The Pharmaceutical Journal
Vol 268 No 7198 p679
18 May 2002

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What it means to staff when hospitals are ahead in electronic prescribing

Will acute trusts be able to meet government targets on electronic prescribing? Zoë Gross describes developments at Wirral Hospital, which is well ahead of the game, and a pilot scheme at Doncaster and Bassetlaw

All acute hospitals are expected to have implemented electronic prescribing (level 3 of the electronic patient record) by 2005. However, less than 35 per cent are currently using electronic prescribing systems (see p697). The Wirral Hospital NHS Trust has been meeting government targets for the electronic patient record (EPR) and electronic prescribing since 1992, according to Keith Farrar, its chief pharmacist. The trust is currently at level 4 EPR. Although the EPR system used at the Wirral is about to be updated, it has been effective for developing electronic prescribing and was easily adjustable to meet local needs, Mr Farrar says.

It is a requirement that all health care professionals working in the trust are trained to use the hospital system before starting their jobs. Across the trust's four sites around 3,800 staff are now trained. Junior doctors are trained to use the system the day before they start working at the hospital. Regular locum doctors, of which there is now a pool, have full access after training and new locums are given restricted access after two hours of training. Those locums working for just an evening are not allowed to access the system which means that they are unable to order drugs for patients. Mr Farrar suggests that to rectify this problem, all hospitals in an NHS region should have the same system. Trainers are available on a 24-hour, seven-days-a-week, basis. Each ward has several terminals and some GP practices are linked to the trust's network, through which they can order laboratory tests and view certain patient information.

Electronic prescribing systems

Electronic prescribing systems reduce clinical risks, such as medication errors, and make better use of medical, nursing and pharmacist's time, Mr Farrar says. These systems are also able to implement agreed standards, including formulary compliance.

Mr Farrar thinks that an integrated hospital system should be used for electronic prescribing. He explains that one of the desirable functions of such a system would be to alert prescribers to information from other hospital departments, such as laboratory, patient administration and pharmacy, when they are prescribing. For example, when warfarin is being prescribed, prescribers should be alerted to the latest INR result and when prescribing digoxin, they should be alerted of the latest serum potassium level and digoxin level, if one has been done.

However, he says that developing interfaces between the different systems is a challenge and there may be delays while accessing information from other systems in the hospital.

One problem with electronic prescribing is that "we still have not got a national specification for drug names and drug codes in computing terms". Some of the doses on the electronic prescribing system on the wards are not compatible with the data that the pharmacy system recognises. For example, a 60mg dose of furosemide will not correspond with the 40mg and 20mg tablet strengths that the pharmacy system recognises. Nurses might assume that if they see the same drug twice it is a duplicate order. He says: "We are working with the NHS Information Authority to identify drug codes. One problem is that many of the people that talk about electronic prescribing come from a primary care background." GPs have been using electronic prescribing systems for a long time but do not appreciate the difficulties that nurse administration presents for electronic prescribing in hosptials.

Network downtime

Another problem is when the network goes down. However, during the past 10 years, the hospital has only lost its system twice; once when a mechanical digger cut through both fibre optic cables and once during the night, but this did not have any significant impact on patient care, he says, as the downtime procedure was implemented quickly. He said: "We now have different routing paths to ensure the JCB problem in unlikely to happen again."

In a discussion session at a recent conference on electronic prescribing (see p697), Mr Farrar said that the hospital has an aspiration to become paperless. Currently a paper back-up of the patient's electronic prescription is printed every time a change is made to their medication. This is kept at the end of the patient's bed. The alternative to doing this is to have a computer on the ward that holds all current information for that ward. This information would take about four hours to print so "it is all a bit of a balance between how much time it takes you to download that information and make it available and to print the information up front," he said.

Mr Farrar says that when the trust implements the Government's policy of having televisions and telephones at patients' bedsides, he sees no reason why the TV should not be a computer with patients' records on." As the technology advances the need for paper will be reduced, but you need a backup in case the computer has an off day."

The way forward

Mr Farrar comments that Wirral Hosptial is also looking at wireless terminals. He believes the way forward is to have mobile terminals that hospital staff carry around with them. "Hand held computers will one day be a solution." At Brigham and Women's Hospital, Boston, Massachusetts, nurses use a barcode reader to record administration of drugs and this is another possibility. However, these are not without their own problems, he says.

An electronic prescribing pilot has been carried out at Doncaster and Bassetlaw Hospitals NHS Trust over the past two years. Also speaking at the conference, Andrew Barker, director of pharmacy, Doncaster and Bassetlaw Hospitals said that the pilot assessed whether the scheme would meet the trust's needs, and also identified the needs of medical, nursing and pharmacy staff. The trust is looking at rolling out electronic prescribing in a number of wards at one site over the next nine months. "Other than a lack of finance, I cannot see a reason not to move quickly now," he said. As with the Wirral scheme, junior doctors are trained as part of their initiation day. The trust also has a team of IT staff that can help locums when necessary, he said.

Mr Barker commented that "the real issue is if we loose the network". However, a procedure is in place where the trust can fall back to a paper system relatively quickly by printing from a shadow version of the software. This is held within the pharmacy department and is independent of the main network and server, he said.

Electronic prescribing is the way ahead and hospitals will need to continue to work towards implementing such systems.