eprescribing at university hospitals birmingham nhs foundation trust ann slee director of pharmacy...

ePrescribing at University Hospitals Birmingham

NHS Foundation Trust

Ann SleeDirector of Pharmacy

ann.slee@uhb.nhs.uk

Presentation Outline

• The system• System functionality• Benefits• Ongoing work

The System

• Developed by Wolfson Computer Lab ▪ Unit within University Hospital, Birmingham

• Continuous development for over 10 years ▪ Always in conjunction with UHB clinical staff

• Core design, development, implementation, 7 staff• Currently 12 staff in PICS team

PrescribingInformationCommunicationSystem

PICS - Overview

Labfeed

Lorenzofeed

Im agingreports

O rders to system s,departm ents

Letters to G Pinfo server

P ICS Auditsystem

Available on 4000+Trust desktop PC s

370 A4-sized tablet PC s

A lso ‘w indsurfers’ (batterypow ered, m obile , large screen PC s)

S ingle application, a ll p latform s

Dischargeletters/sum m aries

Drug requeststo pharm acy

Labrequests(labels)

PIC S

H and-heldor

D esk-topPC s

Results,a lerts,a larm s,prescrib ingwarnings

C lin ical deta ils,requests,prescriptions,adm inistrations

PICS – Clinical Coverage• All wards bar theatres and A/E

– Includes critical care, clinical haematology• Prescribing and medicines administration – paperless• Oral medicines, IVs and parenterals, infusions,

chemotherapy

• Unplanned downtime since March 2004: 0.07%• Multiple redundancy of mirror database and application

servers• ‘Document archive’ backup systems for prescribing +

administration– Allows reversion to paper in emergency

PICS – usage statistics †• Operational across 2 sites, 1200 inpatient beds

– 54 wards, 17 specialties, last in 2008– Some areas for >12 years

• Tablet PCs – 400• Computers on wheels – 50• Desktop PCs – 4000+

• Users with active accounts - 3000• Users logging in per week - 2500

– 600 doctors of all grades– 1600 nurses

• Concurrent users – 250

• Prescriptions written - 24,000/week • Administrations recorded - 125,000/week

† Data from PICS audit period 16/01/2010 to 22/01/2010

Presentation Outline

• The system• System functionality• Benefits• Ongoing work

• ‘Paperless’ management of drug therapy/protocols• In-built real-time checks on drugs, dosages, contra-indications,

interactions, etc.• Results reporting• Automated lab requesting • Real-time, event driven alerts• Clinical procedures• Discharge letters/summaries • Order communications• Clinical observations• Bed state, dependencies, estimated length of stay

Rules-based clinical management system,

configurable by specialty, allowing:

Complex rules Alerts or alarms

(rule specifies those groups that can see and can acknowledge)

Abnormal result levels or rates of change Suggested drug script changes, as a result of:

new results new clinical information duration of script, etc.

Reminders, warnings, information, etc.: arrival of certain report types (e.g. imaging, microbiology) review of sedation levels preferred route for drug administration entry of sedation/ventilation data suspect on-line blood gas data compliance with thrombosis guidance

Complex rules cont.(Single rule can generate several actions)

Laboratory investigation proposals, based on: Clinical classifications Current drug therapy Previous results Inpatient/outpatient status

Drug proposals, e.g.: On admission scripts Post-op drugs Antimicrobial protocols

Drug prescriptions - MRSA protocol

Password-level warnings ignored6 month period

1113

22039

3453

51805

1854

23773

12323

54935

0%

20%

40%

60%

80%

100%

Contraindication Dose Interaction Dose/Freq

Presc Admin

Carried on

Backed off

lvlcat 2

Count of msgid

qtype catname

state

Lower (red) histograms show the number of times the user ‘backed off’ when presented with a password level warning

Drug dictionary (04/02/10)

• Created and maintained in-house• All dm+d drugs included in 2006• BNF contraindications included in 2006

Total drug entries (including dm+d) 8644

Active drug entries = formulary 2165

Chemotherapy rotas 271

Contraindications - BNF (all drugs)

References 117,075

Distinct messages 4399

Contraindications – local (active drugs)

References 7029

Distinct messages 1231

Drug-drug interactions (active drugs)

References 18,207

Distinct messages 2230

Individual dose limits (active drugs) 1949

Daily dose limits (active drugs) 2093

Formulary issues• Steady stream of requests for changes to drug dictionary

– New drugs, changes to dose limits, interactions, contraindications, messages, etc.

• Some from clinical leads, some from irate housemen• Standard change request process with standard forms

– Authorisation managed via a multi-disciplinary team (answerable to Trust Medicines Management Group)

• Some requests cannot be met directly within the application– Need ‘lateral thought’ to use what is available to achieve something close to

the requirement.– Need people with an interest in, and a good understanding of the system

Presentation Outline

• The system• System functionality• Benefits• Ongoing work

Implementing Policies – Example of Antimicrobial

Prescriptions

Structured Prescribing Protocols for Antimicrobials adapts the whole Trust Policy

in prescribing orders / order sets

Prompts doctor to review effectiveness of therapy

Improving Safety – VTE risk assessments

A reminder prompt fires on a daily basis if adherence to VTE

risk assessment guidance is not followed

A compulsory thromboembolism risk

assessment must be carried out during admission process

for all inpatients

Reminder led to a 4% increase in prescriptions for surgical patients, 14% increase for medical patients

Formulary Redirect

Number of Simvastatin Prescriptions per week

Number of Atorvastatin Prescriptions per week

Estimated Cost Savings£250,000 / year

Cost Improvement Programmes – ‘Statin Switching’

Worked with the South Birmingham PCT to support their primary care campaign of Statin Switching to save money by the appropriate substitution of generic simvastatin

Rules for healthcare associated infections e.g. MRSADoctors are required to document risk

factors for MRSA on admission of all patients to drive subsequent

decolonisation rules

Automated prescribing of MRSA decolonisation taking into account

sensitivities

Some of the rules are quite strict!

Audit system Massive potential to the organisation

• Ready access to data generated by the system is essential for a range of uses:– Monitoring system usage – drugs, doses prescribed, late or missed administrations– Clinical audits– Incident investigations– Research, etc.

• Data structures can be extensive and complex

• Inappropriate to run audit queries alongside live operation • Weekly automated export of content to ‘data warehouse’ on separate server

– Currently 140 Gb • Allows:

– Routine weekly/monthly reports - automated email distribution– Ad-hoc reports (clinical audits)– Modelling impact of proposed changes

Omitted Doses – NPSA RRR 009

• Reducing harm from omitted and delayed medicines in hospital

• System supports identification of:– Rates

• Location• Medicine type

– Antibiotic, enteral feed etc

– Identification of types of omission• NBM• Stock missing• PRN assumed

The Execs Review

Trend in Missed Doses – April 2008 – July 2010

Stock Look up in PICS

Benchmark of Omitted Doses

• Comparison with two other systems• Initial data demonstrates similar rates

• Antibiotics– Antibiotics missed – 8.61% vs 10.95%– Shows similar winter increase in doses missed– Roughly 50:50 IV vs oral missed

• Non-antibiotics– Doses missed – 17.95% vs 20.38%– Highest % - analgesics, laxatives, anti-emetics

Presentation Outline

• The system• System functionality• Benefits• Ongoing work

Ongoing Work

• Increased use of data – for example– DDDs for antibiotics– NPSA warfarin requirements

• Counselling• Monitoring Rx verification• Renal injury

Ongoing Work

– Functionality• Outpatients• Anaesthetics• A&E• Handover• Clinical pharmacy support• Recording of ward based testing• Formulary support• Indication driven Rx and increased use of order sets• Rules development

Ongoing Work

• System being marketed - CSE– UK specific functionality– UK specific rules and policy interpretation

• Ongoing benchmarking– Cleveland clinic– Other English Trusts with systems

• Research to demonstrate benefits

Summary - Benefits to the Organisation

• Generic Learning– System Longevity and Systematic Implementation means already

learned the lessons other Trusts still have to face– Clinical Decision Support requires extensive clinical backing

• Improving Quality– Many wider benefits to the Trust beyond paperless prescribing– e.g. VTE Assessment, Infection Control, Indicators, Cost Improvement

Programmes, • Integration is key

– Using PICS as clinical cornerstone – can ‘connect rather than replace’– Enhancing and continuing to build informatics capability