It’s almost a decade since the Audit Commission called for e-prescribing in secondary care. Progress has been slow, but that may be about to change. Daloni Carlisle reports.
There are some people who don’t follow fashion, at least not in the conventional sense. Steve Reggione, senior project manager for e-prescribing software specialist JAC is one of them.
Reggione does not subscribe to the prevailing view that NHS Connecting for Health is somehow responsible for the snail’s pace at which the acute sector has adopted e-prescribing.
“Up to now, the biggest challenge has been the lack of infrastructure in hospitals,” he says. For example, wireless networks and a range of devices to allow clinicians to use sophisticated e-prescribing systems, with built-in decision support tools, at the patient’s bedside.
In fact, while it’s true that the e-prescribing modules for Cerner Millennium and iSoft’s Lorenzo are nowhere in sight, Reggione says: “A lot of people have been critical of CfH, but over the last three to five years it has driven development of the infrastructure.”
Getting to board level
Despite the well-known benefits in terms of patient safety and reducing errors, Reggione reckons that less than 20% of acute hospitals currently use e-prescribing; meaning the rest have stuck with paper and pen.
However, both JAC and its competitor Ascribe report a new level of interest. JAC recently won a contract to provide e-prescribing and electronic medicines management (EPMA) in Merseyside and reports another five trusts in the pipeline for the next 12 months.
Ascribe reports a level of interest “several hundreds of per cent” up on last year. And where once this was the domain of the IT-savvy head of pharmacy, more recently it is chief executives, directors of finance and heads of IT who are pushing for EPMA, says Reggione.
Add the expectations and pressure from an increasingly IT literate medical workforce, and there is a real sea change going on. Gary Mooney of Ascribe says part of the reason is the growing evidence that EPMA delivers real -- as opposed to theoretical -- benefits.
“The mystery of electronic prescribing has gone,” he says. “We now have high quality, complex sites we can point to as reference sites.” Ascribe’s work developing its system at two UK hospitals has shown it to be scalable and clinically safe, he adds.
Well yes, he would say that. There is, however, some independent validation from an exercise run by CfH last year, which evaluated the various systems on offer in the NHS. In June, CfH released a report on the early adopters in the NHS, setting out the best way to implement what is a major change programme with high risks.
Fit with the QIPP
Another driver for renewed interest in e-prescribing is the increased focus on clinical governance, drug expenditure and litigation. The cost of settling legal claims against the NHS for clinical negligence -- which includes medication errors -- rose to £807m last year, up £146m on the year before.
Advocates of e-prescribing point out that it can contribute on all these fronts. “We are not talking about electronic transmission of prescriptions,” says Jonathan Mills, marketing manager for JAC. These are complex systems that link ordering, prescribing, dispensing, patient health data and decision making tools to support prescribers.
E-prescribing improves compliance with trust prescribing policies and reduces medication errors, says Dr Neil Jones, clinical director of FirstDataBank, which provides the decision support tools embedded in a number of e-prescribing solutions.
“Electronic decision support reduces errors by well over 75%,” he says. It eliminates illegible prescriptions at a stroke and can highlight issues such as contraindications, drug interactions and dosages related to a patient’s age or health status.
Dr Jones, who is also a practising GP, finds it incomprehensible that doctors still manage without decision support tools. They are, he says, universal in primary care. “If somebody took mine away I would stop working,” he says. “I would not dream of looking after patients without it now.”
Doses of reality
No-one should be under any illusions that adopting e-prescribing is an easy win, however. A recent National Patient Safety Agency report a case of an e-prescribing system allowing a paracetamol dose to be given too early, as it did not alert a nurse to the drug being prescribed ‘regularly’ and ‘when required’ at the same time.
In another case, a patient was prescribed two naloxone infusions simultaneously. The NPSA warned: “Electronic prescribing and monitoring systems are unlikely to be the answer to avoiding medication errors, but rather are more likely to be the source of new and different errors to those previously recognised.”
Mooney says this is a high risk when systems are not implemented properly. “We have shown over the last decade that there is no such thing as an off the shelf e-prescribing system,” he says. “You can have two very similar hospitals but their clinical processes will be so different that the two could not configure the system in the same way.”
Deploying an e-prescribing system is a long, complex and expensive job that requires extensive planning, close work with software designers and clinical staff, a huge training programme. On the up side, it is a job that can be done incrementally, with no need for a big bang.
Dr Jones says: “It is pretty well recognised that it is expensive. The business case in secondary care shows it takes three to four years of significant expenditure with almost no return and then another three to four years before a hospital starts to get returns.” Others say the timescale is shorter; but the point is well made.
The NHS needs one other dose of realism, highlighted by a recent exchange of views on the news pages of E-Health Insider. Briefly, EHI readers wanted to know whether existing e-prescribing systems are really fully interoperable with hospital patient administration systems and whether they could deliver such complexities as allowing prescribers to view lab reports alongside prescribing modules.
The answer, in short, is ‘not yet’, but as Regionne says: “You only have to look at the places that do have it and what it has achieved for them and compare that with the places that use paper prescriptions that tell them nothing about the patient to see that the benefits are real and immediate.”
When Doncaster and Bassetlaw NHS Foundation Trust started to roll out JAC’s EPMA two years ago, it was a different world in the NHS.
Andrew Barker, clinical director of pharmacy and medicines management at the 1,200-bed trust, explains: “For many wards, this was the first computerised clinical system they had used. We had a lot of work to do in terms of infrastructure, such as putting in radio networks, as well as a cultural change.”
He adds: “That’s got easier as we have gone on. The infrastructure issues have changed and now everybody is using computers on the wards.”
The system is now used by all departments except paediatrics (which is waiting for a release developed with Great Ormond Street Hospital), intensive care (which requires specialist software) and obstetrics, where too few prescriptions are written for it to be worthwhile.
The system includes patient prescribing, electronic administration recording, electronic discharge prescribing and discharge letters.
Asked to identify the benefits, Barker says: “It sounds obvious, but you can always read prescriptions and never lose them. You can always identify which nurse administered a drug. These are major benefits.”
The EPMA has also improved compliance with trust policies and reduced potential adverse reactions by 60%. However, as the trust highlighted to the NPSA for its 2009 report, it has introduced a new type of error -- incorrect selection of a drug from a list by a doctor.
Barker explains: “Because the system takes you directly from selecting a drug from a list through to recommended dosages, it is possible to [select the wrong drug] without this being picked up. We are now working on ways to prevent it.”
Would staff go back to pen and paper? “It’s an interesting question,” says Barker. “We have that as a fall back and when we had a network outage a few months ago we were able to print prescriptions. Everybody said they did not want to do it anymore.”