Hospital Pharmacist
Vol 11 No 5 p201-202
May 2004

Pharmacy intervention monitoring — a clinical tool

By Philip Dean, MRPharmS, Jane Robson, MRPharmS, Philippa Walters, MRPharmS

Since the late 1960s, pharmacy input at ward level has been developing. In 1986 the Nuffield report¹ identified the roles of a clinical pharmacist and, at the most fundamental level, this has included a prescription monitoring service. Pharmacists began to make reactive clinical interventions with doctors and other health care professionals on ward visits but did not routinely document them. Some method of recording these interventions was required in order to account for pharmacists’ time on the wards, justify the demands for increased clinical pharmacy services and as evidence for pharmacists’ actions as litigation increased. Pharmacy intervention monitoring (PIM) was the term used to describe this diverse activity, and it became part of the audit trail for pharmacy services.

Early systems for monitoring pharmacy interventions used simple paper forms and intermittent recording. Analysis was time consuming and difficult, and information retrieval virtually impossible. The clinical value of such systems was therefore limited. The introduction of technology in the form of simple databases or proprietary systems increased the potential usefulness of PIM to pharmacy managers and practitioners.

PIM has now been part of hospital pharmacy practice for more than 10 years, providing most benefit to pharmacy managers justifying and developing services by providing numerical data for exploring workload. Ways in which PIM has been used to develop and improve medicines management are shown in Panel 1. Although these may be of value, the underlying reason for performing PIM now needs re-evaluating.

Many stand-alone desktop PIM computer systems are available in the United Kingdom, either as dedicated software packages, eg, QARX,² or using commercial database software, eg, the Southend system³ and the Nottingham system.⁴ The South West Region Computer system differs from others in that it integrates with the pharmacy dispensary system.⁵

Portable PIM systems now exist following the introduction of palmtop computers and personal digital assistants (PDA).⁶ These PDA systems offer many benefits in terms of ease of entry, avoidance of paper forms, and ability to produce meaningful management information.

However, they all suffer from the lack of integration into the pharmacy patient medication record (PMR) and a lack of real time, networked access to the main pharmacy system databases. The next generation of PIM will require wireless, networked access, allowing full integration to previously desk-top systems.

This article describes the evolution and use of the ASCribe PIM system to overcome these problems, and how we have used technology to develop continuous recording of patient-specific information, generated as a result of clinical pharmacy activity in North Tees and Hartlepool NHS Trust.

The system

Pharmacy Services at North Tees and Hartlepool NHS Trust are provided from three dispensaries and two aseptic units at two different geographical locations in Hartlepool and Stockton-on-Tees. The ASCribe computer system (ASC Software, Manchester, England) has been in use in the trust since 1999, with a single patient database, shared between sites. This means that data (PMR or demographics) entered by any member of the pharmacy team are accessible to all other pharmacy users, at all sites. An increasing number of wards now use the ASCribe order communications software to support the department’s one stop “Dispensing for discharge” service.

In developing PIM we originally started with an agreed dataset, which was used to design some paper forms. This data set for the PIM package evolved from the proposed minimum data set in a previously published consensus statement.⁷ The paper forms were then recreated on a stand alone computer using a Microsoft Access database, and subsequently networked. We then commissioned the transfer into, and integration within, ASCribe. The information collected can be altered by the system manager through a system setting. In May 2000 we started to use this new PIM package, and now any of the pharmacy computer terminals or the ward terminals can be used to record interventions directly onto the system, enabling clinical pharmacists and directorate technicians to undertake PIM on a continuous basis.

The design also incorporates patient demographic data already entered in other parts of the pharmacy system. The PIM database is accessible from the patient specific PMR. This means that data entry and retrieval can occur concurrently with any other activity which accesses the PMR, eg, producing a label. Such principles of once only data entry and simple, rapid data collection are essential to encourage practitioners to use the system.

A structured paper form also remains available as an alternative to direct data entry in circumstances for which direct access is not yet available. We find this useful where we wish to remind ward staff to take further action, and a copy can be attached to the in-patient prescription sheet. We plan, eventually, to be able to print this from the data entry screen. Until development of the Electronic Patient Record (EPR), this paper copy can also be inserted into the patient’s medical record as has been recently
recommended.⁸

As a further development we have recently introduced the use of Sumo Web Pads (hand-held computer tablets) with wireless connectivity to the hospital network. These computer tablets are similar in size to a British National Formulary (BNF) and have a touch sensitive screen. This enables mobile, wire-free, access to the pharmacy system, including PIM software, with access to all usual desktop software, eg, electronic British National Formulary (eBNF), trust intranet, full internet access, word processing and email. All this is available at the patient’s bedside.

Benefits

The old paper systems required cumbersome forms with multiple tick-boxes, and entailed one or more people categorising, entering and collating the data. Desk-top and PDA electronic PIM allows for drop-down menus to prompt for the required answers. This is coupled with free text entry to describe the intervention. Previous systems such as the stand-alone systems described above have the disadvantage of not being accessible at the point of need, eg, on the ward. Although retrieval is improved as compared with paper documentation, there is still some difficulty with retrieval of patient-specific information within the clinical setting. When we add in wireless capability, the entry and recording of interventions occurs in one concurrent step allowing all members of the pharmacy team to assist with data entry.

Integration allows access through the PMR, improving interpretation of the intervention and potentially preventing duplication of interventions. Although many interventions occur in response to prescribing errors, a significant number may not be readily identified without further information.

Networked access to PIM data both at ward level, and in the dispensary through the PMR facilitates discharge planning and continuity of care during the current and any subsequent admission. It is accessible by all members of the large pharmacy team on both sites. The records are, of course, also highly valuable for audit and training purposes.

The Future

The adoption of wireless technology is essential for the achievement of the national IT targets, and the development of electronic patient health records. We describe how PIM contributes to the pharmacy care plan and adds to the EPR. Using the ASCribe system in North Tees and Hartlepool, PIM has evolved from a workload measurement tool for managers, to become a live system where interventions are events that can be manipulated in real time. The result is much more than a retrospective counting system — it forms an essential part of the pharmacy care plan and future EPR. Appropriate access to PIM data at ward level encourages near-patient pharmacy care. Practitioners have the capability to compile a “to do” list of active interventions for their patients, and subsequently to record both quantitative and qualitative (text-based) details of outcome, which are stored chronologically to create comprehensive pharmacy notes. Being patient-based, it is possible to retrieve and view these historical records in the same way that a medication history can be viewed.

Our vision is to allow pharmacy staff to view and update a patient’s record at the bedside, have full access to the pharmacy computer system, order medication, view the eBNF, and access their computer desktop for internet, email and Microsoft Office programs. The PIM system offers the opportunity to resolve a traditional difficulty with clinical pharmacy services — pharmacists failing to fully document their activities.⁹ PIM also makes a substantial, and demonstrable, contribution to patient care.

References

1. Nuffield Foundation. Pharmacy: A report to the Nuffield Foundation. London:Nuffield Foundation;1986.
2. Cousins D, Hatoum H. The development of a computerised quality assurance system for clinical pharmacy. International Journal of Pharmacy Practice 1991;1:86–9.
3. Kennedy K, Wind K. The development of a monitoring package for pharmacy interventions. Hospital Pharmacy Practice 1992;2:93–101.
4. Barber PA. Intervention monitoring project at Nottingham City Hospital. Hospital Pharmacy Practice 1992;2:353–9.
5. Glinn J, Hubbard N, Pickup J. Intervention reporting on the South Western region computer system. Pharmaceutical Journal 1993;25:HS24–6.
6. Clark CM, McGlyn S, Goldberg LA. Clinical pharmacy activity monitoring using Psion series 3 palm top organisers. Pharmaceutical Journal 1995;255:247–50.
7. Barber N, Batty R, Cousins D, Fahey M, Wind K. Consensus statement on a minimum data set for hospital pharmacy prescription monitoring event packages. Pharmaceutical Journal 1992;249:346.
8. Eastern Pharmacy Network senior pharmacy managers. Recommendations for the retention of pharmacy records. Hospital Pharmacist 2003;10:222–4 (PDF 75K)
9. Strand LM, Cipolle RJ, Morley PC. Documenting the clinical pharmacist’s activities: back to basics. Drug Intelligence and Clinical Pharmacy 1988;22:63–7.