REVIEW

Building on Antimicrobial Stewardship ProgramsThrough Integration with Electronic Medical Records:The Australian Experience

Kelly A. Cairns . Matthew D. M. Rawlins . Sean D. Unwin .

Fiona F. Doukas . Rosemary Burke . Erica Tong . Andrew J. Henderson .

Allen C. Cheng

Received: October 13, 2020 /Accepted: December 11, 2020 / Published online: January 11, 2021� The Author(s) 2021

ABSTRACT

Antimicrobial stewardship (AMS) is well estab-lished in Australian hospitals. Electronic medi-cal record (EMR) implementation has lagged inAustralia, with two Healthcare Information andManagement Systems Society (HIMSS) Stage 6hospitals and one Stage 7 hospital as ofSeptember 2020. Specific barriers faced by AMSteams with paper-based prescribing and medicalrecords include real-time identification ofantimicrobials orders; the ability to prospec-tively monitor antimicrobial use; and the

integration of fundamental point of prescribingAMS principles into routine clinical practice.There are few local guidelines to assist Aus-tralian hospitals and AMS teams beyond ‘‘out ofthe box’’ EMR functionality. EMR implementa-tion has enormous potential to positivelyimpact AMS teams through more efficientworkflows and the ability to expand the reachand coverage of AMS activities. There areinevitable limitations associated with EMRimplementation that must be considered. Inthis paper, four Australian hospitals share theirexperience with EMR roll out, AMS customisa-tion and how they have overcome specific bar-riers in local AMS practice.

K. A. Cairns (&) � E. TongPharmacy Department, Alfred Health, Melbourne,Australiae-mail: K.Cairns@alfred.org.au

M. D. M. Rawlins (&)Pharmacy Department, Fiona Stanley Hospital,Murdoch, Australiae-mail: Matthew.rawlins@health.wa.gov.au

S. D. Unwin � A. J. HendersonInfection Management Services, Metro SouthHealth, Princess Alexandra Hospital,Woolloongabba, Australia

S. D. UnwinPharmacy Department, Princess Alexandra Hospital,Woolloongabba, Australia

F. F. DoukasPharmacy Department, Concord RepatriationGeneral Hospital, Sydney, Australia

R. BurkePharmacy and Executive, Sydney Local HealthDistrict, Sydney, Australia

A. J. HendersonUniversity of Queensland Centre for ClinicalResearch, Brisbane, Australia

A. C. ChengDepartment of Infectious Diseases, Alfred Healthand Monash University, Melbourne, Australia

A. C. ChengSchool of Public Health and Preventive Medicine,Monash University, Melbourne, Australia

A. C. ChengInfection Prevention and Healthcare EpidemiologyUnit, Alfred Health, Melbourne, Australia

Infect Dis Ther (2021) 10:61–73

https://doi.org/10.1007/s40121-020-00392-5

Keywords: Antimicrobial stewardship; Aus-tralia; Electronic medical record; Electronicprescribing; Hospitals

Key Summary Points

Why carry out the study?

Antimicrobial stewardship (AMS) is wellestablished in Australian hospitals;however, electronic medical record (EMR)implementation is in its infancy.

AMS teams face barriers to practice withpaper-based prescribing.

We aim to describe how four hospitalsovercame these barriers following EMRimplementation.

What was learned from the study?

EMR has enabled Australian hospitals toovercome specific barriers in AMSpractice; however, it is not withoutlimitations.

EMR has enabled expansion of the fourAustralian AMS programs described.

AMS specific build features for EMRs aresuggested for the Australian setting.

DIGITAL FEATURES

This article is published with digital features,including a summary slide, to facilitate under-standing of the article. To view digital featuresfor this article go to https://doi.org/10.6084/m9.figshare.13353293.

INTRODUCTION

Antimicrobial stewardship (AMS) is well estab-lished in Australian hospitals following itsinclusion in mandatory National Safety andQuality Health Service (NSQHS) Standards in2013. The AMS model implemented at each

institution varies according to local context andresources [1]. Electronic medical records (EMRs)have significant potential to support and com-plement AMS activities [2–4]; however, Aus-tralia has lagged behind other countries withrespect to implementation. There is currentlyno national or state level definition of an EMRin Australia, leading to variable use of the termsEMR and electronic medicines management(EMM). The Healthcare Information and Man-agement Systems Society (HIMSS) analyticsElectronic Medical Record Adoption Model listsan eight stage model of EMR adoption withstages from 0 to 7. Stage 0 has no elements ofkey ancillary clinical systems installed, whereasStage 5 includes full physician documentation,tracking of nurse task completion and anintrusion prevention system. Stage 6 is oftenreferred as a digital hospital which includestechnology-enabled medication and full clinicaldecision support, while Stage 7 is a completeEMR [5]. Recent data indicated that 30% ofAustralian public hospitals have implementedan inpatient EMM solution [6], and, as such,HIMSS validation has not been widely adoptedin Australia at this time. As of September 2020,there are two Stage 6 and one Stage 7 HIMSS-validated hospitals in Australia, compared with2040 hospitals at Stage 6 and 255 hospitals atStage 7 in the United States of America (USA)[7].

In the absence of an EMR, Australian AMSteams face three major barriers in practice: real-time identification of prescribed antimicrobials,the ability to prospectively monitor antimicro-bial use, and the ability to integrate funda-mental point of prescribing AMS principles intoroutine clinical practice. National AMS guideli-nes support EMR implementation [8–10]; how-ever, there is very little published experiencefrom Australia to assist with integration of EMRinto existing AMS programs. We aim to describehow four Australian hospitals have overcomethese specific practice barriers following theimplementation of EMR within their institu-tion, and to provide suggestions for AMSspecific build features for new hospitalsembarking on a digital transformation. Three ofthe four hospitals utilise Cerner� PowerChart�

(Kansas City, MS, USA). This article is based on

62 Infect Dis Ther (2021) 10:61–73

previously conducted studies and does notcontain any studies with human participants oranimals performed by any of the authors.

THE EXPERIENCE

Princess Alexandra Hospital, Brisbane,Queensland

The Princess Alexandra Hospital (PAH) is an850-bed tertiary hospital in metropolitan Bris-bane. PAH is a HIMSS Stage 6 digital hospital[7]. Prior to EMR go-live, the Infectious Diseases(ID) team identified antimicrobial prescriptionsthrough medical staff and ward pharmacistreferrals utilising a combination of telephone,text message, paging service, and randomchart review.

The PAH was the first site for complete EMRfunctionality in Queensland, which is continu-ing to be implemented across all QueenslandHealth hospital sites with governance and con-figurations managed at a state-wide level [11].An EMR (Cerner) was implemented in a three-stage rollout beginning with adverse drug reac-tions and allergies recording, then clinical doc-umentation and nursing care tasks includingpathology ordering and result reporting, withthe final stage being EMM, completed in March2017. The Intensive Care Unit (ICU) utilisesCerner EMR for most functions; however,medications are managed through MetaVisionICU� (iMDsoft�, Israel) which does not inter-face with Cerner.

Point of prescribing AMS functionality wasbuilt through various features, as shown inTable 1. Clinical alerts were limited to allergymismatches, extreme doses, and major druginteractions. Documentation of an indicationfor antimicrobials is mandatory using a free textfield.

Reporting and data extraction has changedover time. During the initial build phase, Dis-cern Explorer� functionality was developed foron-demand antimicrobial reports. While usefulinitially in providing basic reports, a decisionwas made to invest in developing a compre-hensive antimicrobial dashboard which wouldprovide more efficient data extraction along

with an enhanced graphical user interface. Thiswas achieved through a local PAH clinicalinformatics team utilising Qlik Sense� software.Figures 1 and 2 show examples of views seenfollowing implementation of this functionality.This dashboard has since been rolled out andvalidated at numerous Queensland Healthfacilities where it is used routinely. Of note, itwas invaluable in managing prescribing ofpiperacillin/tazobactam during the nationalshortage in 2017 and 2018, facilitating rapididentification and AMS interventions for bothnewly prescribed and ongoing therapy with thisagent. This dashboard, along with the existingEMR functionality, has increased the efficiencyof AMS activities, facilitating more frequent andcomprehensive review of antimicrobial therapy.Governance of antimicrobial-related EMRfunctionality, including order sentences, ordersets, alerts and AMS dashboards, is managedthrough the Statewide Antimicrobials DigitalWorking Group reporting to the QueenslandHealth Medicines Advisory Committee.

Alfred Health, Melbourne, Victoria

Alfred Health (AH) is a 1000-bed health servicein metropolitan Melbourne split across threecampuses. Prior to EMM go-live, the AMS teamidentified antimicrobial prescriptions throughpharmacist notifications through stand-alonethird-party AMS software, Guidance MS� (Mel-bourne Health). AMS ward rounds were under-taken at one campus only.

An EMR (Cerner) has been in place since1999 which has evolved over time to includescanned medical notes, orders, radiology andpathology. Clinical documentation, EMM (in-cluding complex medications) and some deviceintegration were implemented in October 2018and rolled out across all areas of the healthservice, including ICU. Cancer care is the onlytherapeutic area that is currently managedthrough a hybrid system, with chemotherapycurrently charted on paper and supportive caremedications charted in the EMR.

Point of prescribing AMS functionality wasbuilt through various features, as shown inTable 1. Clinical alerts were limited to

Infect Dis Ther (2021) 10:61–73 63

significant and life-threatening allergy mis-matches, drug interactions and renal impair-ment dosing warnings.

A customised report (Discern Explorer�) wasdeveloped to identify all patients prescribedantimicrobial therapy at the time of roll out tofacilitate ongoing post-prescription AMS roundsthat have previously been described [12]. Thisreport has enabled the AMS team to expand its

AMS ward rounds across all three campuses, andto specifically target carbapenem and beta-lac-tam/beta-lactamase inhibitor combination pre-scribing. A ‘High-Risk Category Worklist’ hasbeen enabled for vancomycin and aminogly-coside antibiotics to enable pharmacists toidentify patients prescribed these high-riskantimicrobial agents.

Table 1 AMS functionality incorporated into EMR builds at four Australian tertiary teaching hospitals

ConcordHospital,NSW

Alfred Health,VIC

Princess AlexandraHospital, QLD

Fiona StanleyHospital, WA

Antimicrobial agent indications

mandatory at time of prescribing

Y (free text) Y (free text and

drop down list)

Y (free text) N/A

Antimicrobial order sets Y (limited Cerner

PowerPlana)

Y (Cerner

PowerPlana)

Y (Cerner

PowerPlana)

N/A

Types of antimicrobial order sets in

use

Drug based Drug based

Disease based

Drug based

Disease based

N/A

Automatic stop dates for high risk

antimicrobials

Y N (optional for

prescribers)

N (optional for

prescribers)

N/A

AMS pharmacist electronic referrals Capable but not

in use

Y Y Y

Priority dosing for IV antimicrobials Y (optional) Y Y N/A

Clinical alerts Limited Limited Limited N/A

Significant drug interactions Y Y Y N/A

Life threatening allergy mismatch Y Y Y N/A

Customised order sentences for

antimicrobial agents

Y Y Y N/A

Antimicrobial specific report in use Y Y Y N/A

Identification of high-risk

antimicrobial agents

Y Y Y N/A

Ability to link to local policy Y Y Y N

Data extraction capabilities Y Y Y N/A

Local antimicrobial dashboard in use Y (Cerner

mPage)

N Y (Qlik Sense

software)

N/A

a A PowerPlan is a Cerner-specific set of orders grouped together to enable care for a patient [2]

64 Infect Dis Ther (2021) 10:61–73

Fiona Stanley Hospital, Perth, WesternAustralia

Fiona Stanley Hospital (FSH) is a 783-bed hos-pital in Perth, Western Australia, that was par-tially opened in October 2014, with full

opening complete in February 2015. Prior to theimplementation of an adapted electronic refer-ral system in mid-February 2015, the AMS teamidentified antimicrobial prescriptions usingvarious methods, including pager, email, andtelephone referrals.

Fig. 1 Princess Alexandra Hospital/District-wide antimicrobial screening view

Fig. 2 Princess Alexandra Hospital patient-level antimicrobial therapy view

Infect Dis Ther (2021) 10:61–73 65

An EMR (BOSSnetTM, Core Medical Solu-tionsTM, South Australia) was rolled out at thetime of hospital commissioning in February2015. Components of BOSSnet rolled out werelimited to clinical documentation and integra-tion with third party software required foradditional patient management, includingpathology and laboratory results, medicalimaging/radiology results and clinical docu-mentation within the burns unit. All ICU doc-umentation and medication prescriptions areelectronic through MetaVision ICU. Paper doc-umentation remains for all medication admin-istration and clinical observationdocumentation outside the ICU. Paper docu-ments are scanned and stored in BOSSnet foruser access.

AMS functionality is currently limited to theuse of third-party software enabling electronicreferrals to the AMS team (eReferralsTM (HealthSupport Services, Perth, Western Australia))(Table 1). These referrals, which have beenpreviously described, are entered by pharma-cists and/or doctors to prompt an AMS teamreview. Following the implementation andincreased utilisation of eReferrals, the AMS teamsaw a two-fold increase in the number ofpatients referred for AMS round review whencompared to the previously used manual system[13].

Concord Repatriation General Hospital,Sydney, New South Wales

Concord Repatriation General Hospital (CRGH)is a 750-bed health service in metropolitanSydney. Prior to EMM go-live, the AMS teamidentified antimicrobial prescriptions throughphysical review of the paper charts during auditand feedback rounds, and through medical,pharmacy and nursing notifications via a pag-ing system.

An EMR (Cerner) has been in place since2000 (allergy documentation, radiology,scheduling, pathology results and some orders)with functionality being progressively added.Partial EMM was added in a four-stage rolloutover a period of 9 years. Paper records are cur-rently used to prescribe and administer complex

infusions such as heparin and patient-con-trolled analgesia. CRGH was the first hospital inNew South Wales to implement EMM with EMRfunctionality, and therefore some componentsdiffer to the state-wide build. The CRGH build isshared with seven facilities across two localhealth districts, together with components ofthe state build.

Point of prescribing AMS functionality wasbuilt through various features, as shown inTable 1. Verbal approval codes for restrictedantimicrobials are provided by the AMS teamand documented in the EMR; however, there isno central repository of approval codes withtheir expiry dates.

The AMS program collaborated with theHealth Informatics Unit to develop activesurveillance of antimicrobial use with businessintelligence tools. As the first Australian publichospital to go-live with EMR, CRGH assessed asuite of tools available to support AMS overthree phases. The first phase was using the QlikSense� dashboard; however, hospital resourceswere focussed on the subsequent phases due togreater accessibility for all clinicians and greaterintegration with Cerner. Learnings have sinceled to the development of a state-wide NSWdashboard to measure AMS outcomes which iscurrently in progress. The second phase was aSAP� BusinessObjectsTM report to automaticallyemail a spreadsheet of current antimicrobialorders from the EMR to the AMS team at aspecific time of day. Finally, an AMS live mPa-geTM was developed which went live in early2017. This mPage is a virtual view within Cernerthat collates real-time information from theEMR, including microbiology and pathologyresults, in addition to all current antimicrobialprescriptions (Fig. 3). This mPage has enabledthe AMS team to expand their program includ-ing facilitation of short, weekly, real-time AMSrounds with surgical teams to develop collabo-rative antibiotic plans, with discussions entereddirectly into the mPage. Due to improved effi-ciencies in identifying patients actively pre-scribed an antimicrobial, existing AMS roundstook significantly less time to complete [14].

Overarching governance for EMR changes,including the AMS Live mPage is conducted at

66 Infect Dis Ther (2021) 10:61–73

Local Health District level together with clini-cians and the Health Informatics Unit.

DISCUSSION

We describe EMR implementation in four Aus-tralian hospitals in the context of antimicrobialstewardship and demonstrate the ability ofEMRs to overcome specific barriers faced in localAMS practice. Two of the four hospitals descri-bed have invested in business intelligence toolsto assist with utilisation of EMR for AMSactivities.

EMR roll-out is still in its early stages inAustralia, with less than one-third of hospitalshaving implemented EMM in 2020 [6]. Com-paratively, a survey of 3538 hospitals in the USAidentified that 81% of hospitals had adopted atleast a basic electronic health record in 2015;however, there was wide variation in the func-tionality of these systems [15]. At this time,there are no unifying Australian guidelinesavailable to direct AMS-specific EMR contentbuild, with many individual hospitals develop-ing specific local content to meet national AMSguidelines [8–10, 16]. Australia benefits fromhaving a coordinated national Antimicrobial

Resistance (AMR) strategy [17], and, impor-tantly, the four hospitals described in this paperhad active AMS programs in place, with estab-lished processes, teams and governance prior toEMR go-live. Cerner is currently the predomi-nant EMR vendor for health services on the eastcoast of Australia, with other EMRs includingEpic� (Verona, Wisconsin), BOSSnet andMedChart (DXC Technology, Macquarie Park,NSW) being implemented in smaller numbersacross the remainder of other Australian hospi-tals. Much of the available published literatureon the role of EMR in AMS is based on theexperience of hospitals in the USA [2–4]; how-ever, differences in health service models limitsthe direct applicability to the Australianhealthcare system. EMRs provide opportunitiesto enhance AMS programs; however, there arealso several limitations that should beconsidered.

Strengths of EMR for AMS in Australia

As described by the individual hospitals, theimplementation of EMR has enabled expansionof AMS programs in response to local challengesand need. While it is still early in the broaderroll out of EMR nationally, and as such large-

Fig. 3 Concord Repatriation General Hospital interactive mPage view

Infect Dis Ther (2021) 10:61–73 67

scale data are not yet available, there is emerg-ing evidence that EMR has enabled AustralianAMS teams to identify patients prescribedantimicrobial therapy in real-time withincreased efficiency [18]. Doukas et al. [14]reported an increase number of antimicrobialsreviewed and a reduction in time taken tocomplete AMS rounds from 58 to 44 min fol-lowing the implementation of EMM. Similarly,Rawlins et al. [13] reported more timely AMSround reviews, increased adherence to adviceand reduced use of key antimicrobials over a12-month period following implementation ofthe electronic referral system for AMS wardrounds. Patient identification in paper-basedhospitals relies on pharmacy dispensingrecords, web-based antimicrobial approval sys-tems or through ad hoc communication chan-nels. Real-time patient identification hasenabled AMS teams to prioritise and triagepatients for AMS review, including targetingspecific antimicrobial agents (e.g. during peri-ods of supply shortages) and antimicrobialclasses (e.g. carbapenems).

Broader reviews of the general ability ofEMRs to support healthcare have shown anumber of advantages, including improvedinformation transfer and organisation effi-ciency, while effects on mortality, readmissions,total costs and patient and provider experienceremain uncertain [19]. There are limited data todate to support AMS-specific outcomes follow-ing EMR implementation, with reducedantimicrobial utilisation [20, 21] and reducedrates of Clostridioides difficile [20] reported. Well-designed studies are required to furtherdemonstrate the impact of EMR implementa-tion on AMS process and clinical outcomes.

As described by Pogue et al., the implemen-tation of a Cerner EMR has the ability to facili-tate supplementary elements of AMS, asidentified by the Infectious Diseases Society ofAmerica [2, 22]. Creation of customisedantimicrobial order sentences and order setswithin EMRs enables AMS teams to drive evi-dence-based care with the aim of enhancingguideline adherence and pathway utilisation,antimicrobial dose optimisation and education[2]. Within the Cerner sites described in thispaper, order sets have been rolled out to assist

with the prescribing of both complex, high-riskand narrow therapeutic index antimicrobials inaddition to syndromic order sets. Internation-ally, Krive et al. [23] demonstrated reducedmortality, readmission and length of stay over a5-year period following the implementation ofa syndrome-specific order set for community-acquired pneumonia.

Documentation of indication is a key ele-ment of antimicrobial prescribing [16, 24]. The2018 rate of antimicrobial indication docu-mentation in Australian hospitals was 80%,which is below the suggested best-practice tar-get of 95% [25]. Despite incremental improve-ment in this metric following theimplementation of Australian AMS programs,EMR provides the opportunity to mandate this.Doukas et al. demonstrated improvement inindication documentation for electronicallyprescribed antimicrobial orders from 73 to 97%following EMR implementation (p\0.0001)[14].

The Australian NSQHS Standards (Version 2)mandate the need to review antimicrobial pre-scribing and use, while evaluating AMS programperformance and identifying areas forimprovement [16, 26]. Suggested process, out-come and balancing measures are available [10],and we suggest prioritising the process measureslisted in Table 2 to be measurable through theEMR at the time of go-live. Reports to facilitatereal-time data collection require careful valida-tion prior to use to ensure accuracy of infor-mation, and will ideally enable the ability tobenchmark process and outcome measuresbetween hospitals.

National level volume-based surveillance isavailable through voluntary participation in theNational Antimicrobial Utilisation SurveillanceProgram [27]. Contributions have generallybeen restricted to pharmacy dispensing anddistribution data, and reported as defined dailydoses per 1000 bed-days. EMR roll out willenable calculation of antimicrobial days oftherapy for all patient groups, the preferredmetric for assessing the impact of AMS inter-ventions [28]. This will further enable expan-sion of volume-based surveillance to paediatricpopulations as well as facilitate internationalbenchmarking in the adult setting.

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Limitations of EMR for AMS in Australia

AMS is a complex field, with successful pro-grammes requiring a coordinated approach,including governance systems, guideline-drivenpractice, antimicrobial restriction, audit andfeedback and incorporation of behaviourchange strategies [10]. The ultimate aim of anAMS program is to optimise antimicrobial use.While EMRs are able to address some of the ‘lowhanging fruit’ at the point of antimicrobialprescribing, they cannot address the cultural,contextual and behavioural factors that areknown to influence antimicrobial prescribing[29–31]. By improving the efficiency of AMSteams through faster patient identification,reduced times taken to complete AMS wardrounds and utilisation of in-built AMS func-tionality, such as automatic antimicrobial stopdates, EMR implementation can support Aus-tralian AMS teams to adjust their workflows tofocus on these psycho-social factors relating toantimicrobial prescribing.

The core activity of many Australian AMSprograms are post-prescription ward rounds[1, 12, 32, 33]. These multidisciplinary roundscomprised of an AMS pharmacist and an IDphysician are a highly visible service in Aus-tralian hospitals with paper-based medicationcharts, enabling opportunity for impromptudiscussions between clinicians and AMS teamsabout patients of concern. Some Australian AMSteams anecdotally report reduced AMS teamvisibility following EMR roll out, with feweropportunistic AMS consults generated andreduced engagement with treating teams. Ver-bal communication with prescribers has beenshown to increase acceptance rates for AMSinterventions, and it is imperative that this

strength of AMS rounds is not lost with remoteelectronic reviews [32, 34].

The main EMRs used in Australia weredeveloped and designed for the American mar-ket and developed to maximise hospital billing[3]. These systems have some day-to-day func-tionality that is adaptable for use in Australia;however, much of the content must be imple-mented ‘‘out of the box’’, including limited AMSoptimisation [2, 3]. A number of AMS-specificthird party vendors are available to integratewith EMRs, with varying advantages and dis-advantages [4]. Beyond the integration of busi-ness intelligence tools with EMR, integration ofAMS-specific third party vendors has been lim-ited to date to a small number of Australianhospitals. Development of AMS-specific contentduring the EMR build is a key limitation. Asdescribed by Kuper et al. [4], there is often aheavy reliance on the hospital informaticsteams during this time. Depending on the hos-pital location in Australia, a core state-wideEMR build may be available. The PAH build, forexample, has been rolled out across 14Queensland Health sites to date. Cerner is theprimary vendor in New South Wales and hasbeen rolled out to 195 hospitals as at February2020. There are core state build components,but some local customisation is allowed.Hospitals in other states may be required to takea largely individual approach to meet institu-tional needs. This heterogeneous approachrequires significant personnel and may result induplication of work. Sharing of such learningsand experiences is essential; however, it must bedone in such a way as to minimise any intel-lectual property concerns. Communicationchannels are increasing as EMR roll out increa-ses, but were not available at the time of thedashboard development we describe. Innova-tive AMS initiatives are often omitted from theinitial EMR builds and are developed in theyears post-go-live. It is the authors’ collectiveopinion that the AMS functions listed in Table 3are required for Australian initial EMR builds atthe time of go-live. This will ensure the abilityto benchmark and evaluate AMS programsbetween individual institutions and at a stateand national level.

Table 2 Suggested go-live EMR process measures forAustralian AMS programs

1. Days of antimicrobial therapy

2. Documentation of indication for antimicrobial

therapy

3. Antimicrobial allergy mismatch

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Opportunities and Future Directionsfor EMR and AMS in Australia

The scope for further development andenhancement of EMRs to assist AMS efforts inAustralia is vast. As more sites implement androll out electronic systems, increased sharing ofAMS-related content and ideas are occurring,with scope to undertake well-planned andstrategic research to fully determine the impactof EMRs. Multidisciplinary AMS rounds are akey component of many Australian AMS pro-grams, and EMR implementation provides aplatform to expand and explore different mod-els of AMS service delivery. The opportunityexists to leverage EMR data for additionalenhancements for the Australian healthcareenvironment, including bug–drug mismatchscreening, sepsis alerts, data mining and artifi-cial intelligence, human factors, and imple-mentation research. There is scope to establish anational electronic AMS focus group to developcomprehensive guidelines for EMR roll out tosupport our national AMR strategy and existingresources to assist with AMS programdevelopment.

CONCLUSION

EMR has a large impact on healthcare workflow,including AMS programs. EMR provides oppor-tunities to overcome specific barriers in practiceand facilitates expansion of the reach and cov-erage of AMS activities. Importantly, byaddressing specific barriers to AMS practice,EMR enables AMS teams to focus and impact onmore complex aspects of AMS. However, thereare several limitations that should be addressed,and we have outlined some lessons learned forother hospitals embarking on digital transfor-mation and point towards future enhance-ments. The diversity of different EMR softwareused requires further co-ordination of learningsto complement traditional AMS activities.

ACKNOWLEDGEMENTS

Figures 1 and 2 were developed by Metro SouthHealth Clinical Informatics Team (QueenslandHealth). Figure 3 was developed by, and usedwith the permission of, the Sydney Local HealthDistrict Health Informatics Unit.

Table 3 Suggested minimum AMS build features for Australian EMRs

1. Ability to identify patients prescribed antimicrobial therapy

2. Customised antimicrobial order sentences

3. Mandatory documentation of indication

4. Administration prioritisation of intravenous antimicrobial orders

5. Ability to collate microbiology information

6. Ability to record and collect AMS team interventionsa

7. Ability to generate AMS team referralsa

8. Incorporation of local antimicrobial restrictions and approval codes where applicablea

9. Ability to identify high risk antimicrobial agents (e.g. vancomycin and aminoglycosides)

10. Clinician alerts for severe allergy mismatch and significant drug interactions

a If third party AMS software is not integrated

70 Infect Dis Ther (2021) 10:61–73

Funding. No funding or sponsorship wasreceived for this study or publication of thisarticle.

Authorship. All named authors meet theInternational Committee of Medical JournalEditors (ICMJE) criteria for authorship for thisarticle, take responsibility for the integrity ofthe work as a whole, and have given theirapproval for this version to be published.

Disclosures. Kelly A Cairns, Matthew DMRawlins, Sean D Unwin, Fiona F Doukas, Rose-mary Burke, Erica Tong, Andrew J Hendersonand Allen C Cheng declare they have no con-flicts of interest relating to this work. Andrew JHenderson reports personal fees from Sandoz,outside the submitted work.

Compliance with Ethics Guidelines. Thisarticle is based on previously conducted studiesand does not contain any studies with humanparticipants or animals performed by any of theauthors.

Open Access. This article is licensed under aCreative Commons Attribution-NonCommer-cial 4.0 International License, which permitsany non-commercial use, sharing, adaptation,distribution and reproduction in any mediumor format, as long as you give appropriate creditto the original author(s) and the source, providea link to the Creative Commons licence, andindicate if changes were made. The images orother third party material in this article areincluded in the article’s Creative Commonslicence, unless indicated otherwise in a creditline to the material. If material is not includedin the article’s Creative Commons licence andyour intended use is not permitted by statutoryregulation or exceeds the permitted use, youwill need to obtain permission directly from thecopyright holder. To view a copy of this licence,visit http://creativecommons.org/licenses/by-nc/4.0/.

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