Delivery of e-prescribing into UK hospitals

Delivery of e-prescribing into UK hospitals

There are real clinical benefits to accrue from the implementation of e-prescribing which have quite rightly meant its inclusion as one of the five key clinical elements of health-related IT that form the current strategy for delivery of systems into hospitals. Support has continued to grow nationally over the past few years to underpin this. The 2009 patient safety Health Select Committee report highlighted e-prescribing as being key, as did the National Audit Office recommendations in its report on reducing health-care-acquired infections. The increased awareness of the need to manage medication errors, as demonstrated by National Patient Safety Agency alerts and the Patient Safety First initiative, continues to add pressure for delivery.

As outlined earlier, delays in the delivery of the national programme for IT have created a number of challenges for trusts. A planning blight has effect-ively stalled the implementation of systems pending delivery of the national strategic solutions, meaning that e-prescribing rollout has moved on little over the past 10 years. The exception to this is in oncology, where pressure from the national clinical director for cancer brought about government support for bringing forward the e-prescribing system delivery in 2005. Work by the e-prescribing programme at NHS CFH and the Cancer Action Team at the Department of Health identified system requirements at that time and bench-marked existing systems to determine whether they met current need. Trusts were then invited to bid for monies to support local procurement and imple-mentation of interim systems. Nineteen bids were successful, resulting in a key number of cancer services having systems in place or being implemented.

There have also been a number of discharge systems implemented throughout hospitals to support the target of providing legible discharge information to general practitioners within 24 hours. Many of these systems have been home-grown and lack any form of sophisticated decision support. Implementation has been largely pharmacy-driven, particularly as medical staff see little benefit to themselves in using the system. Errors in transcription are not uncommon and create pressure within pharmacy departments which have to correct them.

More recent national pressure has resulted in a systems of choice approach being adopted for the southern strategic health authority areas following the loss of the southern LSP and stringent deadlines for delivery being set for the remaining two LSPs. Computer Services Corporation is contracted to deliver iSoft’s Lorenzo system in the north, midlands and east and BT is contracted to deliver Cerner’s Millennium system for London. These developments, as well as the need to deliver safer services, should allow us to see progress in the next few years.

Trusts that have implemented systems have been key in supporting system development and in highlighting where benefits may be accrued. Sites that have well-developed systems include Burton, Doncaster, Heart of England, Salford, Sheffield mental health, Sunderland, University Hospital Birmingham, Winchester, Wirral and the first specialist paediatric trust implementation at Great Ormond Street.

The e-prescribing programme at NHS CFH has developed a number of resources that are available to facilitate and support the development and delivery of e-prescribing. Resources are available to support four key areas: (1) system selection and evaluation; (2) clinical safety; (3) implementation; and (4) decision support. Information available includes the functional requirements for systems, hazard frameworks, dose range checking, lessons learnt and challenges with implementing hospital e-prescribing, frequently asked questions, system evaluation methodology and results.

One of the barriers to the rollout of EPR is undoubtedly the perceived cost of introducing an integrated information system. Most hospitals have some degree of IT implementation at the department level, with systems such as patient administration, outpatient scheduling and often laboratory ordering and results reporting available at ward level. As a consequence the IT budget for most hospitals is probably sufficient to support the introduction of an integrated system if spread over the lifetime of the system. However, the perceived procurement and implementation costs are still the biggest barrier to implementation in this area. For those who have introduced such systems, these have tended to be imported from the USA and have required extensive local work to anglicise the existing system or to build it from scratch. There are now systems that have been developed specifically for and implemented in the UK market – whilst these have mostly (but not all) been developed from pharmacy stock control systems, they do offer some of the benefits that e-prescribing systems would be expected to deliver and will certainly support the development of a culture that utilises electronic systems. In the medium to long term those that are stand-alone will require development to integrate with other hospital systems such as pathology, to use NHS IT standards and to deliver sophisticated decision support.

The features of an ideal system are that it should be fast, reliable, locally adaptable to meet user preferences, easy to learn and intuitive in its use, fully integrated or allowing easy interfacing with other systems (such as departmental systems or medical devices and automated systems), and allow-ing easy access to patient data for audit purposes (as well as patient care) – with speed being of prime importance to users. The debate between fully integrated hospital information systems or interfaced ‘best-of-breed’ systems is fiercely contested amongst the varying proponents. The author’s preference is for a fully integrated system that allows users to view relevant data from other applications such as pathology when prescribing medicines such as warfarin, insulin or drugs with a narrow therapeutic index. Whichever option you choose, it is imperative to be able to see the system in operation at a working site and not just accept the impressive demonstration that the vendors offer.