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	The Pharmaceutical Journal Vol 268 No 7185 p204-205 16 February 2002	This article Reprint Photocopy
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News feature

Modernising pharmacy services: some of the latest developments in Scotland

The Scottish pilot of electronic transmission of prescriptions should start within the next month. Electronic prescribing and administration has also been recently introduced at Ayr Hospital. In light of last week's Scottish pharmacy strategy, Clare Bellingham looks into the latest developments in electronic prescribing and prescription transfer

Related websites
A strategy for pharmaceutical care in Scotland [more]
Scottish Executive (www.scotland.gov.uk)

An electronic prescribing and administration system can reduce medication errors

Information is being transferred electronically more and more frequently. In pharmacy, electronic prescribing and electronic transmission of prescriptions (ETP) care are likely to represent the norm in the future.

"The right medicine", Scotland's strategy for pharmaceutical care launched last week (PJ, 9 February, p161 and p168) recognises the changes that electronic information transfer will have and the following actions are set out in the strategy:

Introduce ETP throughout Irvine, Kilwinning and Dundonald Local Health Care Co-operative (LHCC) in 2002 and roll-out the system across Scotland in 2005.
Connect all community pharmacies in Ayrshire and Arran to the NHSnet in 2002.
Develop standards for electronic prescribing in hospital in 2003.

So at what stage are current projects? It looks likely that the Scottish ETP community pilot will be up and running well before similar pilots in England which have faced a number of recent set-backs. Experts in England have suggested that roll-out of ETP is now not expected to be completed before 2006 (PJ, 2 February 2001, p123). In addition, electronic prescribing has already been introduced at Ayr Hospital in Scotland.

ETP pilot

The first prescriptions will be transmitted in the Scottish pilot of ETP by the end of February.

Andrew McLaughlin, senior pharmaceutical adviser, Ayrshire and Arran Primary Care NHS Trust, said that the first phase of the pilot is centred around one general practice and one pharmacy. It is located at Girdletoll in the Irvine, Kilwinning and Dundonald LHCC.

Allan Thomas, community pharmacy adviser, Ayrshire and Arran PCT, explained that the pilot is based on the pull model of prescription transfer. The pull model involves prescriptions being sent to a central server from where the participating pharmacy can download them.

In the pilot, an electronic and paper prescription system will run in parallel. The general practitioner will give the patient a barcoded prescription to take to the pharmacy. The pharmacist will then scan the barcode to initiate the download of information from the central server. "By retaining the paper system in parallel there will be no effect on patient service or patient care," said Mr Thomas.

Phase I of the pilot will last for 12 weeks and the number of patients involved will depend on the number who use the participating pharmacy. "At the point of consultation, patients will be able to choose whether or not they want an electronic prescription," said Mr Thomas. The paper prescription will be valid at all pharmacies so patients can choose to get it dispensed elsewhere at a later time. "Patients will also be asked if they want clinical information to be transferred to the pharmacy," he continued. They can opt out of this. However it is useful for pharmacists to have an idea of the patient's clinical condition.

The ETP pilots in England have faced difficulties over computer software and Mr McLaughlin said that this is an issue which should not be underestimated. Phase I of the Scottish pilot is based on a pharmacy software system developed by NDC. Roll-out to pharmacies using another type of software might create difficulties.

Mr McLaughlin pointed out: "An immediate spin-off of the pilot is that all community pharmacies in the LHCC will be connected to the NHSnet over the next three months." Mr Thomas said that this provides pharmacists with an opportunity to extend their role and will increase communication between pharmacists and PCTs, GPs and acute trusts.

Electronic prescribing

Mock version of an EPA page in use at Ayr Hospital

An extended trial of electronic prescribing and administration (EPA) began in six wards at Ayr Hospital, Ayrshire and Arran Acute Hospitals NHS Trust, in November 2001. The extension of EPA follows a small-scale trial of a similar system which started in 1998 (PJ, 16 September 2000, pR16) and demonstrated that an EPA system reduced medication errors and improved quality of prescription writing.

Michele Caldwell, chief pharmacist, explained that the hospital has worked for three years with the company that produced the software, JAC, in order to develop a Windows-based system that could be implemented across the hospital. The new EPA system was introduced over a three-week period, adding two wards per week, so that it is now in operation in the admission, coronary care and all general medical wards, plus the orthopaedic ward (where the earlier trial took place).

"The scope of the project is to replace the existing prescribing and administration charts with a paperless electronic system," said Mrs Caldwell. In some instances, paper charts are still used. This is for situations where supplementary charts were used under the paper system, for example, for warfarin, insulin and variable rate infusions.

"We have had a positive response from users who want further expansion of the system into other wards, including oncology and care of the elderly wards," she said. However, she cautioned that the trial of the system was still at an early stage and work still had to be carried out to increase user functionality.

Mrs Caldwell explained that the most important benefits of the system are:

legible prescriptions
a reduction in the number of prescribing and administration dispensing errors
information available at the point of need

Drawbacks of the system are:

price of the hardware if only EPA is being implemented
provision of support and training when there is a high turnover of junior medical staff

"In order to roll the system out, there needs to be a move away from the traditional 9am–5pm systems. Trusts need to rethink this and make sure that there is wide access to 24-hour support, seven days a week, from the pharmacy and IT departments, and from the companies that develop this type of software," she said.

James Snell is principal pharmacist at the hospital and is responsible for implementing and supporting the system. "We are currently working on the best way to provide support to a large number of users. It's an exercise in communication to support them and provide information such as changes in software." Feedback on user acceptability will influence refinements in the system and its future design.

Training staff to use the system is obviously an issue. Mr Snell explained that it takes an hour to train doctors and pharmacists, and an hour for nurses plus time to undertake supervised administration rounds to assess competency. "We request that locum staff are available for training before working on the ward," he says.

The EPA system also allows pharmaceutical care planning to be carried out at the bedside. Care plans can then be accessed on-screen throughout the hospital. This was not the case with paper records, said Mrs Caldwell.

Introduction of EPA has the potential to significantly reduce medication errors. In the case of supplying discharge drugs, it will feed directly into the dispensary system allowing technicians to print labels directly (once verified) and hence reduce transcription errors. The system will also be beneficial to pharmacy staff in terms of supplying drugs. "When patients are prescribed drugs on the ward, the EPA system alerts the pharmacy for the drugs to be supplied to the ward providing an alert system for automatic top-up," Mr Snell said.

The next phase of the project will involve the addition of other components including a clinical decision support system that will provide information on drug-drug interactions, drug allergies, drug duplication and dose checking. "We deliberately chose to exclude decision support in the first phase because it adds to the complexity of the change," said Mrs Caldwell. Mr Snell added that the hospital staff are excited by the prospect of feeding the EPA system into electronic admission and electronic discharge systems, and perhaps also into primary care systems.

A formal evaluation of the project will be carried out in due course. However, there has been a positive response to it so far. "We have been pleased with the positive response we have received from both doctors and nurses," said Mrs Caldwell. "However, it is too early to say what the long-term outcomes will be." Mr Snell cautioned: "We have to demonstrate that the system is as safe as the paper system because using software can introduce a range of risks not previously encountered."

Dr Judith Blair, a consultant at the hospital who has been using the system, commented: "In terms of implementation, the project has been extremely successful and that is a testament to the huge amount of effort and planning by the pharmacy and information technology departments."

Mrs Caldwell said that implementing the system would have been impossible without support from the pharmacy staff, who worked around the clock to ensure that all users were fully supported during the period of change.

Modernisation is not always easy. Problems can occur but the end result is nearly always worthwhile. Learning from others who have been through the process can help to smooth the way.

Hospital aspects of the Scottish pharmaceutical care strategy

"The right medicine" calls for redesigning of hospital pharmacy services to ensure that every patient receives care from a clinical pharmacist. It includes an example of ideal pharmaceutical care. In terms of hospital care, this includes liaison between hospital and community pharmacists before and after admission, use of the patient's own medicines while in hospital, support for the patient to understand how to use the medicines and use of electronic prescribing. More details can be found in the strategy document.

It states: "If patients are to fully benefit from the clinical skills of hospital pharmacists then traditional ways of working must be redesigned so that hospital pharmacy services become more patient focused. In some hospitals this is already happening; pharmacy staff base themselves in pre-admission clinics and on admission wards." It highlights the roles pharmacy staff can play in ensuring the correct medicines are prescribed and made available for the patient, and ensuring that patients understand about their medicines.

The strategy calls for the barriers to pharmacist prescribing to be removed. It says that hospital pharmacists should benefit from supplementary prescribing status. It also recognises the role that hospital pharmacists have played in advising on prescribing of medicines as part of the health care team and wants to see this extended.

Other hospital related-issues the strategy highlights include:

• a requirement for modernised IT systems in hospital pharmacies. Standards for electronic prescribing in hospitals are also to be developed

• a call for patient-pack dispensing. Implementation of self-administration schemes in hospitals is to be explored

• a need for workforce issues to be reviewed. The skill mix requirements in hospital pharmacy will be reviewed and how the skills of pharmacy technicians can be utilised will be examined

Dr Norman Lannigan, chief pharmacist, Lothian University Hospitals NHS Trust, said that the strategy was clearly directed at developing pharmacy as a whole and that was welcomed. "The redesign of hospital services is a big challenge but is the right thing to do. It will be a busy five years but is something that will take pharmaceutical care forward," he said. "Hospital pharmacy is pleased with the commitment and confidence shown in it."

Issues covered by the strategy he highlighted included the roles for clinical pharmacists, the aim to give every patient a discharge plan and the establishment of an adverse drug reactions reporting centre (which reflected the fact that pharmacists could report ADRs). The plan to give hospital pharmacists prescribing rights was welcomed and would increase the profile of pharmacy and improve care for patients, he added. "The strategy also attends to the seam between hospital and primary care. There is a challenge for pharmacists to work together to support the patient."