PJ Online | MM Features (Innovative database gives pharmacists passport into clinical team)

Home

logo

Medicines Management
Issue no 3, p7-8
May/June 2002

Features

Innovative database gives pharmacists passport into clinical team

Monitoring the clinical effectiveness of medicines with an innovative medication database could revolutionise patient care. Sam Crowe reports on how the database is being used in two special hospitals

Sam Crowe is a freelance writer

Pharmacists working at two specialist psychiatric hospitals are using an innovative medication database to monitor the clinical effectiveness of psychiatric drugs and non-drug treatments for long-stay patients.

The database not only provides consultant psychiatrists with rapid access to the drug history for each patient, but can also be used to present a treatment "timeline", with blood tests, non-pharmacological patient data and significant events plotted against the medication record over time.

Bernard Huckstep, head of pharmacy services for Nottinghamshire Healthcare NHS Trust, which is using the PPS database at Rampton Hospital, says that the idea behind the database arose from requests made to pharmacists about whether or not medicines were effective.

"A lot of the time we were asked whether these complex psychiatric drugs were working or not. It is always difficult to measure progress, especially in psychiatry, because so many of the outcomes are soft as opposed to treating something like an infection," says Mr Huckstep.

How the database developed

Mr Huckstep began to develop an idea for a medication database that would enable pharmacists to plot patient data against their drug history, over time. An earlier version of the database was written in DOS, but problems with the millennium bug meant that it had to be entirely rewritten. The result was a windows-based database that could present several graphs of patient data and medication histories over time, making it easy to see potential correlations between changes to drug regimens and patient progress.

Mr Huckstep says that before the database was installed, clinical pharmacists would often be asked their opinion about whether or not patients were improving on a particular regimen: "We would be trying to figure out whether or not the drug treatment was responsible for any of the changes we saw." Before the PPS database was introduced it tended to be guesswork, he says.

He points out that an important application for the database is for patients with schizophrenia, because drugs sometimes need to be prescribed over a long period of time, and there is a risk of significant adverse effects. "So it is important to be able to justify why you are giving those drugs," says Mr Huckstep.

The database allows a patient's history of drug treatment to be plotted over time, and can display additional plots of behaviour or measures of progress. This provides a graphical display so that the pharmacist or consultant can see whether or not the way in which a particular drug was started, stopped or switched might affect a patient's behaviour or response to treatment. Broadly, drug treatment is correlated with patient progress, as measured by a range of items, which are individual to each patient. In fact, any relevant measurement can be plotted against drug treatment and time, says Mr Huckstep. "We've plotted physical aggression, verbal aggression, side-effects, extra-pyramidal side-effects — all of these help us to assess the effect of treatment."

Improvement over previous methods

Mr Huckstep is careful not to overstate the accuracy of what the programme appears to say about the relationship between drug treatment and patient progress. But he believes that it is an improvement over the previous methods, which often relied on observation, and which he says can be notoriously subjective in psychiatry.

"What one person may think is aggressive behaviour may not be thought of as so significant by another observer," he points out.

Mr Huckstep says that in many ways the way that the database is used is an extension of the clinical role that pharmacists are being asked to perform. "The clinical pharmacist's role was particularly well-developed in psychiatry, and was much more accepted in psychiatry compared with other disciplines,' he adds.

And he says that the PPS system has given clinical pharmacists a passport into the clinical team. "Consultants at first thought that this was a fantastic medication record, then after a bit they realised that rather than trawling through prescriptions to see what patients had taken the pharmacist could do it at a glance."

Because the database can also be used to plot blood test results and serum drug levels against dose, Mr Huckstep believes that it could have wider applications. "It's important for us to monitor neutrophil levels in patients taking clozapine, and this system gives us that ability," he says.

One downside of the system is the amount of time it takes to physically input the data required. But because pharmacists are responsible for monitoring drug charts, they are asked to enter the data at the same time.

"It is a very useful tool to promote the activities of clinical pharmacists in the current climate of clinical governance because we have to be accountable and able to justify our activities and decisions in managing medicines." Although Mr Huckstep says that this has always been the clinical pharmacists' role, he adds that the idea for the database arose because major decisions about drug treatments in psychiatry were to some extent being made on a whim, with little supporting evidence. So he wanted a system that would provide pharmacists with the ability to make decisions backed by supporting evidence of improvements. Now, he says, pharmacists are regularly asked for their opinions about treatment decisions because of the ability to view patients' medication records quickly.

Implications in other areas

Mr Huckstep believes that the database could have other important applications in other areas of medicine, particularly where complex treatments are involved. Another application in mental health might be to provide an accurate record of a patient's antidepressant history, where several different doctors may see a patient in primary and secondary care.

"I think it has potential in helping decisions about certain cytotoxic treatments, where the relative benefits of treatment are critical, and might be relatively small," he says. For example, it might help clinical pharmacists and consultant oncologists monitor chemotherapy in individual patients, by plotting blood test results against drug regimens and patient progress over time.

"Any illness where drug treatments are given over a long period of time would have potential to benefit from this approach, even chronic disease," says Mr Huckstep.

At Broadmoor Hospital, Berkshire, the pharmacy department is also using the PPS database to generate summaries of medication histories for clinical team meetings. Chief pharmacist Ken Cookson says: "This enables us to get a much better picture of what has happened to the patient on past drugs and dosage regimens, and whether or not they've been tried on particular drugs or combinations before."

Mr Cookson points out that it would take much longer to perform a manual search of paper-based records, and that there is a danger that pharmacists might miss important information.

"We also have a lot of researchers who come and work here for a while who find the medication histories useful. To go through the paper documentation to extract the same information would not only be laborious, but they would probably miss about half the information anyway," he says.

The database has proved useful in providing information about the effectiveness of seclusions among patients. Seclusions involve separating a patient from the main population, so that they can receive one-to-one nursing care during periods of difficulty. By comparing seclusions with the patient's medication history, pharmacists can help inform consultant psychiatrists whether or not a particular medication might be having an effect. Mr Cookson adds that the database is also proving useful for clinical governance and audit applications. It gives pharmacists the ability to extract quickly information on the number of patients taking a particular drug. "It can also be used to compare prescribing patterns between different consultants, or even different units within the same hospital," he adds.

System in its infancy

Although the PPS system has not been in use long enough at Broadmoor to provide meaningful data to enable cost-savings to be made in prescribing, Mr Cookson says that it has already proved successful in a study looking at the prescribing of proton pump inhibitors. "In many ways the system is in its infancy in terms of reporting, and there will be a number of different functions added over time as we need them," he says. Regular user group meetings feed back suggestions to PPS, and the software is amended on a regular basis to reflect improvements suggested by the group.

One idea that Mr Cookson would like to see developed is the ability to link with other databases, so that information on contraindications could be incorporated and the potential for medication errors so reduced. "Linking in to other databases with information about prescribing contraindications when coupled with a medication history database would be a really useful system."

Although the PPS database is currently finding use in long-stay psychiatric hospitals like Broadmoor and Rampton, Mr Cookson believes that it will not be long before other NHS units will want similar medication databases. "When other consultants ring me up and hear what we can do, they all want to know why they haven't got a similar system," he says.

Further information
For further details about the PPS system contact 0800 028 4735