E-prescribing for children Neil A Caldwell, Consultant Pharmacist, Children’s Services, WUTH Honorary Lecturer, LJMU June 2013

What’s different?

What’s different? What’s not?

Different Prescription commonly has many iterations. Initial guesstimate informed, influenced and modified by multiple individuals over time course: formulation, concentration, volume, brand (taste/palatability), availability or administration time. What is margin for variance? What is legal?

Different Clear, unambiguous order but.....you see what you assume prescription should be. 10kg child prescribed: Clarithromycin (125mg/5mL) liquid, give 62.5g po bd. 4 doses charted + checked as given.

Different CDS such as advanced dosing model logic. CriterionDefinition IndicationCondition that makes particular dose advisable Care areaPhysical location of patient, used to infer intensity Chronological ageAge in years, months, days since birth Post-conceptional ageAge in years, months, days since clinician estimated conception Dosing weightUser defined, may not reflect actual weight Renal impairmentQualitative assessment by ordering provider: impaired or not impaired BMC Med Inform Decis Mak 2011; 11: 14

Different Dose rounding: how, when, who, where? Do you round up or down? Influenced by pharmacology, concentration, dose and volume. Are “rules” different for different medicines or indications?

Different Fewer medicines: 4 medicines comprise >50% of scripts in DGH for children. 150 medicines are 98.5% of prescriptions. Adult surgeons often prescribe for children! Off label use of medicines, evidence lacking, risk of significant overdose.

What’s not different Same goal. To create an inpatient or discharge prescription. Drug catalogue: same products for children and adults, dm+d description. Patient PAS system: admissions, transfers, patient identification. Prescribing style: drug, dose, route, frequency. Basics of documenting administration, same but differences in times and double signing. Basic decision support: allergy checking and interactions. Worries about alert fatigue.

Personal opinion... Target children first in system design. If works for children, will work for adults, but not vice versa. Perfect system is pipe dream. Should never replace practical common sense. Wherever possible, design out common “mistakes.”

An observation.. “Evolution of EP mirrors child development. After long and protracted birth EP arrived, and initially throve. During infancy it suffered minor setbacks and a serious scare. It’s now come through these tribulations intact if a little chastened. As EP leaves the toddler years behind it faces a challenging world knowing that with support and guidance it can look forward to childhood with optimism.” Arch Dis Child 2012;97:124–128

E-prescribing must cover your Rs right patient right medication right dose right volume right route right time right documentation