Transcript ePrescribing at University Hospitals Birmingham NHS

ePrescribing at University Hospitals
Birmingham
NHS Foundation Trust
Ann Slee
Director of Pharmacy
[email protected]
Presentation Outline
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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
Prescribing
Information
Communication
System
PICS - Overview
Lab
feed
Discharge
letters/summaries
PICS
Lorenzo
feed
Imaging
reports
Lab
requests
(labels)
Drug requests
to pharmacy
Orders to systems,
departments
Clinical details,
requests,
prescriptions,
administrations
370 A4-sized tablet PCs
Also ‘windsurfers’ (battery
powered, mobile, large screen PCs)
Results,
alerts,
alarms,
prescribing
warnings
Hand-held
or
Desk-top
PCs
Single application, all platforms
Letters to GP
info server
PICS Audit
system
Available on 4000+
Trust desktop PCs
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
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PICS
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usage
statistics
Operational across 2 sites, 1200 inpatient beds
– 54 wards, 17 specialties, last in 2008
– Some areas for >12 years
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Tablet PCs – 400
Computers on wheels – 50
Desktop PCs – 4000+
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Users with active accounts - 3000
Users logging in per week - 2500
– 600 doctors of all grades
– 1600 nurses
Concurrent users – 250
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Prescriptions written - 24,000/week
Administrations recorded - 125,000/week
† Data from PICS audit period 16/01/2010 to 22/01/2010
Presentation Outline
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The system
System functionality
Benefits
Ongoing work
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Rules-based clinical management
system,
configurable by specialty, allowing:
‘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
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.:
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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)
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Laboratory investigation proposals, based on:
 Clinical classifications
 Current drug therapy
 Previous results
 Inpatient/outpatient status
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Drug proposals, e.g.:
 On admission scripts
 Post-op drugs
 Antimicrobial protocols
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Drug prescriptions - MRSA protocol
Password-level warnings ignored
6 month period
lvlcat 2
Count of msgid
Lower (red) histograms show the number of times the user ‘backed off’
when presented with a password level warning
100%
80%
54935
23773
1854
12323
60%
state
Carried on
Backed off
40%
51805
22039
20%
1113
3453
0%
Contraindication
Dose
Interaction
Presc
Dose/Freq
Admin
qtype
catname
Drug dictionary
(04/02/10)
Total drug entries (including dm+d)
8644
Active drug entries = formulary
2165
Chemotherapy rotas
271
Contraindications - BNF (all
drugs)
Contraindications – local
(active drugs)
Drug-drug interactions
(active drugs)
References
117,075
Distinct messages
4399
References
7029
Distinct messages
1231
References
18,207
Distinct messages
2230
Individual dose limits (active drugs)
1949
Daily dose limits (active drugs)
2093
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Created and maintained in-house
All dm+d drugs included in 2006
BNF contraindications included in 2006
Formulary issues
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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
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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 compulsory
thromboembolism risk
assessment must be carried
out during admission process
for all inpatients
A reminder prompt fires on a
daily basis if adherence to VTE
risk assessment guidance is
not followed
Reminder led to a 4% increase in prescriptions for surgical patients,
14% increase for medical patients
Cost Improvement Programmes –
‘Statin Switching’
Number of Atorvastatin
Prescriptions per week
Number of Simvastatin
Prescriptions per week
Formulary
Redirect
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
Estimated Cost Savings
£250,000 / year
Rules for healthcare associated
infections e.g.
MRSA
Doctors 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
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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.
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Data structures can be extensive and complex
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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
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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
25.00%
20.00%
15.00%
10.00%
5.00%
0.00%
Apr- May- Jun- Jul-08 Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr- May- Jun- Jul-09 Aug- Sep- Oct- Nov- Dec- Jan- Feb- Mar- Apr- May- Jun- Jul-10
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Omitted_Antibiotics
Omitted Non-Antibiotics
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
Presentation Outline
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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
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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