ePrescribing of Chemotherapy The Leeds Experience Julie Mansell, Lead Chemotherapy Pharmacist, Leeds Cancer Centre

Background at Leeds Teaching Hospitals SJUH Opmas 1993 Cookridge Design partners – Chemocare® 1995 Introduced to breast cancer clinic, gradual rollout Cookridge site → oncology SJUH, haematology 60+ consultants 5000 patients per annum Oncology, haematology, BMT, trials including early phase Treatment given orally, day case, in-patient and ambulatory All chemotherapy prescribed using Chemocare®

Improved safety 2006 Journal of Quality and Safety in Healthcare “Effect of computerisation on the quality and safety of chemotherapy prescription” Oncology centre in Lausanne Examined chemotherapy errors before and after implementation Classification of errors Major = drug name, dose, route of administration Before 141 errors in 940 prescriptions (19% major) After 6 errors in 978 prescriptions (0% major) Error rate reduced from 15% to 0.6% Marc Voeffray et al. Effect of computerisation on the quality and safety of chemotherapy prescription Qual. Saf. Health Care 2006;15;

Complex prescribing – ideal target Narrow therapeutic index and highly toxic– potential for harm is great Wide range of doses e.g. Methotrexate 10mg to 12g/m 2 Dose, interval, route varies with tumour type Dosed on BSA, weight, fixed Several medicines in most regimens Supportive medicines to deliver safely Multiple day treatment with different medicines on different days BEP – Bleomycin D2, 8,15 Etoposide D1,2 3 Cisplatin D1, 2 Modifications for myelosuppression, renal + liver impairment frequent Common use of acronyms Classes of agents with very different uses e.g.rituximab/trastuzumab

National Drivers Manual for Cancer Services Rolling quality assurance programme for cancer services Purpose - enables quality improvement both in terms of clinical and patient outcomes % ePrescribing Chemotherapy Services in England: Ensuring quality and safety National Chemotherapy Advisory Group 2009 Group established to advise DH on development + delivery of high quality chemotherapy services “Handwritten prescriptions for parenteral chemotherapy should be replaced as soon as possible by pre-printed forms or, preferably, by fully validated electronic prescribing systems” Chemotherapy measures S-139 to 142 Electronic Prescribing – covers criteria for system and SOP’s

Benefits and successes (1) Reduces prescription errors Legible Faster for complex treatment

Benefits and Successes (2) Quality assurance Consistency of prescribing Controls access to protocol for certain diseases only Central control of change Set maximum doses/ routes that cannot be overwritten Reduces variation in clinical practice Template sign-off by consultant, 2 pharmacists Calculation of patient variables e.g. GFR, BSA

Benefits and Successes (3) Pharmacy specific Integrated worksheet and label preparation Automatic dose rounding RAPID RESPONSE REPORT NPSA/2008/RRR04 “Doses of vinca alkaloids should be prepared for use by dilution in small volume intravenous bags, rather than in syringes”

Additional benefits Audit and review of practice Identifies case series for research projects SACT dataset Facilitates service re-design Improves prescribing efficiency in clinic Easily accessible treatment view on admission

Specific Challenges/Limitations Reluctance/resistance to change Technophobes! Age range/ skills of staff across MDT Slower for simple treatments Find Clinical and Managerial Champions Employ national drivers Promote additional benefits Patience and perseverance! Training burden Time consuming –start up/new staff/upgrades Level 1 competency (prescribing scenarios) Employ (if possible) a designated ePrescribing lead

Specific Challenges/Limitations Loss of knowledge Doses of chemotherapy never learned Supportive medicines not appreciated Teach and test the basics Errors ePrescribing = different errors ≠ NO errors If template incorrect - affects multiple patients Depends on quality of input e.g. 0mg/ height and weight mistakes Foster a quality culture Check and check again Review common themes

Specific Challenges/Limitations Technical challenges Difficult to set up templates for complex regimens Chronomodulation / trial dose bands National system – unable to make many in-house tweaks No administration module → paper copy for records Be creative, but maintain safety

Future Challenges Paper-lite Long established use of prescription as communication tool Reluctance to change Use clinical (multi-professional) champions Use local drivers – efficiency Project group