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E-prescribing
Laura Bucknell
Head of Medicines Optimisation
Controlled Drugs Accountable Officer
Medication Safety Officer
Gloucestershire Care Services (GCS) NHS Trust
• Provide a range of services to Gloucestershire's population of
approximately 605,000 people in an area just over 3100km²
• Run seven Community Hospitals with just under 200 beds
• Provide Nursing, Physiotherapy, Podiatry Re-ablement and Adult Social
Care in Community settings
• Run Health Visiting, School Nursing and Therapy services for children
• Provide a number of specialist services including Sexual Health, Heart
Failure, MND and Parkinsons, Home Oxygen, Community Dentistry,
Diabetes, MSKCAT, Rapid Response
• GCS has been using SystmOne for record keeping since 2013
• Over 50 % of GP practices in Gloucestershire use SystmOne for prescribing and record keeping
SystmOne – Gloucestershire Care Services’ Clinical System
E-prescribing
• Implementation of the inpatient e-prescribing and administration module on our Community Hospitals wards began in April 2016 and ended a year later- 7 hospitals
• Community e-prescribing module in place in all minor injury and illness units, all specialist services
• Next phase – health visiting and community nursing
Clinical Ownership
• The most important thing! • Patient safety • Clinical engagement from all professionals -
champions Clinical system team are great at process but they are not clinicians
Setting up the Project
Project Board • Oversight and scrutiny • Sign off • Risk and issue log • Clinician heavy! Planning • Initial scoping • Medicine formulary development • Identifying stakeholders/ENGAGEMENT • Process maps : As Is and To Be • Standard Operating Procedures • Project Board sign off
Lessons learnt (If I had a crystal ball!)
Going live with EPMAR
• Time to train - Have you covered everyone? - Ongoing training needs • Big bang or drip feed? - What are the risk? - What do you need? • Support on the day of go live and afterwards • Follow up and review - Stop the Chinese whispers and ‘work-arounds’ • Audit the change
Doctor engagement
• This was really hard
• Marmite • Find a champion • Process for raising clinical queries
Discharge Medication • No automatic pull of information as we assumed
• Medicines reconciliation required to reduce risk • Is the process different to paper??
Warfarin/ sliding scale insulin • Variable dose prescribing tab not fit for purpose for
Warfarin and sliding scale insulin prescribing
• Additional problems for GCS - INR results not available until late in the day - Doctors not on wards all day Short term solution/risk management • Agreed protocol for variable dose prescribing and review Medium term • Back to paper! • Near Patient Testing for INR in Community Hospital
VTE risk assessment and prophylaxis • Template for assessment developed
• No prompts • Assessments missed • Assessment done but prescribing missed
Issues – people and processes
• Managing expectations
• Acceptance of change • Short memory of what happened before
• Engage so not perceived as ‘done to’ • Sending a task is no replacement for Human factors e.g. talking • Assumptions that the IT will fix everything – risk with prescribing and
administration will remain. AN ELECTRONIC SYSTEM DOES NOT REMOVE THE NEED FOR CLINICAL JUDGEMENT AND KNOWLEDGE OF POLICY/PROCEDUREs
It looks different!
• Don’t underestimate the impact of this • On paper everything at a glance • VTE/ warfarin issues • We developed a summary page
Alert/pop up overload
• We thought it would help! • Risk of important alerts being ignored • Only allergies/sensitivities, high risk and contra-indications • Clinical knowledge
Smart card Access Issues • What access rights to people need any – governance
issues? • Agency nurses
• Out of hours doctor cover – paper charts
• Pharmacist require full access rights to annotate
prescriptions
• Monitor access
Workstations on Wheels
• Moving WOWs between rooms raised issues for infection control
• Decontaminate WOW when entering/ leaving rooms
• Leave WOW outside of the room – risk of incorrect administration
• Purchasing wipe-able keyboards
Business Continuity and the Listener Client
• Not a simple process (cost v risk)
• Allow time to ensure working BEFORE go live
• Who needs to know how it works?
• Clear processes
Engagement and support from system teams • Local tweaks and changes happen quickly • Much harder for bigger changes • Little clinical focus • Small fish in a big pond!
Thank fully we have an amazing in-house clinical system team
What went well
Medicines Formulary • Dedicated technician time to input formulary onto
the system
• Huge time commitment • Prepopulate common items Remember the ongoing upkeep/review
Clinical Safety • Reduced re-write errors as well as saving clinical time • No more ‘missing’ drug charts!
• Clear, legible charts
• Reduction in prescribing and administration errors
• Highlights possible interactions – pop up overload!!
• Reduction in delayed/omitted/blank administration charts
• Ease of audits
Mandatory Fields • Allergy status
• VTE risk assessment
• Clinical indication and review date for
antimicrobial prescribing
Nursing colleagues
They love it!
Formulary Compliance • Countywide formulary on SystmOne
• Prescriber can only select a formulary item in first
instance
• Allows easy reporting on formulary compliance • Makes prescribing reviews easy
OVERALL…
The benefits outweigh all the issues!
Thank you for listening
Any questions?