Hospital Pharmacist
Vol 10 No 5 p186
May 2003

Will we ever get a co-ordinated approach to electronic prescribing?

By Allan Karr MRPharmS MBA and John Farrell, MRPharmS

Many hospital pharmacists believe that the development of a fully integrated electronic prescribing system for the secondary care sector is the "holy grail". Such a system not only allows the transmission of a prescription in an electronic format, but also integrates with electronic patient records (EPR) and clinical decision support functions. The benefits of a fully integrated system are clear to all. For example:

• Medication errors are likely to be reduced because prescriptions will be legible and because allergy status and information on drug interactions can be displayed at the point of prescribing

• More rapid and effective clinical decisions can be made because data sheets and NICE guidelines can be made available at the point of prescribing

• Adherence to hospital formularies is enhanced because non-formulary prescribing can be highlighted at the point of prescribing. This could save money from the approximately £1.8bn currently spent each year on drugs in the secondary care system

• Prescriptions can be changed without the prescriber being on the ward, for example when the prescriber is on-call, because there is remote access

• Financial accountability can be improved because costs can be recorded at the patient level, and so the appropriate primary care trust can be charged

• Discharge times can be speeded up because there will be less inefficiency in the medicines supply chain

• Valuable data on prescribing habits, on the impact in primary care of prescribing in secondary care, and on the effect of treatments on clinical outcomes can be compiled, which facilitates a more focussed planning of health care

• Audits of prescribing and drug administration habits will be facilitated because information will be readily available

Some progress has already been made in completing the electronic prescribing jigsaw puzzle. For example, a collaboration has been set up between the British National Formulary and First DataBank to supply data to electronic prescribing systems. A secondary care product code dictionary is being compiled by the NHS Information Authority and the accessibility of NHS Net is expanding.

However, in many aspects, there is still a long way to go. The arduous nature of the task ahead, and how time consuming it will be, should not be under-estimated.

The lack of a centralised approach is a particular cause for concern. Various different systems are in place at the hospital trusts that have already adopted electronic prescribing. Those trusts that are planning to obtain an electronic prescribing function will be putting the contract to supply the service out to tender to a range of IT service providers. Such an individualist approach to the tendering process means there is little co-ordination across the country. It is also inefficient and leads to "reinvention of the wheel".

In addition, the specific requirements of the electronic prescribing system can sometimes take more of a "back seat" to the EPR requirements. EPR is generally better developed, and so suppliers are able to give more information about it during the tendering process.

Different IT suppliers will naturally develop their own electronic prescribing systems in different ways. It will be interesting to see how the different systems handle the prescribing issues associated with the more complex treatments such as intravenous regimens, TPN, therapeutic dosage monitoring and anticoagulant therapies. It will also be interesting to see how the different systems evolve over time.

Even if the functionality of the various systems is very similar, the design of the screens and the prompts used can be very different. This means that it might be difficult to integrate the systems to form some sort of a national system within secondary care. Also, differences in software between the systems will mean that expensive interfaces will need to be produced before any such integration can occur.

The various pharmacy computer systems currently in existence, for example, JAC and ascribe, can make it difficult for pharmacists to "hit the ground running" when they change jobs. These problems will be amplified several-fold if different hospitals have different electronic prescribing systems, because nurses and doctors (the latter of whom often change job en masse due to clinical rotation systems) will also need to be retrained.

If one system does eventually come to predominate, this could lead to efficiency savings. It will, however, be problematic for those who have honed their skills on different systems. Without strategic management, a plethora of systems could be on the market for some time.

The secondary care sector has therefore by default taken a decentralised or local approach to IT. Although significant NHS funds have recently been earmarked for IT in general, no funding has been specifically designated for the adoption of a centralised approach to electronic prescribing.

In the primary care system, where such funding has been available, a more "holistic" approach has resulted, with general practitioners (GPs) all having access to the same "Prodigy" system, and all benefiting from the contributions of the Sowerby Centre in Newcastle, who carried out much of the initial development. Community pharmacists, together with drug wholesalers, may well be linked into an electronic prescribing system in the near future. It would be interesting to get feedback from GPs, and others, who have been using "Prodigy" for a while to see if any of the lessons they have learnt can be extrapolated into the secondary care sector.

It seems as though those in the secondary care system can learn from those in the primary care system on this point. The professional challenge towards implementing medicines management schemes in the future cannot just be left to chance. A co-ordinated approach to electronic prescribing must be the strategic way forward.