Electronic prescribing and the life of a clinical pharmacist

1. Electronic prescribing and the life of a clinical pharmacist Ewan Maule Directorate Lead Pharmacist Emergency Care and Cardiology City Hospitals Sunderland NHS Trust

2. Background • Meditech HISS system • Led by medical director and chief executive • Multi-disciplinary project team • Rolled out over 1 year along with medicines management • In-patients, not out-patients

4. COMPUTERS • Reliable and make continuous rapid consistent but simple decisions • PEOPLE • Careless and make inconsistent, relatively slow but complex decisions

5. Tom Smith works in a hospital without an EP system Bob Jones is a pharmacist in a hospital with the meditech EP system A Day in the Life

6. 9-10.30am - identifies new patients. Collates drug histories by speaking to patients and GP 10.30-11.30am - walks around ward looking at existing patients kardex’s to identify changes in drug therapy, then compares with notes 9-9.15am – runs off report of all new patients 9.15-10.30am – compiles drug histories (uses EP to identify last admission, recent out-patient clinics or prescriptions, correspondence where relevant) 10.30-10.45am – Runs report of all newly prescribed items to review Tom Smith Bob Jones

7. 11:30am – 12.30pm - handwrites prescriptions for patients being discharged. Files paper copy in notes. 12.30 - 12.45 Methotrexate daily! Chasing and educating F1 12.45pm – short lunch! 10:45-11.30am – transcribes discharge prescriptions using EP. Copy is now logged on system with comments. 11.30am - discussion with F1 who wonders why he cant prescribe methotrexate 15mg daily. Education given 11.45am – runs report of missed doses for audit 12pm – lunch!

8. 1pm – attends consultant ward round. Mr Bloggs is newly confused – empirical antibiotics. But kardex has gone missing! 2pm – Consultant asks if Mrs Scott was on treatment for her Alzheimers. Tom says no. 3pm – Mrs Scotts daughter comes in and asks why her mother has not been receiving her galantamine. Consultant turns to look at Tom. 1pm – attends consultant ward round. Points out that Mr Bloggs confusion coincided with being initiated on tramadol - discontinued 2pm – Notices Mrs Scott had galantamine prescribed at previous out-patient clinic. Bob advises consultant this has not been prescribed yet.

9. 4pm – Mrs Prescott complains her husband has not been getting his Parkinsons medication at the right times. Kardex has been signed at appropriate times. As condition is deteriorating, dose of L-Dopa is increased 4.15pm – 5pm - Final Kardex check – no time to look at Kardex for audit data 4pm – Mrs Prescott complains her husband has not been getting his Parkinsons medication at the right times. EP shows nurses have been giving L-Dopa at 8am drug round, not 6am as he usually takes it. Nurses made aware. Wife reassured 4.15pm – 4.30pm – EP check

10. 5.15pm - 5.15pm -

11. What features do we use?

12. Remote access • Access to any patient record from any PC on any site • Basic review of non-attended wards • Non-paper prescriptions • ‘Quick check’ for newly prescribed items or dose check can be done remotely, or without checking individual charts – can aid targeting/prioritisation

13. Allergy Recording • Allows allergy/ADR and nature of reaction to be stored permanently • Penicillamine allergies!

14. Create ‘sets’ for common conditions Reduces prescribing/picking errors Promotes adherence to formulary/guidelines Order Sets

15. Order Sets • H Pylori • Care of the dying pathway • MRSA skin decolonisation • Cellulitis • Post-op analgesia • Paediatric post-op analgesia (based on weight)

17. Warnings • Automatic warnings e.g. methotrexate • When are they seen?

18. Prescribing decision support • Dose steps - ‘Take 5.666667ml daily’ • Route of administration • Only allows ‘sensible’ prescribing • Exception to every rule? – paeds? • Value in added ‘noise’?

19. Dose defaults • E.g when amoxicillin is entered, TDS is automatically entered in the ‘frequency’ field • Used sparingly • Quinidine

20. Integration with results • Biochemistry, haematology and microbiology results all utilise system • Potential for integration • Sliding scale insulin • Heparin • Sensitivities

21. Replacing stationery

22. How has EP changed us?

23. Patient contact

24. Able to swallow medication? IV Compatibility Checking / Appropriateness of Route Accuracy of Drug History

25. Remote Access • Visual clues lost • Lower profile with patients? • Easy to become lazy – comfy chairs in pharmacy! • Restricts opportunities for ad hoc counselling • Communication skills of new pharmacists? • Counselling sheets (reminder cards) are pre-printed and delivered by technicians – even less patient contact time for pharmacists?

26. Clinical Governance • Audit is immeasurably easier • Easy access to all manner of prescribing, administration and activity data • Clearer audit trail • Accessibility and accuracy of information for investigation of incidents

27. Role of the Pharmacist • Intervention can be made at point of prescribing • dialogue initiated by medics • Often seen as ‘IT pharmacists’ • Greater understanding of and enthusiasm for EP than medics/nurses? • Ties in with primary care formulary control

28. ‘Alert’ of newly prescribed items can be identified and processed without leaving pharmacy – considerable technician time saved (further savings when interfaced with robot) • A lot of the benefits result in us being further removed from the patient • ‘The computer does my thinking for me’ • What happens during downtime?

29. Summary • Kardex replacement • Decision support – limited value (good for yes/no decisions, not for ‘yes, but…’ decisions) • EP only identifies problems – pharmacists are still needed to solve them • Prescribing problems – noise pollution and automated thinking • Clinical pharmacy problems – reduced patient contact

30. Greater overall influence • Coverage of all wards to some degree • More preventing errors, less correcting errors • Higher profile within staff groups • Tight formulary control • Prevention of certain significant errors • Mistakes will still be made!

31. Words of wisdom • Beware of the noise • Decision support – how much do you want people to think? • Prescribing functionality – can make prescribing very easy (dose defaults) – or very difficult (warnings and noise) • Beware of rogue Kardex’s

32. Words of Wisdom • Downtime procedures • Stay friends with IT! • Focus on what you need from the system, not what it can offer