Electronic prescribing and the life of a clinical pharmacist Ewan Maule Directorate Lead Pharmacist Emergency Care and Cardiology City Hospitals Sunderland NHS Trust

Background Meditech HISS system Led by medical director and chief executive Multi-disciplinary project team Rolled out over 1 year along with medicines management In-patients, not out-patients

COMPUTERS –Reliable and make continuous rapid consistent but simple decisions PEOPLE –Careless and make inconsistent, relatively slow but complex decisions

A Day in the Life Tom Smith works in a hospital without an EP system Bob Jones is a pharmacist in a hospital with the meditech EP system

Tom Smith Bob Jones am - identifies new patients. Collates drug histories by speaking to patients and GP am - walks around ward looking at existing patients kardex’s to identify changes in drug therapy, then compares with notes am – runs off report of all new patients am – compiles drug histories (uses EP to identify last admission, recent out- patient clinics or prescriptions, correspondence where relevant) am – Runs report of all newly prescribed items to review

11:30am – 12.30pm - handwrites prescriptions for patients being discharged. Files paper copy in notes Methotrexate daily! Chasing and educating F pm – short lunch! 10: am – transcribes discharge prescriptions using EP. Copy is now logged on system with comments am - discussion with F1 who wonders why he cant prescribe methotrexate 15mg daily. Education given 11.45am – runs report of missed doses for audit 12pm – lunch!

1pm – attends consultant ward round. Mr Bloggs is newly confused – empirical antibiotics. But kardex has gone missing! 2pm – Consultant asks if Mrs Scott was on treatment for her Alzheimers. Tom says no. 3pm – Mrs Scotts daughter comes in and asks why her mother has not been receiving her galantamine. Consultant turns to look at Tom. 1pm – attends consultant ward round. Points out that Mr Bloggs confusion coincided with being initiated on tramadol - discontinued 2pm – Notices Mrs Scott had galantamine prescribed at previous out- patient clinic. Bob advises consultant this has not been prescribed yet.

4pm – Mrs Prescott complains her husband has not been getting his Parkinsons medication at the right times. Kardex has been signed at appropriate times. As condition is deteriorating, dose of L-Dopa is increased 4.15pm – 5pm - Final Kardex check – no time to look at Kardex for audit data 4pm – Mrs Prescott complains her husband has not been getting his Parkinsons medication at the right times. EP shows nurses have been giving L-Dopa at 8am drug round, not 6am as he usually takes it. Nurses made aware. Wife reassured 4.15pm – 4.30pm – EP check

5.15pm -

What features do we use?

Remote access Access to any patient record from any PC on any site –Basic review of non-attended wards –Non-paper prescriptions –‘Quick check’ for newly prescribed items or dose check can be done remotely, or without checking individual charts – can aid targeting/prioritisation

Allergy Recording Allows allergy/ADR and nature of reaction to be stored permanently Penicillamine allergies!

Order Sets Create ‘sets’ for common conditions Reduces prescribing/picking errors Promotes adherence to formulary/guidelines

Order Sets H Pylori Care of the dying pathway MRSA skin decolonisation Cellulitis Post-op analgesia Paediatric post-op analgesia (based on weight)

Warnings Automatic warnings e.g. methotrexate When are they seen?

Prescribing decision support Dose steps - ‘Take ml daily’ Route of administration Only allows ‘sensible’ prescribing Exception to every rule? – paeds? Value in added ‘noise’?

Dose defaults E.g when amoxicillin is entered, TDS is automatically entered in the ‘frequency’ field Used sparingly Quinidine

Integration with results Biochemistry, haematology and microbiology results all utilise system Potential for integration –Sliding scale insulin –Heparin –Sensitivities

Replacing stationery

How has EP changed us?

Patient contact

Accuracy of Drug History IV Compatibility Checking / Appropriateness of Route Able to swallow medication?

Remote Access Visual clues lost Lower profile with patients? Easy to become lazy – comfy chairs in pharmacy! Restricts opportunities for ad hoc counselling Communication skills of new pharmacists? Counselling sheets (reminder cards) are pre- printed and delivered by technicians – even less patient contact time for pharmacists?

Clinical Governance Audit is immeasurably easier –Easy access to all manner of prescribing, administration and activity data –Clearer audit trail –Accessibility and accuracy of information for investigation of incidents

Role of the Pharmacist Intervention can be made at point of prescribing –dialogue initiated by medics Often seen as ‘IT pharmacists’ Greater understanding of and enthusiasm for EP than medics/nurses? Ties in with primary care formulary control

‘Alert’ of newly prescribed items can be identified and processed without leaving pharmacy – considerable technician time saved (further savings when interfaced with robot) A lot of the benefits result in us being further removed from the patient ‘The computer does my thinking for me’ What happens during downtime?

Summary Kardex replacement Decision support – limited value (good for yes/no decisions, not for ‘yes, but…’ decisions) EP only identifies problems – pharmacists are still needed to solve them Prescribing problems – noise pollution and automated thinking Clinical pharmacy problems – reduced patient contact

Greater overall influence –Coverage of all wards to some degree –More preventing errors, less correcting errors –Higher profile within staff groups –Tight formulary control –Prevention of certain significant errors Mistakes will still be made!

Words of wisdom Beware of the noise Decision support – how much do you want people to think? Prescribing functionality – can make prescribing very easy (dose defaults) – or very difficult (warnings and noise) Beware of rogue Kardex’s

Words of Wisdom Downtime procedures Stay friends with IT! Focus on what you need from the system, not what it can offer