This book is the result of several years of reflection and work in the field of electronic prescriptions and medication management. I would therefore like to acknowledge and thank a number of people whose help and support has been invaluable in the production of this book.
Chapter 1
Philosophical and Social Framework of Electronic Medicines Management
Introduction
Definitions and Terminology
It is an apt description of some of the EP systems currently in use in the UK. It is also an appropriate definition for many of the US EP systems currently available.
The Benefits of Automated Systems
Some of these benefits have also been reflected in the large quantitative studies of systems in the US. However, it is recognized by experts in the field that the realization of these benefits is dependent on system design.
EP and the Individual
An EP system can be used to facilitate new ways of dealing with critical incident-based CPD. Many healthcare managers will understandably see the successful implementation and use of an EP system as:.
EP and the Organisation
Nevertheless, some managers will see the EP system as a "quick fix" for one or more long-standing problems in the organization. Implementing and deploying an EP system in a hospital is a major business project and will require formal project management and project structure – the standard methodology for this is PRINCE 2 in the UK healthcare environment.
EP and the State
In the UK, the Connecting for Health program (formerly the National Program for IT (NPfIT)) has been running since 2002, with the aim of delivering a range of healthcare functions across the UK NHS. A number of NHS Trusts in the UK have stopped ongoing implementation projects, with the intention of adopting the CfH software when it became available.
Legal Requirements for EP Systems
In the UK there is a requirement to keep records of the receipt and supply of controlled medicines. These improvements make it possible to establish a more complete audit trail for the supply of controlled medicinal products.
EP Systems and Professional Liability
It must contain the dose and, for a preparation, the form and strength of the preparation. In some cases, a licensed medicine is used for an unlicensed indication, or in a patient group where it does not have a license – using medicines approved for adults in children is a common scenario.
Confidentiality and Consent
In many cases, a patient's consent is implied when a medication history is extracted from a GP's letter; The starting point is that the patient has agreed to the referral. Indeed, in many scenarios consent must be assumed to be implied; If explicit consent had to be obtained at every stage of the patient care process, a healthcare provider's work would quickly become unmanageable.
Ethical Issues
Related to the issue of confidentiality is the issue of a patient's consent to having their information stored on an EP system. But in situations where information – e.g. a prescription history – is elicited from a patient, or when other information is obtained from the patient (such as the drug review scenario described in Chapter 6), with the intention of putting the information on the EP system, then explicit consent must be obtained from the patient to store the data for a designated purpose.
Conclusion
Notes and References
Chapter 2
History and Context of Electronic Prescribing in the US and UK
The Development of Information Technology in Healthcare
These areas have not been as well developed, possibly due to (a) the complexity of algorithms required to perform the necessary clinical decision support on EHR data; (b) the lack of expertise available for IT vendors' design of these systems and (c) the dependence of such systems on the availability of appropriate technology for handling images (X-rays, MRI scans, CAT scans, etc..) One of these clinical applications, still in its infancy, is electronic prescribing. If hospital information services can be illustrated as a pyramid, EP systems form the peak of the pyramid and are built on the foundation of other more basic functionality (see Fig. 2.1.
Development of EP Systems in the United States
The most notable center for EP use in the US is Brigham and Women's Hospital, Boston. Another early implementation of CPOE was the system at Wishard Memorial Hospital, Indianapolis, Indiana,12 which was implemented in the late 1980s and documented in a study published in 1993.
Development of EP Systems in the United Kingdom
The system was then extended to two further care of the elderly wards, the admission unit and the ophthalmology ward. Future development of the system will involve improving the system to become a thorough electronic prescribing and medication administration system.
Development of EP Systems: A European Perspective
Since being designed at Wolfson Laboratory, the system has been taken over by healthcare IT supplier McKesson for further development. The authors concluded that the system had a positive impact on safe and effective prescribing on the renal unit.
Integration of EP Systems with Pharmacy Systems
This distinction is worth noting because although there is a need to connect an EP system to a pharmacy system, many implementers emphasize the distinction between an EP system and a pharmacy system. Essentially, an EP system is patient-centric, whereas a pharmacy system will be product-centric.
Development of Medicines Information Services and Their Integration with EP Systems
EP Systems and Oncology Systems
In 2005, the UK government announced its intention to introduce an e-prescribing initiative for oncology and cancer care. However, it is unclear when oncology functionality will be developed for the proposed national solution under the auspices of the UK's Connecting for Health programme.
The Development of Consolidated Electronic Medicines Management Systems in Hospitals
For this reason, CfH undertook a benchmarking process in 2006 in which it evaluated a range of existing oncology management solutions from specialist vendors. The benchmarking process raised awareness of oncology prescribing systems and it is likely that there will be various further implementations of specialist systems in NHS Trusts and Cancer Networks in the UK, before any general EP system in hospitals. United Kingdom.
Barriers to Implementation of EP Systems
Chapter 3
The potential for IT systems and applications to facilitate changes in work practices by automating mundane, logical processes is now well known throughout business. Thus, the introduction of a new software solution can lead to an organization meeting its business goals more effectively, with a paradigm shift – a radical change in working methods – for those involved in the business area.
Principles of Business Process Redesign
Given the large number of business processes and scenarios operating in a healthcare environment, it is inevitable that some processes will not be supported by a single system. Third, the importance of business processes must be clearly understood in their context before a software solution can be designed to support them.
Medicines Management in Hospitals: Existing Business Processes
The drug overview is then used as a basis for the drug supply and drug administration in the hospital. The nursing staff then administers the medicine to the patient according to the information on the medicine card.
Organisational Benefits of EP
Workflow Management for Clinical users of EP Systems
Prescribing Workflow Design
Second, the completeness of the displayed prescription history will depend on the completeness of the prescription data that was recorded in the first place. For any EP system, there is a balance between the completeness of data capture during the prescribing process, and the ease and usability of the system for.
Medicines Administration Workflow Design
The need for confirmation boxes can be reduced through the appropriate use and emphasis of audit standard options, but the risk management implications of these developments should be carefully considered. However, the underlying rules used by an electronic drug delivery system are potentially complex and must be carefully considered in relation to established policies and professional practices within a hospital or healthcare provider organization.
Facilitation of a Seamless Pharmaceutical Supply Chain
In addition to the ability of an EP system to streamline drug ordering and supply in a hospital, it has been suggested that EP systems can help facilitate a seamless pharmaceutical supply chain from manufacturer to patient. As a result, the means now exist for a seamless pharmaceutical supply chain from the pharmaceutical industry to pharmaceutical wholesalers and then through central purchasing agencies and hospital pharmacies to the patient.
Reduced Use of Paper and Consumables
Clinical System Intraoperability
As previously mentioned, a comprehensive prescribing history in the EP system is important to ensure evidence-based working practices and user confidence in the system. In the UK, for example, there is currently no model for transferring medicines data from hospital EP systems – where they exist – to GP systems or community pharmacy systems in primary care.
Improvement in Hospital Business Processes due to Electronic Dissemination of Prescriptions
Furthermore, the organizational benefits of EP systems also depend on the structure and objectives of the research in which they were demonstrated. An important factor in streamlining prescribing processes in hospitals is the ability to remotely view the electronic prescribing file at a number of different locations.
Contribution of Workflow Improvement to Professional Practice Development
Chapter 4
Nor can electronic systems address the human elements of communicating risk information and assimilating risk information by individual patients. First, however, it is necessary to review the potential risks associated with the medication management process and the general principles of how these risks can be managed, before considering the specific aspects of risk reduction with EP systems.
Principles of Risk Management in Therapeutics
There are many risks that can arise from the drug administration process in this form: (a) the wrong drug may be delivered from the medicine cart; (b) the correct medication may be supplied, but incorrect information is recorded on the medication chart and (c) the patient may receive a time-critical medication late due to delays in the medication round procedure. However, EP systems can reduce the risks associated with the drug delivery process by providing electronic drug delivery, thus creating a closed-loop process (i.e. the entire process of drug delivery is electronically controlled ), as discussed in Chapter 3.
Reduction in Medication Error Rates With EP Systems
Experience From US Implementations
They found that both interventions resulted in a 55% reduction in undetected serious medication errors during the implementation period, from 10.7 events per 1000 patient-days to 4.86 events per 1000 patient-days (p = 0, 1). Bates et al.4 (1998) reported that the rate of undetected errors arising from the transcription process was significantly reduced by 84%, from 1.3 events per 1000 patient-days to 0.2 events per 1000 patient-days .
Experience From UK Implementations
Non-intravenous drug administration errors were reduced from 7% (across 1,473 non-i/v orders) before implementation to 4.3% (across 1,139 orders) after implementation of the system. One of the pharmacies in the Trust uses barcode product selection, which achieves a slightly lower dispensing error rate of 0.0022 errors per person.
Increases in Medication Errors Due To the Introduction of EP Systems
Because of the high staff-to-prescribing ratio and highly controlled environment, the lowest dispensing error rate was at the Trust's chemotherapy manufacturing facility, where the authors calculated a zero error rate. Barcode technology has also been used by EP systems to reduce errors in the medication administration process on the ward.
Reduction of Medication Errors Due To the Availability
The study examined ADEs throughout the electronic prescribing process by conducting a prospective daily review of the electronic medical record for a random sample of all admissions over a 20-week period in a US hospital. The study observed that ADE rates were still relatively high after the introduction of CPOE, if decision support systems were not present as an integral part of the system.
These included (a) an increase in the percentage of orders for the formulary recommended drug in a specific drug class; (b) a decrease in the percentage of orders for a drug with doses that exceeded the recommended maximum dose for that drug and (c) an increase in the use of the approved frequency of administration for a drug. In the USA, the Joint Clinical Decision Support Workgroup (JCDSWG) published recommendations for EP system DS function development.
Problems With Evaluating Risk Reduction Aspects of EP Systems
Miller and colleagues argue for the development of US-wide drug database and terminology standards to support DS, and have indicated that EP systems will not be widely implemented in the US, in rural areas as well as large neighborhoods, until this occurs. .
Chapter 5
Data Support for Electronic Medicines Management
In addition to the data items described in the first three categories above, which are recorded in patients' individual prescribing records within the EP system, there is a requirement that an EP system provides a system of clinical alerts and alerts for clinical decision support at the time of prescription. Consequently, DS functions on EP systems require data tables to store the various clinical alert messages that would be required, and an indexing and querying system to generate the appropriate clinical alerts at the relevant point of the workflow.
Coding Systems for EP Concepts
1 Many of the coding systems have their historical origins in the need to classify and enumerate medical events for public health purposes. Read codes have been used extensively for coding diagnoses, problems and prescribing medicines in GP systems in Great Britain.
The Development of Medicines Information Reference Sources
Many pharmaceutical compendiums – for example the British National Formulary or the Martindale Extra Pharmacopeia – are now also available in electronic form, on CD-ROM for single-user or network access. However, the required content of standard drug documents, SmPC and PIL, is now high.
Sources of Drug Databases, and Their Implementation Within EP Systems
Also, with a third-party data supplier, the legal responsibility for the internal quality of the drug data falls on the data supplier. In the US, some authors have in the past questioned the quality of data from third-party data suppliers.
Requirements of Drug Databases for Supporting EP Systems
The main disadvantage of using a third-party dataset is the cost of using the data. Currently, the most important third party data providers for providing drug data to EPs and suppliers of medication management systems are First Databank, Inc.
Medicine Nomenclature
Synonyms
Product Mapping
Pharmaceutical Forms
However, care should be taken not to conflate concepts of route of administration with concepts of form within data - for example, "subcutaneous injection". Also, proprietary terms for certain pharmaceutical forms - for example, "Spansule ®", should be avoided, in favor of a generic concept (in this example, "inhalation capsule".
Routes of Administration
Dose Information Management
In any case, many topical products such as creams and ointments consist of a defined supply (100 g tube) but with undefined dose and administration amounts (one application), so that the number of dose/administration aliquots that make up the supplied amounts cannot be calculate.
Admixtures
Non-indexed Products
Data for Decision Support Tools
Accuracy and reliability of clinical alerts is a key consideration in the implementation of DS tools. However, this approach is very laborious, in the same way as building a custom drug database.
Legal Issues with EP Data
Chapter 6
Electronic Medicines Management: Support for Professional Practice
Modernisation of Healthcare Working Practices
Electronic medication management: supporting professional practice. a) The growing complexity (and cost) of new therapeutic developments and the range of available therapeutic interventions require greater reliance on clinical evidence in therapeutic practice. The increasing expectations of patients regarding information about the benefits and risks of their treatment, together with the availability of information about medicines from other sources (eg the Internet).
EP Systems: Support for Professional Practice
But EP systems can now enable the treatment of chronic diseases, and this will have an impact on the pharmacist's role and the pharmacist's necessary professional competences and thus continued professional development needs. It is therefore important that this part of the EP system is designed to be as user-friendly as possible for the care staff doing theirs.
Audit Logs in EP Systems
They can even be useful in providing evidence of malpractice; In Wirral Hospitals17, a nurse was arrested for unauthorized prescribing using a doctor's credentials because the doctor was not present at the hospital at the time the unauthorized prescribing occurred, as shown in the system audit log. An important consideration with audit trails in EP is that the database is designed from the outset with appropriate audit logging tables, to provide a sufficiently comprehensive data set to support audit trails, and the extent to which the audit logging and reporting features can be configured for each hospital location.
Use of EP Systems for Clinical Audit
The results of such an assessment can be used to develop a guideline for the use of the drug in the hospital if such a guideline does not already exist. Discrepancies may be due to: a) On-demand (prn) use of drugs such as analgesics and antiemetics where consumption by the patient is variable and where there may be little correlation with the number of dosage units dispensed by the pharmacy.
EP Systems and Patient-Centred Medicines Reviews
A summary of the operational flow for drug reviews can be as follows: a) The reviewer selects the patient record for review. The system would prompt the reviewer with suggested recommendations for the prescriber, either to be included in the drug review form as is, or to be bypassed by the reviewer based on their clinical experience. f) The completed medication review form will then be sent to the prescriber and displayed for action by the prescriber when the patient record is further accessed.
Involvement of EP Systems in Clinical Research
EP Systems: Support for Continuing Professional Development
The potential role of the EP system in the training of non-prescribing physicians will be discussed at length in Chapter 7. A further advance would be the development of an active prescribing simulation module where the EP system would automatically present a specific patient and clinical scenario to the trainee prescriber and the prescriber would then prescribe to the patient using the EP system.
Integrated Care Pathways and Clinical Guidelines
EP Systems: A Gateway to Medicines Information Reference Sources
Chapter 7
Electronic Medicines Management and Non-medical Prescribing
Background to Non-medical Prescribing
This group carried out two prescribing reviews (known as 'Crown Reports'), which have been key to non-medical prescribing in the UK. Since 2006, all extended formulary nurse prescribers have become independent nurses and can prescribe from a full formulary (within their scope of practice and if authorized by their employer).
Experience of Non-medical Prescribing
Benefits and Risks of Non-medical Prescribing
Given that some concerns about the training of prescribers are independent and complementary. The role of EP systems in managing and supporting prescriber-led non-medical services.
Role of EP Systems in the Management and Support of Non-medical Prescriber-led Services
The potential of EP systems to support training and continuing professional development (CPD) was discussed at length in Chapter 6. However, there are certain ways in which EP systems can support the training needs of non-prescribers – for example, the use of care plans, inclusion clinical guidelines, access to reference sources of drug information and simulation training. From an organizational perspective, healthcare providers must have a robust clinical governance system in place to govern all prescribing activities, including the management and enablement of non-medical services led by prescribers.
EP Systems and Role-Based Access (RBAC)
National Care Records Service (NCRS) standards were first published, many vendors analyzed the data structure and operation of legacy systems to determine what development was required to make them "backbone compatible". Thus, it may not be possible to replicate all aspects of local user permissions in a national system.
Records Management and Multi-user Systems
This download process will also include synchronizing the patient data on the portable device with the patient data on the main application. In any case, there may be difficulties in assembling data to provide prescribing decision support tools on the wearable device.
Workflow for Different Prescriber Types
As mentioned above, an important distinction between non-physician prescribers is between dependent and independent prescribers. It should be noted that at this point there may be a slight difference between (independent) prescribers and independent prescribers;
Information Support for Different Non-medical Prescriber Types
However, given the customary way of using referral information for passive decision support within EP systems, consideration should be given to implementing more active decision support for non-medical prescribers. However, for independent non-medical prescribers there may be a case for actively offering prescribing support information within the prescribing process.
Support for Patient Group Directions (PGDs)
Such resources can be readily made available for describing decision support within an EP system, subject to licensing agreements for the published resources. System designers should consider the applicability of functionality to prevent sensitive personal information—for example, regarding treatment for HIV infection and sexually transmitted diseases—from being visible in the overall prescription profile, which would be visible to a wide range of users in healthcare. organization and beyond, but still be listed in the physical data and be available for decision support control.
Support for Training and CPD for Non-medical Prescribers
The system would then simulate a response (or lack of response) to the patient's treatment, in terms of clinical observations and feedback test results, etc. The prescriber would then revise the therapeutic strategy based on the patient's simulated response .
Adverse Drug Event (ADE) Reporting
ADE data capture at the point of consultation would mean that more details of the ADE would be available at the outset, reducing the need for follow-up by pharmaceutical companies or regulatory bodies. If necessary, the ADE will then be flagged to the attending physician to be validated prior to transfer.
Non-medical Prescribing: Management and Clinical Governance
Chapter 8
The previous chapters have aimed to do this based on a number of recognized areas of advantage in EP systems. Many of the areas of innovation described here are very advanced when you consider the proportion of healthcare providers in the UK and US with EP systems and the level of functionality these EP systems provide.
The Challenge of Device Integration
Device integration upstream of the prescribing process generally aims to facilitate clinical decision support. Device integration downstream of the prescribing process is generally about the automated planning and delivery of treatment to the patient.
Hardware Platforms and Infrastructure
A welcome future innovation would therefore be the development of electronic medicine lockers for patients, so that the administration of medicines can be controlled per patient. The use of wireless workstations has enabled the development of electronic drug administration and enabled physicians to prescribe medications electronically during the ward round.
Assistive Technology
Therefore, there is very little, if any, experience in using secondary care EP systems to collect monitoring data for chronically ill patients, either from GP systems (primary care systems) or from remote devices. Indeed, the greater the potential impact of a new technology on a patient's personal life – and a near-patient telemedicine monitoring system can potentially have a greater impact on a patient's lifestyle – the more information and there will surely be a patient. the need to adopt a new technology or procedure.
Identification and Communications Technologies
While this may be the norm in some countries, it is not routinely the case in Britain. Wireless networks are also how other EP systems near patient services will be facilitated in the future.
Issues and Limitations with Quantitative Research on EP Systems
Political Issues with EP
32 Third, it has been argued that large government-sponsored IT projects suffer from a lack of coordination that undoubtedly hampers their timing; this argument has been made in the UK for hospital electronic prescribing 33 and electronic transfer of prescriptions (eTP) in the community. Impact of a closed-loop electronic prescribing and administration system on prescribing errors, administration errors, and staff time: a before-and-after study.
Appendix
Worldwide Experience of
Hospital Electronic Prescribing
Index
Uncaught dose medication error rate, 64 Non-formulary drugs, 72, 97 Non-formulary prescribing, 65, 72 Non-indexed products, 90–91 Uncaught medication errors, 64 Uncaught potential side effects.