Tony Cornford Information Systems and Innovation Group Department of Management The London School of Economics and Polit

1. Evaluation of the Electronic Prescription Service in Primary Care in England Tony Cornford Information Systems and Innovation Group Department of ManagementThe London School of Economics and Political Science contact: t.cornford@lse.ac.uk Sydney, 8 April 2008

2. The ISI Group is.lse.ac.uk

3. Recent and Current Work • A study of electronic prescribing in two English hospitals for the Patient Safety Research Programme. Final report, Safer, Faster, Better? Evaluating electronic prescribing available at http://www.pcpoh.bham.ac.uk/publichealth/psrp/Publication_PS019.htm. • Related papers in Quality and Safety in Health Care : http://eprints.lse.ac.uk/2684/

4. Recent and Current Work • Starting a new project (£750k) for the Connecting for Health Evaluation Programme (CFHEP) to assess the electronic transmission of prescriptions in England. Details of the commissioning brief are at http://www.pcpoh.bham.ac.uk/publichealth/cfhep/Project_CFHEP004.htm.

5. Recent and Current Work • Negotiating final details of a project (£1.5M) for the Evaluation of the adoption of the NHS Care Record Service in secondary care – see call at http://www.pcpoh.bham.ac.uk/publichealth/cfhep/invitations.htm

6. What I want to know….. • What Australia does in the area of electronic transmission of prescriptions or similar systems, or more generally on building/exploiting electronic infrastructures. • Approaches to evaluation of such systems and of in particular of their implementation processes. • Establishing new half unit (30 hour) MSc course on healthcare information systems jointly for own department and the LSE health/social planning MScs. Interested in what you offer and how you teach this field.

7. Origins of EPS • Part of the National Programme for Information Technology (NPfIT) in England (2002) • Delivered “Centrally”, but in practice through PCTs, pharmacies and software suppliers • Using core infrastructures N3 • Support for the 1 to 2 Million prescriptions written each working day in England • “..will be more efficient, consistently accurate and able to cope with expected further increases in the number of prescriptions issued”

8. Why EPS –what to evaluate? • Patients/Carers • Fewer ADEs • Pre-dispensing will save time • New dispensing choices; repeat prescribing/dispensing or mail order and internet (one day) • Potential for fewer out of stock items • GP • Reduced times signing prescriptions (e.g. repeats)

9. Why EPS –what to evaluate? • Pharmacy • Extend role in medicines management • Time saved in handling queries • Improved speed and potential for medication recall notices • Reduced time preparing Rx for submission to PPD, faster payment • “Business benefits” • PCT (Primary Care Trust) • Potentially more information to help manage the prescribing budget

10. Plus other Stakeholders • Other HCP prescribers • Appliance providers • Public at large • Software suppliers • Pharmacy chains and supermarkets • Small Pharmacies • Prescription Pricing Division (PPD) • Secondary Care Providers (discharge)

11. Electronic Prescription Service • Release 1 in use • Release 2 soon to be used in practice • This Evaluation is of Release 2

12. Functionality of R1 vs R2

13. EPS release 2

14. EPS R2 Deployment Timeframe • Keep pushing R1 to establish/solve problems • Start R2 in 5 PCTs, then roll on and out • First implementers is May 08? • Many GP and Pharmacy systems yet to conform and upgrades to be performed • 140 GP/Pharmacy combinations (10*14) • Probably little transaction activity most of 08 • Critical mass and take off late 08/ early 09

15. Background to evaluation • Funded by CfH Evaluation Programme • Team with substantial track record in the significant … • Areas: safety research, ICT evaluation • Approaches: quantitative and qualitative • Health Professions: pharmacists, GPs • Locations: London and Nottingham

16. The team • London • The School of Pharmacy • Nick Barber, Tina Brock, Bryony Franklin • LSE • Tony Cornford, Will Venters • Nottingham • Primary Care, Pharmacy, Sociology, Statistics • Tony Avery, Rachel Elliott, Justin Wearing, Sarah Armstrong

17. The Framework Cornford et al. 1994

18. Examples of our approach • Qualitative evaluation of an electronic prescribing and administration systemQual. Saf. Health Care, 2007; 16: 271 - 278. • Barber, Cornford, Klecun • The impact of a closed-loop electronic prescribing and administration system on prescribing errors, administration errors and staff time: a before-and-after studyQual. Saf. Health Care, 2007; 16: 279 - 284. • Franklin et al

19. The Aims • Assess safety compared to prior work practices • Assess initial adoption experience to inform wider rollout • Assess the wider consequences of use for patients, doctors, pharmacists, pharmacies, PPD, and beyond.

20. Four work packages • Safety: medicines and dispensing errors • Patients and their medicines • Work practices and Service Adoption • Organisational and economic consequences

21. Safety: medication and dispensing errors • Controlled before and after study of dispensing errors (label and content errors - currently 1.6 and 1.7%) • Also changes in rate and type of prescription problems identified by the pharmacy • 6 intervention PCTs, 6 control. 56 pharmacies in total. Both measured before and after implementation.

22. Patients and their medicines • Perceptions of ETP before introduction • Early and mature experiences and perceptions • Views of those choosing not to use the service • Compliance behaviour and presentation timing

23. Work practices and service adoption • Influence on GP practices and changes in workload and work flow • GP experiences/perceptions • Influence on Pharmacy practices and changes in workload and work flow • Pharmacist experiences/perceptions

24. Organisational and economic consequences • Organisational and business process change • Within GP practices; PCTs • Within pharmacies and other dispensers • Other NHS stakeholders, including PPD • Opportunity for fraud

25. Additional work • International review and networking • E-research • Establish website for information, chat rooms etc • Draw on existing data stores and data flows • Explore creation of dashboards and other data stream exploitation opportunities

26. Methods • Formative and summative ambitions • A mixture of methods • Interview, observation, survey (mail and phone), e-research, self report • Conduct over 2 years 6 months

27. Evaluation issues • Need to match flexibility of delivery in real world with requirements of good research • First users ?May08? • Critical mass of users/transactions ?end 08? • Parallel system underway in Scotland • Need to tie in with EPS team’s own evaluation within implementation • Need trust and fluid communication between ourselves, implementation team and other stakeholders

28. Evaluation progress • Started January 08; lead researcher now in post • Current activity • Established website www.epsevaluation.org.uk • Stakeholder mapping • Qualitative manual for the field work • Establish international • Progress • Literature • Network • Applying for Ethics Committee approval

29. Questions?

30. The Framework Cornford et al. 1994

31. http://www.connectingforhealth.nhs.uk/systemsandservices/eps/supplierstatus/pharmacy-1http://www.connectingforhealth.nhs.uk/systemsandservices/eps/supplierstatus/pharmacy-1