Improving patient safety and infection. Patient Safety Forum Dr J Coleman 1 ELECTRONIC PRESCRIBING AND CLINICAL DECISION SUPPORT (CDS)

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1 Improving Patient Safety and Infection Control Through Electronic Prescribing Dr Jamie Coleman Senior Lecturer in Clinical Pharmacology / Honorary Consultant Physician The brief Clinical computing technologies for quality & safety: Electronic Prescribing Medication Administration (Using example of UHBFT s EPMA solution - PICS) Reducing clinical / medication errors: Clinical Decision Support Preventing patient misidentification : Barcoding medication administration The use of computerised decision support for Infection Control Using data to support Medicines Optimisation Definitions ELECTRONIC PRESCRIBING AND CLINICAL DECISION SUPPORT (CDS) Electronic Prescribing and Medication Administration (EPMA) System which allows medications and other prescribed therapies to be managed electronically through the entire medicines use process ep is also known as Computerised Physician Order Entry (CPOE) in North America Clinical Decision Support (CDS) Process for enhancing health-related decisions and actions Using pertinent, organized clinical knowledge and patient information to improve health delivery eprescribing UK Context PRIMARY CARE ep is Universal Few core systems SECONDARY CARE 6% fully implemented* 1/3 putting in systems Spectrum of systems * Cresswell, Coleman et al. PloS One. 2013; 8(1): e EPMA systems Foundations and Functionality Hospital Systems are quite variable In terms of where they come from Grown out from Pharmacy Stock Control Systems Part of a wider EHR integrated solution Anglicised European Solutions Developed from Primary Care eprescribing System Home Grown Systems Dr J Coleman 1

2 Our System Development Process Queen Elizabeth Hospital, Birmingham Locally Developed Hospital-wide Electronic Prescribing System More than just eprescribing Specialty specific rules Developed by Wolfson Computer Lab Long history of highly generalised healthcare IT systems HEALTH INFORMATION TECHNOLOGY AT UHBFT Continuous development for over 10 years Always in conjunction with UHB clinical staff Core design, development, implementation, 7 staff Currently 12 staff in PICS team Description Information Hospital beds Specialties 17 In prescribing terms - PICS registered staff 5080 Weekly logins doctors nurses Peak concurrency ~500 Non-inpatient episodes 5,400 Weekly prescriptions 32,000 Weekly administrations 137,000 From this using these to this PICS a developing Electronic Clinical Record Laboratory Flow Sheets Urinalysis Charts Fluid Balance Infection Control Operation Noting Clinical Flags Physiological Observations MEDICATION & PATIENT SAFETY Dr J Coleman 2

3 The need for eprescribing In hospital Adverse Drug Reactions ~15% admissions Preventability ~ 50% Measurement of errors varies Cost of in hospital ADRs for England million Contribute to mortality and morbidity Strategies for prevention needed Davies EC et al. ADRs in Hospital In-Patients. PLoS One 2009; 4(2): e4439 The five rights (of CDS) Right patient information, to the Right drug person, in the Right dose format for intervention, through the Right route Right channel, at the Right time Right time in workflow Adapted from Improving Medication Use and Outcomes with CDS HIMSS 2009 Third party information Laboratory Data Drug interactions / duplication checking Drug Lab interactions Basic Benefits to Expert Error Surveillance Patient diet Drug food interactions Diagnoses Allergy / hypersensitivity GP Drug Hx Lab Order Comms Contraindication checking Allergy & ADR checking Medicines reconciliation Therapeutic drug monitoring Basic Benefits Legibility Accessibility Basic parameters Reduce errors due to erroneous or absent information Expert error detection Rules based surveillance with alerts outside order entry Reduce errors of omission or commission Evidence-based Benefits Review of the impact of CPOE on medication errors Relative risk reduction of 13% to 99% 23/25 show risk reduction One study with increased rate due to disconnection and transcription errors Home-grown systems compared better to commercial systems Ref: Ammenwerth et al. J Am Med Inform Assoc (5): BARCODING MEDICATION ADMINISTRATION Dr J Coleman 3

4 Benefits of ing local considerations Barcoded patient (rather than drug) selection Reduction in misidentification errors Change in Medication Workflows Only part of full Barcoded Medication Administration solutions Ref: Barcoding Medication Administration Ref: Sakoweski et al. Am J Health-Syst Pharm. 2008; 65: Implementing Policies Example of Antimicrobial Prescriptions INFECTION CONTROL AND AMTIMICROBIAL STEWARDSHIP Prompts doctor to review effectiveness of therapy Structured Prescribing Protocols for Antimicrobials adapts the whole Trust Policy in prescribing orders / order sets Rules for healthcare associated infections e.g. MRSA Medication Monitoring Automated prescribing of MRSA decolonisation taking into account sensitivities Doctors are required to document risk factors for MRSA on admission of all patients to drive subsequent decolonisation rules Therapeutic Drug Monitoring Monitoring for Adverse Effects Prompting Changes (e.g. IV to Oral Switch) Some of the rules are quite strict! Dr J Coleman 4

5 The Paperless Review Urinalysis Charts Laboratory Flow Sheets Acutely Ill Patients are Alerted via Blackberry Physiological Observations Fluid Balance Connectivity with exchange server allows wide area alerts via Dedicated mobile devices (Blackberry ) receive alerts to critical care outreach Acknowledgment capability via response Sepsis Sniffer being considered USING DATA FOR MEDICINES OPTIMISATION PICS Audit system Inappropriate to run audit queries alongside live operation Daily automated export of PICS content to data warehouse on separate server Currently ~180 Gb Microsoft SQL Server Allows: Routine weekly/monthly reports Automated distribution Ad-hoc reports (clinical audits) Modelling impact of proposed changes Accessible by informatics and research teams Clinical Dashboard Turning data into information Antibiotic - % Missed Doses Date Intervention A 15 April 2009 Pause function for doctors B 04 August 2009 Missed Doses go live on clinical dashboard C 15 December Introduction of coloured indicators to show due / 2009 overdue drugs D 24 February NPSA Rapid Response Alert * 2010 D 30 March 2010 Chief Executive Missed Dose Root Cause Analysis * meetings Step change in % missed doses when information shared with clinicians / managers Further highly significant change when CEO started RCA meetings Dr J Coleman 5

6 EPMA systems not quite as intelligent as Amazon! THE FUTURE OF EPMA IN ENGLAND National Evaluation: The implementation of eprescribing systems in English hospitals NIHR funded Programme Grant: Describe the procurement, implementation, adoption and maintenance of the basic and more advanced eprescribing systems. Estimate their effectiveness and costeffectiveness. Develop best practice recommendations for procurement and a toolkit for their successful integration into NHS hospitals. QUESTIONS? j.j.coleman@bham.ac.uk Acknowledgments National Institute for Healthcare Research eprescribing team in Birmingham Research teams in Birmingham, Edinburgh and Nottingham The views expressed in this presentation are not necessarily those of the NIHR, the Department of Health, University Hospitals Birmingham, University of Birmingham or the CLAHRC-BBC Theme 9 Management/Steering Group Dr J Coleman 6