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?