prescribing process, and ease and usability of the system for the prescriber. A system might have a 12 stage prescribing process to enable the clinician to prescribe a complex regimen, but this may not be acceptable a busy clini- cian using the system. One way of addressing this issue might be to use pre-de fi ned orders (PDOs) for commonly used prescriptions (e.g. Furosemide 40 mg Tablets – one to be taken each morning), so that the clinician can select a complete medication order in a single process. This approach was used in a pilot at Southmead Hospital, Bristol, UK [ 40 ] to speed up the prescribing process and to incorporate implicit deci- sion support , in the form of prescribing guidance. However, use of PDOs may lead to different kinds of error due to incorrect selection of a PDO, or errors within a PDO being propagated inadvertently through large numbers of patient records.
As well as the number of operations required to generate an electronic medicine order, in terms of de fi ning the order details – medicine, form, strength, dose, route, frequency etc – consideration needs to be given to the number of con fi rmation boxes (“double dares”) and warning messages that appear during the work fl ow for differ- ent types of prescribing. It is well recognised that, if a system presents an excessive number of clinical warnings in any particular work fl ow, especially warnings that are irrelevant to the speci fi c prescribing scenario, the user will begin to ignore the warn- ings (so-called “ warning fatigue ”).
The need for con fi rmation boxes may be reduced by the appropriate use of control default options and highlighting , but the risk management implications of these developments need to be considered carefully. Furthermore, due to the increasing granularity of data – both coded data from patient records, and drug data within deci- sion support systems – decision support data providers are now looking at aggre- gated querying techniques to produce single warning messages that are more intuitive to the particular prescribing scenario.
Just as the prescribing work fl ow of an EP system can affect the ef fi ciency with which clinicians prescribe medicine, so the medicine administration work fl ow of an EP system can streamline the process of medicines administration in a hospi- tal environment. As with the prescribing work fl ow , the medicine administration work fl ow is highly dependent on the user interface and the screen layout.
The medicines administration work fl ow must have appropriate forms and con- trols to present the administration of various different medication types that might be administered in hospitals, such as:
• Regular medicines – those given at regular intervals (e.g. amlodipine 10 mg daily)
• When required (PRN) medicines – those given when necessary (e.g. paracetamol for pain relief, also antiemetics post surgery)
• Once only (stat.) medicines (premedication for surgery or vaccines)
• Fluids (e.g. 0.9 % sodium chloride, or 5 % dextrose)
• Continuous infusions
In order to present the complexities of all prescription types in a concise manner, some EP systems have chosen to design a medicines administration screen that, to a greater or lesser extent, mimics the traditional medicine chart or Kardex, with sec- tions for each of the prescription types – regular, when required, once only, fl uid and
81 Workflow Management for Clinical Users of EP Systems
continuous infusions. Figure 3.2 shows the design of a medicines administration screen for scheduled (regular) medicines on an EP system. This allows administra- tion of the medicine within a de fi ned timeframe, and also provides other functions to support medicines administration (witnessing for CDs, referential data on the medicine etc).
In an EP system, the design of the administration screen will facilitate and manage the medicines administration process. For example, the different order types might be displayed on different tabs on screen, so that the nurse can view all active orders according to order type. Scheduled orders – due at a particular time – could be dis- played distinctively – for example, highlighted in red. The order could then revert to the standard background once the administration had been recorded (or alternatively show in, for example, green for a set period of time after the administration had been recorded, to indicate that it was a current administration that had recently been done).
For regular medicines , there would be a facility to input a user code for the person administering the medicine; for other order types, there should be a facility to record a user code , a date and time of administration and a dose , where a variable dose is required. With all scheduled order types, there should be the facility to record a missed-dose code .
Alternatively, all of the orders scheduled to be given at any given time could be displayed on one administration screen, regardless of order type. The disadvantage of this, however, is that they may not be immediately viewable alongside the whole record of prescribed medication.
Fig. 3.2 Layout of an EP system medicines administration screen (by kind permission of JAC Computer Services Ltd)
Electronic medicine administration has the advantage that it can force users to conform to a general process for medicines administration. However, the underlying rules used by an EP system for electronic medicine administration are potentially complex and would need to be carefully considered, in relation to the established poli- cies and professional practices within a hospital or healthcare provider organisation.
Among others, the following issues would need to be considered:
(a) What would be an appropriate time window for highlighting a scheduled prescrip- tion as due for administration? For example, with a regular medicine , the system might highlight it in red for an hour either side of the scheduled administration time
(b) What would be an appropriate time window for allowing a scheduled prescrip- tion to be administered? For example, with a regular medicine , the system might enable recording of an administration (cells active and highlighted) for an hour either side of the scheduled administration time.
(c) Should once only medicines and fl uids display as being administrable as soon as they are electronically signed by the prescriber? If they are not administered, how long should they persist on the administration pro fi le?
(d) Should “ lock out” functions exist for when required medicines ?. For example, the system might disable the prescribing of paracetamol based analgesics more frequently than every 4 h and at doses of more than eight tablets in 24 h.
Other issues that would need to be considered in detail would be the design of administration functions for continuous infusions and controlled drugs , the con fi guration of missed dose codes and the provision of an on-hold and off-hold facility for items that have been prescribed, but which need to be withheld pending other events, for example pathology test results . The latter function is useful in a number of situations involving elective treatments – for example chemotherapy .