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Stephen Goundrey-Smith is an electronic prescribing and pharmacy informatics specialist from Banbury, Oxfordshire
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All the indications are that the future of the NHS is electronic. The
overarching National Programme for Information Technology (NP.fIT) now
dominates the agenda for both NHS staff and health care IT suppliers.
The IT industry — or, at least, those organisations that have won
bids to be local service providers (LSPs) — have now started the
long and gradual development process to make their software solutions “spine
compliant”, ie, able to communicate with other applications elsewhere
in the NHS. This involves, among other things, the ability to connect
to a single patient data spine (PDS) for patient demographic data, the
formulation of a comprehensive electronic booking service (EBS) function
and the introduction of integration engines and data messaging standards
to ensure that all of this can take place. The ultimate goal of all of
these developments is the electronic health record — a cradle-to-grave
medical record for each citizen which may be accessed from anywhere in
the UK.
Electronic revolution
The electronic ordering and supply of medicines can, and should, be
part of this electronic revolution. There is clear evidence that the
use
of electronic systems can be of benefit in the process of ordering,
supply and administration of medicines. Such systems rationalise the
use of pharmacy staff time, thus freeing staff to undertake more patient-focused
clinical roles. Furthermore, IT can be a significant factor in the
reduction of medication error rates.
In 1991, the Audit Commission’s “Spoonful of sugar” report
indicated that pharmacy automation was a key factor in re-engineering
hospital pharmacy services for a modern working environment. Since then,
the benefits of automation, such as a reallocation of staff time and
a reduction of dispensing error rates, have been demonstrated by leading
pharmacy centres.
More recently, the chief pharmaceutical officer’s report on medication
errors, “Building a safer NHS: improving medication safety”,
has indicated specifically that IT has an important role to play in the
reduction of medication-related errors, and that “where possible
electronic prescribing systems should always be used”. The report
cites research
evidence from the US indicating that the electronic prescribing process
reduces medication-related errors. If electronic prescribing is so important
for reducing error rates, why does the documented evidence for this have
to come from sources in America? Why is there not more published research
on electronic prescribing systems for centres in the UK?
My experience is that, although there are one or two places in the UK
that have considerable experience of electronic prescribing — the
Wirral Trust is an oft-quoted example — most NHS hospitals have
made little progress in this area. Some hospitals have introduced electronic
prescribing successfully in a single, well-defined clinical specialty.
Others have had a electronic prescribing pilot which has been of limited
scope, or has run into difficulties. But a well-publicised, general roll-out
of electronic prescribing in an NHS hospital seems to be as elusive as
the Holy Grail of Arthurian legend.
This is reflected in the IT agenda as well as in the pharmacy agenda.
Electronic prescribing in secondary care is not a single, distinct entity
in the National Care Records Service initiative of the National Programme
for Information Technology; it mainly subsumes to requirements for patient
administration systems and messaging standards. Electronic transfer of
prescriptions (ETP) in primary care fares only slightly better: the discontinuation
of the three ETP pilots last year has jeopardised the overall timescale
for the introduction of ETP. Nevertheless, it is a key part of the National
Care Records Service and the messaging standards to enable this are currently
being devised by the HL7 organisation (www.hl7.org). It also has the
advantage over secondary care electronic prescribing in that there are
important commercial considerations with ETP in the community, relating
to the reimbursement of pharmacy contractors. Sidelined in secondary care
Despite its importance to prescribers and pharmacists, secondary care
electronic prescribing remains sidelined in the NHS IT agenda. There
may be a number of good reasons for this. First, NHS managers rightly
identify a number of major clinical and political issues with electronic
prescribing. Although a successfully implemented electronic prescribing
system will reduce medication error rates, as has been suggested by
US research, paradoxically there is an increased clinical risk associated
with the process of implementation, pilot and roll-out of such a system.
This risk is inevitable for a new computer system involving new working
practices, and project managers will naturally want to evaluate and address
this risk. This will involve careful quality and benefits testing of
new software and formulation of appropriate working procedures and a
due diligence review process to deal with the medicolegal implications.
Furthermore, as electronic prescribing is a new venture and will affect
a number of professional groups in the NHS, consultation with the various
stakeholders involved before implementation is essential. Moreover, those
who have introduced electronic prescribing successfully agree that a
system of training for all potential users is crucial to a successful
implementation. This training should include all the professional stakeholders — doctors,
pharmacy staff and nurses — so that an ethos of ownership is cultivated
across an organisation. The training should also include all types of
staff, including locum medical staff and bank nurses, to ensure maximum
user orientation and maximum data capture, thereby reducing clinical
risks associated with non-capture of data. All of these processes take
time and cannot in any way be short-circuited. Perception of difficult implementation
Secondly, among IT professionals, there is a perception that, because
it is specialist and there are various risk areas, electronic prescribing
is difficult to implement. Consequently, in industry product strategies,
electronic prescribing tends to be put in second place behind older
and commercially proven solutions, such as patient management systems
and order communications. Companies may perceive that they do not have
the budget, the expertise or the time to deliver such projects. It
is interesting to note that, at present, the one IT supplier that appears
to be making significant progress with the development of an electronic
prescribing solution is JAC, with its specialist pharmacy knowledge
gleaned through its role as market leader in pharmacy systems.
However, with the National Programme for IT agenda and the increased
public expectations of appropriate use of IT in health care, there is
a growing imperative for widespread adoption of electronic prescribing.
Not only are there benefits in terms of error reduction and appropriate
use of staff time, there is now evidence that electronic prescribing
can speed up the patient discharge process — an issue that is of
crucial logistical and political importance to the NHS at this time.
Nevertheless, further publication of formal research evidence of the
benefits of electronic prescribing in the UK health care environment
is necessary to persuade NHS managers that electronic prescribing is
a risk worth taking and IT industry managers that electronic prescribing
is a technology worth investing in.
Such research evidence is required to form the basis for a sound business
case for electronic prescribing implementations. When such evidence is
available and knowledge is shared for the good of all who would benefit
from a truly national electronic prescribing initiative, supported by
National Programme for IT developments, then prescribers, pharmacists
and IT providers will be greatly helped in their quest for the Holy Grail
of electronic prescribing. |
The
Pharmaceutical Journal