eprescribing at university hospitals birmingham nhs foundation trust ann slee director of pharmacy...
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ePrescribing at University Hospitals Birmingham
NHS Foundation Trust
Ann SleeDirector of Pharmacy
Presentation Outline
• The system• System functionality• Benefits• Ongoing work
The System
• Developed by Wolfson Computer Lab ▪ Unit within University Hospital, Birmingham
• Continuous development for over 10 years ▪ Always in conjunction with UHB clinical staff
• Core design, development, implementation, 7 staff• Currently 12 staff in PICS team
PrescribingInformationCommunicationSystem
PICS - Overview
Labfeed
Lorenzofeed
Im agingreports
O rders to system s,departm ents
Letters to G Pinfo server
P ICS Auditsystem
Available on 4000+Trust desktop PC s
370 A4-sized tablet PC s
A lso ‘w indsurfers’ (batterypow ered, m obile , large screen PC s)
S ingle application, a ll p latform s
Dischargeletters/sum m aries
Drug requeststo pharm acy
Labrequests(labels)
PIC S
H and-heldor
D esk-topPC s
Results,a lerts,a larm s,prescrib ingwarnings
C lin ical deta ils,requests,prescriptions,adm inistrations
PICS – Clinical Coverage• All wards bar theatres and A/E
– Includes critical care, clinical haematology• Prescribing and medicines administration – paperless• Oral medicines, IVs and parenterals, infusions,
chemotherapy
• Unplanned downtime since March 2004: 0.07%• Multiple redundancy of mirror database and application
servers• ‘Document archive’ backup systems for prescribing +
administration– Allows reversion to paper in emergency
PICS – usage statistics †• Operational across 2 sites, 1200 inpatient beds
– 54 wards, 17 specialties, last in 2008– Some areas for >12 years
• Tablet PCs – 400• Computers on wheels – 50• Desktop PCs – 4000+
• Users with active accounts - 3000• Users logging in per week - 2500
– 600 doctors of all grades– 1600 nurses
• Concurrent users – 250
• Prescriptions written - 24,000/week • Administrations recorded - 125,000/week
† Data from PICS audit period 16/01/2010 to 22/01/2010
Presentation Outline
• The system• System functionality• Benefits• Ongoing work
• ‘Paperless’ management of drug therapy/protocols• In-built real-time checks on drugs, dosages, contra-indications,
interactions, etc.• Results reporting• Automated lab requesting • Real-time, event driven alerts• Clinical procedures• Discharge letters/summaries • Order communications• Clinical observations• Bed state, dependencies, estimated length of stay
Rules-based clinical management system,
configurable by specialty, allowing:
Complex rules Alerts or alarms
(rule specifies those groups that can see and can acknowledge)
Abnormal result levels or rates of change Suggested drug script changes, as a result of:
new results new clinical information duration of script, etc.
Reminders, warnings, information, etc.: arrival of certain report types (e.g. imaging, microbiology) review of sedation levels preferred route for drug administration entry of sedation/ventilation data suspect on-line blood gas data compliance with thrombosis guidance
Complex rules cont.(Single rule can generate several actions)
Laboratory investigation proposals, based on: Clinical classifications Current drug therapy Previous results Inpatient/outpatient status
Drug proposals, e.g.: On admission scripts Post-op drugs Antimicrobial protocols
Drug prescriptions - MRSA protocol
Password-level warnings ignored6 month period
1113
22039
3453
51805
1854
23773
12323
54935
0%
20%
40%
60%
80%
100%
Contraindication Dose Interaction Dose/Freq
Presc Admin
Carried on
Backed off
lvlcat 2
Count of msgid
qtype catname
state
Lower (red) histograms show the number of times the user ‘backed off’ when presented with a password level warning
Drug dictionary (04/02/10)
• Created and maintained in-house• All dm+d drugs included in 2006• BNF contraindications included in 2006
Total drug entries (including dm+d) 8644
Active drug entries = formulary 2165
Chemotherapy rotas 271
Contraindications - BNF (all drugs)
References 117,075
Distinct messages 4399
Contraindications – local (active drugs)
References 7029
Distinct messages 1231
Drug-drug interactions (active drugs)
References 18,207
Distinct messages 2230
Individual dose limits (active drugs) 1949
Daily dose limits (active drugs) 2093
Formulary issues• Steady stream of requests for changes to drug dictionary
– New drugs, changes to dose limits, interactions, contraindications, messages, etc.
• Some from clinical leads, some from irate housemen• Standard change request process with standard forms
– Authorisation managed via a multi-disciplinary team (answerable to Trust Medicines Management Group)
• Some requests cannot be met directly within the application– Need ‘lateral thought’ to use what is available to achieve something close to
the requirement.– Need people with an interest in, and a good understanding of the system
Presentation Outline
• The system• System functionality• Benefits• Ongoing work
Implementing Policies – Example of Antimicrobial
Prescriptions
Structured Prescribing Protocols for Antimicrobials adapts the whole Trust Policy
in prescribing orders / order sets
Prompts doctor to review effectiveness of therapy
Improving Safety – VTE risk assessments
A reminder prompt fires on a daily basis if adherence to VTE
risk assessment guidance is not followed
A compulsory thromboembolism risk
assessment must be carried out during admission process
for all inpatients
Reminder led to a 4% increase in prescriptions for surgical patients, 14% increase for medical patients
Formulary Redirect
Number of Simvastatin Prescriptions per week
Number of Atorvastatin Prescriptions per week
Estimated Cost Savings£250,000 / year
Cost Improvement Programmes – ‘Statin Switching’
Worked with the South Birmingham PCT to support their primary care campaign of Statin Switching to save money by the appropriate substitution of generic simvastatin
Rules for healthcare associated infections e.g. MRSADoctors are required to document risk
factors for MRSA on admission of all patients to drive subsequent
decolonisation rules
Automated prescribing of MRSA decolonisation taking into account
sensitivities
Some of the rules are quite strict!
Audit system Massive potential to the organisation
• Ready access to data generated by the system is essential for a range of uses:– Monitoring system usage – drugs, doses prescribed, late or missed administrations– Clinical audits– Incident investigations– Research, etc.
• Data structures can be extensive and complex
• Inappropriate to run audit queries alongside live operation • Weekly automated export of content to ‘data warehouse’ on separate server
– Currently 140 Gb • Allows:
– Routine weekly/monthly reports - automated email distribution– Ad-hoc reports (clinical audits)– Modelling impact of proposed changes
Omitted Doses – NPSA RRR 009
• Reducing harm from omitted and delayed medicines in hospital
• System supports identification of:– Rates
• Location• Medicine type
– Antibiotic, enteral feed etc
– Identification of types of omission• NBM• Stock missing• PRN assumed
The Execs Review
Trend in Missed Doses – April 2008 – July 2010
Stock Look up in PICS
Benchmark of Omitted Doses
• Comparison with two other systems• Initial data demonstrates similar rates
• Antibiotics– Antibiotics missed – 8.61% vs 10.95%– Shows similar winter increase in doses missed– Roughly 50:50 IV vs oral missed
• Non-antibiotics– Doses missed – 17.95% vs 20.38%– Highest % - analgesics, laxatives, anti-emetics
Presentation Outline
• The system• System functionality• Benefits• Ongoing work
Ongoing Work
• Increased use of data – for example– DDDs for antibiotics– NPSA warfarin requirements
• Counselling• Monitoring Rx verification• Renal injury
Ongoing Work
– Functionality• Outpatients• Anaesthetics• A&E• Handover• Clinical pharmacy support• Recording of ward based testing• Formulary support• Indication driven Rx and increased use of order sets• Rules development
Ongoing Work
• System being marketed - CSE– UK specific functionality– UK specific rules and policy interpretation
• Ongoing benchmarking– Cleveland clinic– Other English Trusts with systems
• Research to demonstrate benefits
Summary - Benefits to the Organisation
• Generic Learning– System Longevity and Systematic Implementation means already
learned the lessons other Trusts still have to face– Clinical Decision Support requires extensive clinical backing
• Improving Quality– Many wider benefits to the Trust beyond paperless prescribing– e.g. VTE Assessment, Infection Control, Indicators, Cost Improvement
Programmes, • Integration is key
– Using PICS as clinical cornerstone – can ‘connect rather than replace’– Enhancing and continuing to build informatics capability