There is a slow revolution taking place in the hospital sector. The introduction of electronic prescribing and medicine administration systems looks set to reduce medication errors and improve operational efficiency. We look at how this aspect of healthcare is developing

While community pharmacists in England are grappling with the issues thrown up by the national roll-out of EPS2, an e-prescribing revolution is also taking place within the UK’s hospitals.

There is no nationally imposed solution here, though, and the Electronic Prescribing and Administration Systems (EPMA) used in hospitals provide rather more than just an electronic version of a doctor’s paper prescription. Up to a dozen companies are vying for business in what is a rapidly developing market driven, in England’s case, by a healthy dose of government funding.

Back in May 2013, Health Secretary Jeremy Hunt announced a £260 million ‘Safer Hospitals, Safer Wards’ fund for the hospitals in England to increase their use of e-prescribing and electronic patient records. A further £250 million was made available in a second ‘Integrated Digital care Technology’ fund – including some £50 million rolled over from earlier projects that had not met deliverability targets.

The funds were to be used by hospitals to ‘replace outdated paper-based systems for patient notes and prescriptions’, according to the Department of Health. They were seen as critical stepping stones in helping the NHS go paperless by 2018. Over 40 e-prescribing projects were funded. Hospitals at the top of the list for funding included Leeds Teaching Hospital, getting £7.7 million for an integrated health record and e-prescribing project, and Guy’s & St Thomas’ £3.1 million for an e-prescribing project.

Ann Slee, the e-prescribing lead for NHS England, gives an indication of the rate of change when she says: ‘A paper back in 2011 identified that the number of NHS trusts with e-prescribing and medicines administration systems was around 13 per cent. That figure will be over 50 per cent within the next 12 months.’

It’s happening in Scotland too. NHS Scotland’s eHealth strategy to 2017 was set out in 2011. It also envisages a paper-light NHSS and supports the roll-out of electronic prescribing across Scotland through a national procurement process. However, an integrated approach to include patient records is constrained to some extent, since in January 2010 NHS Scotland purchased a four year national licence for InterSystems’ TrakCare package to allow development of a national patient management system.

Where is the benefit?

EPMA systems are complex and can take up to a year or more to roll out, ward by ward, across a hospital site. They come in two flavours, explains Ann Slee, as stand-alone e-prescribing systems, or applications that integrate with electronic patient records or patient administration systems.

Implementation, she says, is most effective when the three main users groups – pharmacists, doctors and nurses – all buy in to the project. ‘If medics drive the process they see the supply side as irrelevant,’ she says.

The core of the case for introducing e-prescribing in hospitals is that it has the potential to save huge amounts of time and it addresses key medication safety issues.

Some 133,000 prescriptions could contain errors every year

The traditional system of manual prescribing is time-consuming and inefficient. Picture the scenario where the daily ward round takes place, after which a junior doctor follows to write prescriptions. This process can be lengthy, particularly if the necessary drug charts have ‘wandered’ from the bedside. It might take over 10 minutes to assemble the right information and write a prescription.

Using a system that has all the necessary data immediately available on screen can reduce this to a couple of minutes. Prescribing during the ward round, rather than after, also allows for an on-the-spot discussion of any prompts or advice which the EPMA system gives to the clinician through its clinical decision support tools.

Getting the prescription written is only the start of a process. It then has to be taken to the pharmacy, and any queries have to be resolved. These exchanges can take up vast amounts of nursing and pharmacy time, especially on telephone ‘call-backs’. And then the dispensed drugs have to be taken back to the ward.

An EPMA system transmits the prescription to the dispensary in real-time, with less likelihood of corrupted text, medication errors, or lengthy queries. ‘EPMA is estimated to reduce the time it takes to prescribe, check, supply and administer in-patient drugs from overall 3 hours 33 minutes to 1 hour 3 minutes,’ says the business case submitted by Guy’s and St Thomas’ for the project.

Medication errors are a fact of life in NHS Trusts, as they are in primary care, but the scale of the problem is quite frightening. The General Medical Council published a report in 2009 suggesting that the error rate for in-patient prescribing by first year trainee doctors is 8.9 per cent, and that about 2 per cent of the errors made are critical or fatal.

Assuming that the total number of prescriptions issued for patients in a single hospital is more than 1.5 million annually, figures would suggest that some 133,000 prescriptions could contain errors every year

Save 364 mistakes a day

Sheffield Teaching Hospitals NHS Trust says that on average each of its in-patients has six to seven prescriptions during their hospital stay. Assuming that the total number of scripts issued for STH patients is more than 1.5 million annually, the GMC figures would suggest that some 133,000 prescriptions could contain errors every year, or an average of 364 per day.
University Hospitals Birmingham NHS Foundation Trust, an ‘early EPMA adopter’, provides some corroboration for this claim. It estimated that its EPMA system ‘trapped’ up to 400 prescribing errors per day - a similar figure. UHB also reported that its EPMA system halved the number of medication errors during a 12-month period.

Medication safety and operational efficiency aside, EPMA can bring other benefits. Many NHS Trusts that have used EPMA have found it helps control drug expenditure and adherence to the local medicines formulary. Estimates vary on the annual amount that may be saved from 2 to 9 per cent on the drug budget. For a Trust like Sheffield, with a medicines budget of around £76 million, even a 2 per cent saving amounts to £1.5 million a year.

With the current focus on antibiotic stewardship an EPMA system should allow improved antibiotic prescribing and help reduce the incidence of hospital acquired infection. In support of SHT’s business case iSoft (an EPMA system supplier and now part of CSC) estimated that – based on its experience in implementing systems in other large teaching hospitals - EPMA could result in a 10 per cent reduction in the number of MRSA or C.difficile cases.

Clinical decision support is another powerful benefit offered by an EPMA system. Typically, it allows ward staff and clinicians to check drug contra-indications, dosage will flag duplicated therapy. It also puts ward staff on their mettle because prescribing and any subsequent amendments can be traced back to the originator. Since EPMA maintains a continuous and detailed audit trail there can be no hiding behind muddled paperwork.

 

Personalised health and care

The rush to e-prescribing is not without problems, and has its critics. Competent project management is needed to introduce systems across large institutions, and implementation is not cheap. The number of system suppliers currently engaged means any hope of an integrated digital patient care record in England in the near future seems doomed, and few projects seem to have wider objectives such as sharing information with GPs, community pharmacy or social care.

In fact many EPMA systems will not interface with standard hospital dispensary systems such as JAC and Ascribe. To the uninitiated the reason appears banal. ‘They do not link in because prescribing is dose-related, and running a dispensary stock management system alongside that can be an issue,’ explains Ann Slee. Developments in this area are likely to be drive by the requirements of the Dictionary of Medicines and Devices (DM+D), a database of unique identifiers (codes) and associated textual descriptions for representing medicines and devices, which becomes mandatory in NHS systems in 2017 and will provide a common platform.

Where technology developments in the NHS may go over the next five years is set out in ‘Personalised Health and Care 2020’, published in December 2014. Its proposals will, it suggests ‘give care professionals access to all the data, information and knowledge they need’ – real-time digital information on a person’s health and care by 2020 for all NHS-funded services…’ Hospital pharmacists should have just about got to grips with what EPMA can do for them, and what it can’t, by then. Whether it will improve the discharge processes and help bridge the gap between secondary and community pharmacy remains to be seen.