Exempted from this legal proviso are short extracts in connection with reviews or scientific analyses, or material provided specifically for the purpose of being loaded and executed on a computer system, solely for the use of the purchaser of the work. Duplication of this publication or parts thereof is permitted only under the provisions of copyright law at the publisher's location, in its current version, and permission for use must always be obtained from Springer.
Introduction
Chapter 1
There has also been an increase in consumerism in healthcare, with a corresponding decrease in paternalism on the part of healthcare professionals. The concepts of the “empowered patient” and the healthcare professional as the patient's “partner” in the healthcare process are now widely used by healthcare policy makers.
IT in Pharmacy – Purpose and Scope
Pressing public health issues and their budgetary impact, particularly in the disadvantaged sections of the population, are huge drivers of the development of new professional roles in healthcare and the use of IT to enable these roles in both the UK and the US. In order to discuss the information requirements of the pharmacy profession and the IT role in the pharmacist's working life, it is necessary to review the history of the pharmacy profession [1] and the environments in which the profession operates.
The Profession of Pharmacy – Past, Present and Future
Therefore, the formation of the NHS led to a decrease in sales of proprietary drugs by pharmacies. These developments increased the amount of drug information available in the public domain, although many professionals were concerned about how unbiased some of the information was.
The Development of Clinical Pharmacy
From the mid-1980s onwards, the policy direction of the community pharmacy was to expand its role beyond dispensing. In addition, a range of new services have been introduced in UK community (retail) pharmacy.
The Development of Information Technology in Healthcare
GP systems have been in use since the mid-1980s and offer a range of features to support the work practices of GPs/primary care practitioners. Although GP systems were available for prescribing in medical practices as early as the 1980s, their integration into the routine work practice of general practitioners was much slower.
The Quest for Intraoperability
This presents a number of problems – (a) duplication of effort in designing and configuring functions that may be common to all systems (eg patient selection functions), (b) duplication of staff effort in inputting of data in the systems, (c) introducing risk because all elements of the patient file are not visible to a user through a single system. In many UK and US hospitals, a hospital-wide patient administration system (PAS) or hospital information system (HIS) has been installed, along with order communication systems, which deal with order messages in broader meaning (eg radiology orders as well as pathology and pharmacy orders).
Coding of Medicines Concepts
Diagnosis-related groups (DRGs) were developed in the United States by the Healthcare Finance Administration as a means of assigning a treatment cost to a patient's diagnosis. Read Codes (subsequently called Clinical Terms) were developed in the UK to enable clinicians (mainly in general practice) to code events in the electronic patient record and thereby enable statistical audit of the patient care process in primary care.
Medicine Item Codes
Electronic Information Sources for Pharmacy and Therapeutics
Many pharmaceutical collections – 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. Furthermore, since the introduction of the SmPC structured format a few years ago, much of the information available to healthcare professionals from the pharmaceutical industry in the UK and Europe has been presented in a structured way that could be incorporated into electronic systems.
Electronic Drug Databases
Likewise, in the case of a third-party data supplier, the data supplier is legally responsible for the internal quality of the medicinal product data. The main disadvantage of using a third-party dataset is the cost of using the data.
Information Technology to Support the Medicines Use Process
A third party data supplier's data must be consistent and accurate, with business processes in place for compiling and evaluating their data. Using a third-party data set removes maintenance responsibility from the software vendor or healthcare provider (although a data set-up by the software vendor may be required).
Information Technology to Support Clinical Pharmacy
Traditionally, hospital pharmacy drug information services used a range of drug reference resources – some in electronic form – to support the activities of clinical pharmacists in the hospital [3] and their queries about the use of drugs in specific patients. Many drug reference databases have been specifically adapted to provide high-quality drug reference information on hand-held devices by medical staff and clinical pharmacists [25.
IT and the Interface Between Pharmacy and the Pharmaceutical Industry
However, since the advent of personal digital assistants (PDAs), handheld devices and smartphones and the development of electronic drug reference resources for use on these devices, clinical pharmacists have been able to access drug reference resources such as the electronic British National Formulary on a handheld device with the patient 's bed. In addition to these, a variety of stand-alone systems have been developed to support specific aspects of clinical pharmacy, such as pharmacy intervention monitoring, pharmacokinetics and therapy monitoring and patient information.
Clinical Safety
Safety standards are also being developed for connected devices, such as glucose meters, which can automatically send data to electronic health records. These include IEC80001, introduced in 2011, which will require healthcare providers to properly document and assess network systems and components that interface with medical devices.
Pharmacy IT as a Sociotechnical Innovation
These were comparable to safety standards in industries such as aviation or nuclear power, where safety and the prevention of critical incidents have long been a concern. These standards would apply to all systems that could be used for direct patient care, such as general practitioner systems, hospital EP systems and other specialist clinical systems.
Conclusion
Chapter 2
This chapter examines the development of electronic health records (EHRs) in general, discusses the legal and design issues with EHRs, and describes how EHRs are used in pharmacy practice and how they can support other systems and enable new initiatives in the profession can make. Issues such as access and sharing of EHRs, subject (patient) access to records, specific record systems in the United States and the United Kingdom, the benefits of EHRs and how they can support pharmaceutical care will be discussed.
Development of Electronic Patient Records
Legal and Professional Framework for EHRs
In Great Britain, the Data Protection Act 1998 requires healthcare professionals to obtain a patient's consent to store information about him or her to support the services provided, stating the purpose for which the information is being collected. This has not been a major problem for pharmacists in the past, but as pharmacists take on new roles and provide clinically focused professional services, they will need to establish appropriate documentation of patient care interventions to provide accountability for their professional decision-making.
Information Governance and Data Sharing
Healthcare professionals should have a shared responsibility for maintaining and ensuring data quality in a shared recording system. Governance arrangements should be put in place to address errors and disagreements in shared systems of record.
Often access to the record is requested by the representative of the patient, rather than the patient himself. Access to the patient's EHR by a healthcare professional should be based on the professional's role, and whether they have a caring relationship with the patient.
Electronic Health Record Initiatives
Patient permission must be sought from the care setting wishing to view their Care Summary Record. For example, the use of SCR can help to resolve a discrepancy between the pharmacy system and the prescription, or between the pharmacy system and the patient's recall.
In a study looking at the identification of adverse events related to amlodipine in UK general practice, Mohamed et al. The use of EHRs to screen patients for medication-related problems was also demonstrated by Roten et al.
Clinical Pathways and Content
While several software tools have been developed to support pharmacist consultations (inside and outside pharmacy management systems) for new pharmacy services, it can be hoped that there will be more standardization of clinical assessment tools and content for pharmacy activity in the future. This may involve adopting clinical content or workflows developed in a multidisciplinary way, but there will be a need to develop material specifically to support pharmacist work processes.
Optimisation of EHRs for Pharmaceutical Care
In the UK, these tools have been developed by various healthcare professions, mainly occupational therapists, but their use in pharmacy practice is still in its infancy, as pharmacists have traditionally not conducted their consultations in a formal environment with a workstation at the point of consultation. Once the clinical content is developed and approved by professional bodies, it can be adopted by suppliers of EHR and other systems.
Applications of EHRs for Pharmacists
The Royal Pharmaceutical Society of Great Britain has previously released guidance on recording interventions [40], with advice on when interventions should be recorded, where interventions should be recorded and how long intervention data should be kept. Although the guideline provides broad advice on what information should be recorded, it does not cover this in detail.
The Content of a Pharmaceutical Care Record
The delivery of PGD can take place in a number of settings, for example in the patient's home, in a walk-in clinic or in a residential home, and not just in the pharmacy. The visit may take place because the patient is homebound, but may also be related to a delivery service.
Conclusions
Chapter 3
Electronic Prescribing and Medicines Administration in Hospitals
However, in the US, electronic prescribing may be referred to as computerized physician order entry (CPOE), although strictly speaking, this only applies to the prescription data capture process, not any decision support function, and may apply to any type of order (eg pathology test etc.) not just a medical order. Additionally, the term electronic prescribing is sometimes used incorrectly to describe the computer generation of a paper prescription (see Chapter 5), or it can be used to describe the electronic transfer of prescriptions (eTP) to the community, which will be referred to elsewhere other in this book.
It is an adequate description of some of the EP systems currently in use in the UK. It is also an appropriate definition for many US EP systems currently available.
Reduction in Medication Error Rates with EP Systems
The EP system led to a significant reduction in prescribing error rates for hospital prescriptions, but interestingly not for discharge prescriptions. However, the EP system facilitated systematic data acquisition to enable analysis of prescribing errors.
Effect of EP Systems on Medication Error Rates in Paediatrics
18 ] investigated the effect of an EP system with clinical decision support on the incidence of medication errors and adverse events (ADEs) in a hospital in the Netherlands. These included (a) an increase in the percentage of orders for the recommended drug in a particular 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.
Work fl ow Management for Clinical Users of EP Systems
In an EP system, the design of the administration screen will facilitate and manage the medicine administration process. For example, with a common medicine, the system can enable recording of an application (cells active and highlighted) for an hour either side of the scheduled application time.
Discharge Process Ef fi ciency
However, the ground rules used by the EP system for electronic medication administration are potentially complex and should be carefully considered in conjunction with the established policies and professional practices of the hospital or healthcare provider organization. Other issues that should be considered in detail would be the design of administration functions for continuous infusions and controlled drugs, the configuration of codes for missed doses, and the provision of hold and opt-out options for items that have been prescribed but need to be held until further notice. events, such as pathology test results.
Facilitation of a Seamless Pharmaceutical Supply Chain
In addition to how an EP system can simplify medication ordering and supply within a hospital, it has been suggested that EP systems can help facilitate a seamless pharmaceutical supply chain from manufacturer to patient. Consequently, the means now exist for an uninterrupted pharmaceutical supply chain from the pharmaceutical industry to pharmaceutical wholesalers, and then through central procurement agencies and hospital pharmacies to the patient.
Reduced Use of Paper and Consumables
Clinical System Intraoperability
With EP system interfaces or integration, there is therefore the potential for portability of prescription history to and from other systems. As previously mentioned, a comprehensive prescribing history within an EP system is important to ensure evidence-based practice and user confidence in the system.
Improvement in Hospital Business Processes due to Electronic Dissemination of Prescriptions
A number of studies have postulated organizational effectiveness as benefits of using an EP system. But, more than perhaps any other EP system benefits area, organizational benefits cited for EP systems are most dependent on the political and socioeconomic contexts in which they are demonstrated.
Security of Prescriptions and Prescribing Information
Quality of Care Bene fi ts
The impact of a closed electronic prescribing and administration system on prescribing errors, administration errors and staff time: a before and after study. The impact of electronic prescribing on medication errors and avoidable side effects: an interrupted time series study.
History and Development of Dispensary Technology
This chapter explores the various technologies used to automate the pharmacy dispensing and medication supply process, describes their strengths and some key problem areas, and highlights areas of potential future development.
Pharmacy Robot Design and Operation
The Medimat system, which works in the same way as the Speedcase, with random storage and semi-automatic loading, is suitable for low to medium turnover. Product storage in Consis is on a channel storage basis rather than a random storage basis.
Adoption of Pharmacy Automation in the UK
The system was set up with two picking heads - one for single items and one for multiple items - with a total of 11,000 items stored in the unit. At the time of go-live, controlled medicines could not be stored in the Consis system.
Drivers for Use of Automation in Pharmacy
However, there are few published articles quantifying the actual benefits of pharmacy robots. The scientific basis for the benefits of pharmacy robots is discussed in the next section.
A number of efficiencies in the dispensing process have been observed in system evaluations. Pharmacy robots can be expected to improve prescription throughput in the pharmacy.
As with electronic prescribing, there is relatively little quantitative data on the benefits of pharmacy automation. This will (a) provide evidence that will be useful to other hospitals at the stage of building the business case for automation, and (b) ensure that the benefits of pharmacy robots are fully understood before any steps are taken to integrate them. with other electronic medication management technologies.
Electronic Ward Cabinets
In addition to this, if the cabinets are cluttered, there may be errors in the selection of medicines (especially if there are similarities in name and package design). The way the cabinet is used will depend on the type of ward and the types of patients on the ward.
These units can also be used to enable and control the dispensing of TTO/discharge pre-labeled packs of commonly used medications such as analgesics, laxatives and antibiotics, depending on the specialty of the ward. On the other hand, medical wards will have a wider variety of stock drugs, and this can be more challenging to stock and maintain the cabinet.
Implementation Issues with Electronic Ward Cabinets
Managers should consider how the cabinets can be evaluated for possible benefits prior to purchase. This may include looking at the cabinets in operation at similar hospitals and assessing their business cases, although there have been some studies suggesting that some benefits of automated dispensing systems (eg reduction in delivery time) can be evaluated using computer simulations of these units [ 28.
Remote Dispensing Systems
While there are benefits to barcode administration (discussed in detail in Chapter 3), nursing staff will often find workarounds (BCMA workarounds) in the barcode administration system that will negate the benefits. The kiosk therefore provides the patient with the security benefits of an automated cabinet (increased accuracy of product selection etc.) and automated stock control, together with a pharmacy service, advice and information available from a pharmacist.
Specialist Dispensing Systems
The benefits of the system for the community pharmacist have been described and there is an algorithm to assess the financial viability of the system in a given pharmacy. ASHP national survey on informatics: assessment of adoption and use of pharmacy informatics in the United States
Chapter 5
In the UK NHS, primary care prescribing accounts for approximately 80% of the total medicines budget [ 1. Given the sheer financial and human resources allocated to primary care networks in many health economies, it is essential that the systems used to enable medicines management and community pharmacy practices ensure high quality of care, efficient use of resources and appropriate use of the skills of all professionals involved in the medication use process.
Electronic Medicines Management in Primary Care
In Great Britain, systems used in general practice (GP systems) have been used routinely since the 1970s. The market leader in the UK, with 60% of the market, is EMIS, but other suppliers include InPractice Systems (INPS)(Vision), iSOFT (Synergy and Premiere) and Microtest.
Clinical Coding for GP Systems
Text appended to Read coded entries must never change the meaning of the original coded concept. The semantic scope of the codes is often uncertain and there is variation in their applicability even in the same practice.
Data Quality in GP Systems
These services are useful in increasing the use of standard codes and should be considered by practices. Some systems still allow users to create their own practice-level codes, but the use of unique practice-generated codes is not recommended.
GP System Functionality
Prescribing medicine was one of the first functions of early GP systems to be widely accepted. However, some of these problems may also be related to the design of the system, and pharmacists should be aware of them.
GP System Safety and Usability
This uses similar data transfer processes to those used to transfer data from one active GP system to another. Reading back to the target system of data collected in the time period from the final source system data extraction to the target system 'cut over'.
Electronic Transfer of Prescriptions (ETP)
In the UK, the English EPS uses a Smartcard system to provide access to the service on the national backbone. With EPS Release 2, an electronic prescription is transferred from prescriber to dispenser, and a prescription token is given to the patient in paper form.
Prescribing Management Software
Design and implementation of a computerized decision support system for the diagnosis and management of dementia syndromes in primary care. Identification and establishment of consensus on the key security features of GP computer systems; an e-Delphi survey.
History and Development of Pharmacy Systems
Chapter 6
The development of pharmacy systems to support work processes in both hospital and community pharmacies has taken place over the last 40 years in the UK, USA and other countries. The introduction of pharmacy systems by local (retail) pharmacies in the UK took place at about the same time.
Pharmacy System Requirements and Use
The literature on the development of the US pharmacy system in the 1970s and early 1980s is reviewed by Knight and Conrad [5] and by Burleson [4], and the problems and issues associated with the implementation of the early systems are described. [ 6– 8. There is little published data on the usability of pharmacy systems, although this area has been important in the UK in recent years as suppliers of pharmacy systems have redesigned their systems to make them compliant with electronic transfer of England. prescription system (eTP), Electronic Prescription Service (EPS).
Pharmacy System Architecture
Community Pharmacy System Functions
In the UK, hospital pharmacy systems may have a local hospital number as a patient ID, although the use of the NHS number is now mandated in UK hospitals. As with a GP system, pharmacy systems will alert the user to drug interactions, duplicate treatment, allergies and dose control.
Hospital Pharmacy System Functions
Hospital pharmacy systems need inventory management functions (departmental inventory lists) – to enable inventory management not only in the pharmacies, but also in the different departments and departments of the hospital. Hospital pharmacy systems are department systems of larger institutions, in a way that community pharmacy systems are not.
Stock Control Methodologies in Hospitals
PO drugs should be clearly marked in the medication record and allow appropriate labeling to be produced. It then provides the patient with a supply of a medicine that can be used in hospital (and self-administered if appropriate for the patient) and then provides approximately a 2–3 week supply for the patient on discharge.
Pharmacy System Interfaces
For these reasons, a system of 28 day (one stop) dispensing was introduced in many UK hospitals in the late 1990s. However, the hospital pharmacy may have to relabel some 28-day supply items with new dosage instructions or supply additional items at discharge.
Reporting
Availability of Clinical and Medicines Information Through Pharmacy Systems
System Functions
As with GP systems, procedures should be in place to enable data transfer and migration from other pharmacy systems. Community pharmacy systems require appropriate interfaces with external systems, such as eTP and other regional or national systems and initiatives.
A recurring theme in the literature on pharmacy systems is the completeness of pharmacy records compared to prescription records. In any case, recent work in the US has questioned the quality and usefulness of decision support features in pharmacy systems.
Other Pharmacy Departmental IT Applications
Due to the data fragmentation problem of parallel use of prescription and pharmacy records, there is a clear argument that prescribers and pharmacists, and indeed all health professionals, should have read and write access to a common record. This section describes some of these activities and some of the IT solutions developed to support them.
Extension of EP Functions from Pharmacy Systems
Fridge Temperature Monitoring Software
Integrated Community Pharmacy Systems
Systems to Support Clinical and Enhanced Services in Community Pharmacy
Logistics – the management of the supply chain – is an essential part of any business, as the ability to deliver the right product is a prerequisite for trading. If this is not done, it will lead to loss of sales and customer dissatisfaction. This chapter provides an overview of pharmacy supply chain processes, the technologies used in the supply chain, particularly barcode product identification, and how these technologies can be optimized to streamline the supply chain and maximize the potential benefits to deliver. ts mentioned above.
Current Pharmaceutical Distribution Processes
In the UK, a Special Offers Tariff has been introduced to ensure that prices paid by pharmacies (and ultimately the NHS) are reasonable, and also to create some transparency around prices and margins in the supply chain. Using the EAN code enables pharmacy robots, but it is often the last point in the supply chain where electronic identifiers are used.
Development of Barcodes and Optical Technology
A type of 2D data matrix barcode that originated in Japan is the QR code, which can be used to connect mobile phones to the Internet with selected websites and is being routinely used in communications, media and advertising. The European pharmaceutical industry is planning to adopt the 2D data matrix barcode, and many companies are using data matrix codes for product tracking.
Radio Frequency Identi fi cation (RFID)
2D matrix barcodes cannot be scanned with conventional laser scanners, but many stores now use handheld image scanners, and eventually image scanning technology may become cheap enough to be scaled up for universal retail applications.
The Regulatory Framework for Supply Chain Harmonisation
This will enable continuity of medication identification between NHS registers and all points in the supply chain, enabling greater use of technology to reduce medication ordering, dispensing and administration errors. That EAN.UCC open global standards (of product identification and RFID. EPC)) has been formally selected for coding and symbolizing all pharmaceutical products available end to end (active ingredient for consumption) UK supply chain.
Rationale for Barcode Symbology Harmonisation
The aspiration of a seamless pharmaceutical supply chain with electronic management and tracking will not be achieved without a concerted effort to develop standards and harmonize supply chain coding and processes across the industry.
Bene fi ts of Barcode and Optical Technology in Pharmacy and Medicines Management
Commerce in Pharmacy
One of the pharmacies in the Trust used barcode product selection, which achieved a slightly lower dispensing error rate of 0.0022 errors per person. Barcode drug identification on wards relies on the availability, configuration and scalability of the appropriate hardware.
