Scrip studies

E-prescribing should increase safety and efficiency. The safety case is the one that trusts are focusing on now; but in the post-white paper world they are likely to look for efficiency too. Daloni Carlisle reports. Daloni Carlisle reports.

When the board of Worcestershire Acute Hospitals NHS Trust considered the case for e-prescribing earlier this year – and gave it the go-ahead – it was not the financial savings that won the case.

“It was patient safety primarily,” says Nick Hubbard, clinical director of pharmacy and therapies. “It was not about saving money.”

The clinical safety benefits of e-prescribing are generally acknowledged. But while system suppliers talk about efficiency gains, Hubbard views the financial case as less sound.

He says: “There is not much evidence published in the public domain that identifies cash releasing savings into an organisation; and that it what trusts would be looking for.”

This is not to say that Worcestershire does not envisage efficiency savings being made. It is just that they are hard to identify. After all, what trust measures how many hours nurses spend chasing up discharge drugs in order to quantify how much they save by introducing e-prescribing?

Hubbard envisages the system supporting the new quality measures that are being implemented across the NHS.

For example, the new CQUIN (Commissioning for Quality and Innovation) payment associated with deep vein thrombosis prophylaxis will require acute hospitals to risk assess 90% of their patients and give them appropriate treatment. Hubbard says: “With e-prescribing you can make it mandatory as well as audit and report.”

Looking for decision support

Worcestershire is not the only trust now actively considering e-prescribing. After years of slow progress, more and more are taking the leap; as a recently published survey in the Journal of the Royal Society of Medicine Short Reports showed.

Researchers from the University of Nottingham identified 46 English hospital trusts that were either thinking of implementing or currently implementing an e-prescribing system. Knowledge support, decision support and interoperability with other elements of the patient administration system were the functionality of greatest interest.

This fits with Hubbard’s views. His key criteria - as he now moves into selecting a supplier and securing the funds - are for interoperability and fully integrated decision support.

There is other evidence of this being a priority elsewhere. First Databank, the UK’s major supplier of drug knowledge databases and active clinical decision support, this autumn signed a contract with BT to supply its Multilex Drug Data File into RiO, the electronic patient record that is now being installed at community and mental health trusts in London and the South of England.

One of the most high profile trusts to leave the programme – The Rotherham NHS Foundation Trust – has also announced that it will be adopting the Multilex DDF as a key component of its patient record system.

The fact that this is news rather dumbfounds Dr Neill Jones, clinical director for First DataBank and a practising GP. “We have been using these sorts of systems in primary care for 20 years now,” he says.

“There are certain errors that have quite simply been eliminated as a result. The thought of going back to paper and trying to work out the interactions between the seven or eight different drugs that a patient with a long term condition might be prescribed... well, put it this way; I wouldn’t want to try.”

He estimates that around 5% to 10% of trusts currently use prescribing decision support software but he hopes to see this increase rapidly, not least as a result of work to integrate such tools into e-discharge modules (see below) and to simplify their use.

Chasing the money

The next big question for Hubbard is whether the money will be available to implement his carefully crafted business plan. He sincerely hopes so and says: “I believe a lot of trusts will go down this route even in cash strapped times. We need to be able to utilise staff to greatest efficiency and e-prescribing does help that.”

Pauline Sweetman, an independent e-prescribing consultant agrees – but thinks progress will not be immediately apparent. She says: “Trusts that have been frustrated by the National Programme for IT in the NHS will be keen to engage directly with suppliers.

“Some will be looking at prescribing systems rather than complete electronic health record systems. They have the opportunity now to engage directly with the supplier of their choice; but they may not now have available resources.

“So potentially the numbers will significantly increase - although an implementation is likely to take around two years from start to 'finish'; that is from looking for a supplier to when the users are comfortable that the system is tailored to their trust and working as they would like.”

The current landscape is not just one of more trusts moving towards e-prescribing but also of new players coming into the marketplace. Alongside the well-established players such as Ascribe and JAC and those procured by NHS Connecting for Health within Lorenzo, Cerner and RiO there is, for instance, NoemaLife UK.

This Italian-German group offers low-cost clinical workflow solutions – including an e-prescribing module – and expanded its European base to the UK in April 2010. It is currently involved in a pilot project in one UK hospital.

Robyn Tolley, managing director, says: “There is a lot of energy in the NHS with people wanting to get e-prescribing sorted. There is a great deal of interest in a stand-alone solution that integrates with the existing clinical systems in a hospital.

“The key trick is to integrate into what doctors and nurses do and not to introduce a new system that puts a whole new perspective on workflows.

“If you are asking nurses to log out of one clinical system and then into e-prescribing then you double their work and you do not get adoption. Our plan is to offer something highly cost effective and extremely flexible.”

Starting with discharge

The popularity of systems such as JAC and Ascribe can’t be overlooked, though. The University of Nottingham survey found they were favoured by 60% of their sample. The two companies say that there is a good financial case in addition to the safety case for their solutions.

Paul Thomson, head of Ascribe’s e-prescribing division says figures from trusts he has worked with show that there are significant savings to be made in drugs costs (typically 6%, or somewhere between £250,000 and £750,000 a year); the time taken to discharge patients (£2m); reduction in drug usage (£400,000); and reduced length of stay (£625,000).

He also makes the financial case for e-prescribing in relation to CQUIN. “Trusts will either gain a quality payment or be penalised if they do not hit the target on assessing and treating patients at risk of venous thromboembolism,” he says. “This could be as much as £800,000 per year per trust.”

There is no getting away from the cost of implementation, however. Not least because full blown e-prescribing comes with some significant infrastructure needs - such as a wireless network and mobile devices for doctors and nurses.

It is an investment step too far for some. A number of hospital trusts – among them Hillingdon, Ealing and West Suffolk – have opted to take an incremental approach, starting by incorporating decision support into electronic discharge solutions.

By standardising terminology, this allows junior doctors and nurses at ward level to communicate safely with pharmacists via an electronic system.

“Incorporating DM+D into discharge summaries is a great building block for introducing e-prescribing,” says Adrian Towler, managing director of Bluewire Technologies, a software company that has worked with clinical communications specialists SRC to develop the module used in Hillingdon, Ealing and West Suffolk.

“There are big financial benefits – with discharge quicker and more streamlined, patients can be discharged sooner so saving bed space – as well as communication with the GP. You have also cracked the first element of clinical engagement.”

Ascribe’s Thomson agrees that trusts may prefer to take this softly, softly approach to introducing e-prescribing and many products will lend themselves to a modular implementation.

“You do not necessarily need all the bells and whistles,” he says. “The thing to remember is that introducing e-prescribing is not just about pharmacists. It is a major change process that requires clinical engagement and change management. It is a journey, not a destination.”