Implementing a Network E-prescribing Solution
Chair: Jeff KoundakjianFormer Lead Pharmacist
North Wales Cancer Centre
Electronic Prescribing – a Network Approach
BOPA symposium October 2008
David Barber – BOPA 2008
These slides are intended to provide additional material to illustrate the points made in the presentation and should not be used out of context
Introduction
• The network• Background• Business case and procurement• Implementation• Benefits and drawbacks• The future
LSCCN ePrescribing Project
The Network
LSCCN ePrescribing Project
LSCCN ePrescribing Project
Lancashire & South Cumbria Cancer Network
• 1.5m population• 4 Trusts• 6 chemo units• 20,000 chemo
attendances• Cancer centre at LTH• Haematology at BVH• “Decentralised”
LSCCN ePrescribing Project
Background
• June 2006 – DH and CAT announced capital funding for interim EP system for oncology
• National solution to be implemented when available (about 4 years)
• Business cases from Trust or network to be completed by September 2006
• Preferred supplier to be named by March 2007
LSCCN ePrescribing Project
Electronic Prescribing Solution
LSCCN ePrescribing Project
LSCCN ePrescribing Project
Interim Solution
LSCCN ePrescribing Project
Features of an Interim Solution
• No interfaces– Time consuming– Politically sensitive– Complex– Expensive– Unreliable
• Simple– Less validation– More freedom– Minimise “culture shock”
LSCCN ePrescribing Project
Initial Working Group
• Network pharmacist• Lead service improvement facilitator• Network manager• Head of D&T• Lead clinician
LSCCN ePrescribing Project
Business Case - Benefits
• Why do we need it?– Safer prescribing– Network wide reporting– Scheduling
LSCCN ePrescribing Project
Safer Prescribing
• About 5-10 serious prescribing errors per month at Cancer Centre
• About 1 case maladministration per year• Errors:
– Dose alterations not continued– Miscalculations– Transcription errors– Wrong dose– Illegible prescriptions
LSCCN ePrescribing Project
Network Wide Reporting
• LSCCN is a decentralised network – treatments available at all sites
• LSCCN consistently performs badly on audit of NICE drug use performed by CAT
• Planning new developments• Capacity and demand• D&T• Audit
LSCCN ePrescribing Project
Scheduling
• 5 sites using paper scheduling• Cancer centre using MS Outlook• Maximise capacity
LSCCN ePrescribing Project
Business Case – Costs
• Identify costs– Capital
• Software• Hardware• Setup
– Revenue• Maintenance• Support• Capital charges
LSCCN ePrescribing Project
Costs – Capital• Software
– Initial purchase– User licenses
• Hardware– Server– PCs– Other e.g. printers, network points
• Setup– IT– Training– Configuration e.g. regimens, documentation– Validation
LSCCN ePrescribing Project
Costs - revenue• Maintenance
– Server– Other equipment– System admin
• New regimens• New users
• Support– IT– Supplier
• Capital charges– Depreciation– Interest
LSCCN ePrescribing Project
Business Case
• Who do we need?– Oncologists– Finance– Pharmacy– Nursing– IT
LSCCN ePrescribing Project
Oncologists
• Access to patients’ prescriptions from anywhere in network
• Prescribe using PC not chart
• Up to date prescription info
• Calculations• Quicker(?)
LSCCN ePrescribing Project
Pharmacy
• Reduce prescription errors
• Reduce paper chasing
LSCCN ePrescribing Project
Nursing
• Accurate prescribing• Reduce paper chasing• Nursing
documentation(?)
LSCCN ePrescribing Project
IT
• Income stream• Interim solution• Where is CfH?
LSCCN ePrescribing Project
Finance
• All the above
LSCCN ePrescribing Project
Working group
• Expanded to include– Haematologist– More pharmacists (oncology and chief)– IT staff from Morecambe Bay
LSCCN ePrescribing Project
Technical Architecture
LSCCN ePrescribing Project
Outcome of LSCCN Bid – October 2006
• Successful (ish)
– LSCCN awarded ~£500k for purchase of ePrescribing software
– MBHT agreed to host– MBHT procurement to assist in tender
LSCCN ePrescribing Project
Tendering Process
LSCCN ePrescribing Project
Advert in OJEU(Dec 06)
20 expressions of interest(Jan 07)
Operational requirements(Aug-Dec 2006)
Site visits by applicants(Feb 07)
5 responses
Site visits to Norwich and UCLH(March 07)
Preferred supplier selected(26th March 2007)
2 bids
Supplier presentations(March 07)
LSCCN ePrescribing Project
• US based company• Manufacturers of XRT equipment• Expanding European base
Implementation May- August 2007
• Establish implementation plan• Hardware installation (MBHI)• Database initiation (Canada)• Software installation• Establish local steering groups• Mapping exercise
LSCCN ePrescribing Project
Regimen Building
• WebEx training• Internet portal• Regimen building
– 2 pharmacists– 4 months– ~300 regimens
LSCCN ePrescribing Project
Training
LSCCN ePrescribing Project
Training
• Super-user training– 4 sites– 3 days at each site– Nurses, pharmacists, IT, reception/admin
staff
• Cascade training
LSCCN ePrescribing Project
Administration• Information governance• Contingency plans• Error reporting• Change management• System admin• Communication plans• Legal issues• SOPs• Validation
– Regimens– Processes– Reports
LSCCN ePrescribing Project
Roll-out (October-December 2007)
• Staggered go-live• New patients from go-live date• Minimum dataset
– Name– NHS no.– DOB– Tumour type & stage– Allergy status
• Scheduling• Nurse administration
LSCCN ePrescribing Project
Results (what we did right)
• Roll out completed on time and within budget (got VAT part-refunded)
• 1st fully networked cancer network in the UK (we think)
• All solid tumour chemotherapy prescriptions (and most IV haematology) electronic since February
LSCCN ePrescribing Project
Benefits Realisation – Safety
Fewer calculation errorsNo transcription errorsLegible prescriptions× Wrong regimen
– Need regimen for every eventuality e.g. IV/oral, cisplatin/carbo, infusor/pump, trial arms
× Creatinine- Entered manually
LSCCN ePrescribing Project
Benefits Realisation – Scheduling
• Now possible• Variable uptake• Further training
LSCCN ePrescribing Project
Benefits Realisation - Reporting
• Basic reporting possible• Network wide – good• Local unit – poor
– Where does patient belong?• Report building
– Complex– Expensive– Time consuming– Varian report builder now available
LSCCN ePrescribing Project
Results (where could we have done better)
• Training– What do we need to know?– How do we set up an unknown system?– Further training organised
• Data entry– Underestimated time to enter patients
• Validation errors– Capecitabine minimum dose 1300mg– Caelyx regimen set to 3 weekly
LSCCN ePrescribing Project
Results (where could we have done better)
• Prescribers “jumping the gun”– Paper prescriptions do not translate easily to
electronic ones– Differences in rounding etc– Paper and electronic prescription in circulation
• IT– Should have got fully engaged at all sites from
outset
LSCCN ePrescribing Project
Teething Troubles
• Access rights– “Why won’t it let me do my job?”
• Number/position of PCs• Printing issues• General software faults (mostly minor)
– Crashes– Network issues– Creatinine clearance calculator
LSCCN ePrescribing Project
Other Benefits (the bits we like)• No paper chasing• Access from anywhere in network• 1 log-in• Network consistency• Manage change
– Antiemetics– Dose banding– Hydration
• Reporting• Very flexible system• Stable program
LSCCN ePrescribing Project
Drawbacks (the bits we don’t like)
• Printed prescriptions• Steep learning curve esp. Prescribing• No electronic clinical check• Lots of paper
– 1 x A4 per cycle/day
• Very passive system – difficult to keep track• No paper to scribble on!
LSCCN ePrescribing Project
Non-interfaced system
• Duplicate patients– Rare– Manageable
• Creatinine clearance for carboplatin– Be vigilant!
LSCCN ePrescribing Project
The Future
• Improve reporting & data quality• C-PORT• Notes• Oral chemo• Communication• System upgrades• CFH
LSCCN ePrescribing Project
Thanks for Listening
Any questions
?LSCCN ePrescribing Project