* Cresswell, Coleman et al. PLoS ONE 2013; 8(1): e53369 Electronic Solutions to improve the quality and safety of Antimicrobial Prescribing Presented by Dr Jamie Coleman Senior Lecturer in Clinical Pharmacology & Honorary Consultant Physician Overview Electronic Prescribing Medication Administration / Clinical Decision Support How systems can be configured using CDS to support: Drug Selection Drug Verification Drug Administration Monitoring Potential unintended consequences of eprescribing Audit & Secondary benefits Electronic Learning Resources ELECTRONIC PRESCRIBING AND CLINICAL DECISION SUPPORT (CDS) Definitions Electronic Prescribing and Medication Administration (EPMA) System allowing medications & 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 EPMA systems: Foundations and Functionality Hospital Systems are quite variable In terms of where they come from SECONDARY CARE 6% fully implemented* 1/3 putting in systems Spectrum of systems 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 Jamie Coleman 1
Adapted from Improving Medication Use and Outcomes with CDS HIMSS 2009 Benefits of eprescribing BASIC Risk Reduction Legibility Accessibility Communication Speed Simple rules Dose defaults / validation Form-route combinations Order Sentences Drug-drug interactions ADVANCED Complex Rules Drug Disease Contraindications Drug-lab interactions Order Sets (including labs and radiology) Reminders, warnings, information Thromboprophylaxis IV to oral switch Etc. Third party information Laboratory Data Patient diet Diagnoses Allergy / hypersensitivity GP Drug Hx Lab Order Comms Drug interactions / duplication checking Drug Lab interactions Drug food interactions Contraindication checking Allergy & ADR checking Medicines reconciliation Therapeutic drug monitoring The 5 Rights of Drug Therapy eprescribing from Experience Right information, patient to the Right person, drug in the Right dose Right format for intervention, through the Right route Right channel, time at the Right time in workflow Queen Elizabeth Hospital, Birmingham Locally Developed Hospitalwide Electronic Prescribing System More than just eprescribing Specialty specific rules Description Information Hospital 1200+ beds Specialties 17 PICS registered staff 4300 Weekly logins 3200-900 doctors - 1600 nurses Peak concurrency 400+ Weekly prescriptions 24,000 Weekly administrations 125,000 SUPPORTING DRUG SELECTION / PRESCRIPTION Dr Jamie Coleman 2
Jahansouz et al. Am J of Health-Syst Pharm Vol 69 Jul 15, 2012 Drug prescribing functions CDS to aid selection: Order Sets (predefined treatment protocols) Pre-defined treatment protocols JAC Electronic Prescribing and Medicines Administration System Structured Prescribing Protocols for antibiotics links to a Trust-wide policy in the click of a button Protocols (Order Sets) begin with the word Infection Descriptive text used to define the indication and guide prescriber to correct regimen Pre-defined treatment protocols JAC Electronic Prescribing and Medicines Administration System Drug prescribing functions CDS to aid selection: Order Sets (predefined treatment protocols) Avoiding errors Dose range checking Drug Interactions Renal dosing Allergy checking In this example Necrotising fasciitis, (second-line), (not absorbing) a 4-drug regimen is preselected for the prescriber The prescriber has the option to modify the regimen before prescribing Enforcing rational use of Antimicrobials Managing HCAIs: Prescribing of decolonisation Targeted prolonged use of Tier 3 (broad spectrum) antimicrobials Prior policy compliance was poor Order set for tier 3 drugs with hard stop unless alphanumeric code entered (0700 to 2100) Monthly spend went from ~$100k to $57k (p=0.15) Alerts in the patient record with a hover hint providing information Laboratory data automatically fed into PICS special rules for infection control issues Dr Jamie Coleman 3
Pharmacy verification and messaging SUPPORTING PHARMACISTS' WORKFLOW Administration: CDS supports the nursing workflow SUPPORTING MEDICATION ADMINISTRATION Monitoring Therapeutic Drug Monitoring Monitoring for adverse effects Prompting changes (e.g. IV to oral switch) SUPPORTING MONITORING AND STEWARDSHIP Dr Jamie Coleman 4
Patel et al. Am J of Health-Syst Pharm Vol 69 Sept 15, 2012 To Err is System. Aarts and Gorman. Int J Med Informatics 2007;76: S1 The Paperless Review Acutely Ill Patients: Alerting via Blackberry Urinalysis Charts Operation Noting Laboratory Flow Sheets Infection Control Clinical Flags Fluid Balance Physiological Observations Connectivity with exchange server allows wide area alerts via email Dedicated mobile devices (Blackberry ) receive alerts to critical care outreach Acknowledgment capability via email response Sepsis Sniffer being considered Antimicrobial Stewardship: Example of appropriate de-escalation of therapy Pip-Taz initial focus of deescalation project Customised alert to patients receiving Pip-Taz for +ve culture results of organism susceptible to narrower spectrum Rx Pharmacists reviewed the EMR to recommend alternate options De-escalation events increased from 6% to 60% by study completion (p<0.001) A NOTE OF CAUTION (OR 2) Electronic eiatrogenesis TO ERR IS SYSTEM Alert fatigue Pick-list errors It s the computer s fault Penicillamine Penicillin G Penicillin V SECONDARY BENEFITS Dr Jamie Coleman 5
Missed medication doses in hospitalised patients. Int J Qual Health Care (2013) doi: 10.1093/intqhc/mzt044 Clinical Dashboards Clinical Dashboard: turning data into information 5 4 3 Average LOS 2 1 6 7 0 8 20 0 40 60 80 100 120 16868 Four Hour Wait Targets +ve MRSA -ve Dashboard Antibiotic - % missed doses Date Intervention Current stats in dashboard display 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 Stats from previous 6 months in table Step change in % missed doses when information shared with clinicians / managers Further highly significant change when CEO started RCA meetings Transparency of Data Dr Jamie Coleman 6
Individual Snapshot Appropriate Accountability is the mantra THE FUTURE OF EPMA IN ENGLAND EPMA systems not quite as intelligent as Amazon! 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. The Future of eprescribing Working with system providers to develop more intelligent CDS tools to support the Antimicrobial Stewardship Decisions Use EPMA systems to automate the reporting of quality indicators and provide national benchmarking data Ensure that medicines use is optimised as we move to the paperless hospitals of the future ELECTRONIC LEARNING & INFORMATION RESOURCES Dr Jamie Coleman 7
Charani et al. J Antimicrob Chemother. 2013 Apr;68(4):960-7 As an aside - overwhelming clinical information The burden of medical evidence is significant although figures vary 35,000 biomedical journal articles published annually 150,000 articles / month 120,000 RCT/year 500,000 articles are indexed in PubMed every year Smart Prescribers use Smartphone Applications (at Imperial College London) Imperial Antimicrobial Prescribing Application Mixed Method Evaluation across 5 teaching hospitals App downloaded by 40% Junior doctors in 1 st month and 100% by 12 months 1,900 access sessions per month (cf 221 hits on intranet version of policy) Wide audience reached using point-of-care CDS elearning in UG www.prescribe.ac.uk Electronic Formularies Targeted training elearning in PG NHS West Midlands commissioned the development of an elearning programme Started in 2010 Available to all FY doctors in NHS Midlands, East & EOE www.safeprescriber.org SCRIPT SCRIPT contains 40 modules across a wide range of crucial therapeutic areas The modules are structured to include a pre- and post-test of 10 questions designed to monitor knowledge acquisition Clear audit trail of completion available to clinical tutors Dr Jamie Coleman 8
SCRIPT Compulsory training modules, including Prescribing in Infection Case-based Interactive Video / Audio Certified Other elearning Platforms are available Resources to support CPD, appraisal, revalidation and exam preparation Acknowledgments National Institute for Healthcare Research eprescribing team in Birmingham Research teams in Birmingham, Edinburgh and Nottingham Microbiologists, Infection Control and Medicines Management Teams at Queen Elizabeth Hospital Birmingham Health Education West Midlands / SCRIPT Project team 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 Conclusions EPMA systems with CDS can reduce medication errors and increase prescribers concordance with guidelines SCRIPT Taster pages available at: ANY QUESTIONS? Systems can enhance the pharmaceutical care of patients when combined with antimicrobial stewardship strategies elearning Strategies can enhance knowledge and skills of new prescribers j.j.coleman@bham.ac.uk Dr Jamie Coleman 9