Background

The focus of our clinician-led Information Management & Technology team is to support our clinical teams to deliver excellent care with compassion.  A key priority for the team is to achieve a paperless or paper-light NHS by 2018, as required by the Department of Health. 

In autumn 2014 our board approved funding for delivery of an electronic prescribing and medicines administration (EPMA) system to improve our service and as part of the journey to achieve a paperless NHS.  We have received confirmation of a successful bid for £1,328,360 from the NHS England Integrated Digital Care Fund* (round 2).  This matches half of the total investment required to deliver EPMA (£2.6 million).  The cost includes software licencing, configuration and implementation as well as additional computer hardware required to assist doctors and nurses deliver patient care. We were the only NHS organisation in England to receive all of the funding that was requested.  This reflects the strength of the application and the confidence that NHS England has in our ability to deliver the advantages to our patients and local health economy. 

Current system

Our current system for prescribing and administration of medicines is paper based, with the exception of discharge prescription and chemotherapy. Problems with the current system include :

 

• Illegible hand writing on prescriptions and charts.
• Incomplete information being recorded on an order.
• In-appropriate ordering.
• Transcription errors
• Lost or misplaced drug charts.
• Physically transferring the order from wards to dispensaries is not timely.
• Error in calculations for specific medicine doses.

The NPSA have calculated the cost of medication incidents nationally to be £750m. The EQUIP study (2009) identified a prescribing error rate in secondary care of 8.9%, and NICE guidance highlighted up to 70% of patients have at least one error in their initial prescription when admitted to hospital. Locally, there were 1011 incident reports on Datix relating to medicines in 2013 / 14, and audits undertaken in 2014 have identified prescribing error rates of up to 24%.

EPMA systems are specifically designed to reduce the risks associated with traditional methods of prescribing and administering medicines.

Scope of the new EPMA system

The new EPMA will include:

• Electronic generation of the prescription
• Electronic recording of medicines administration
• Full record of all medicines prescribed and administered held within the electronic patient record (EPR)
• Electronic transmission of medicine supply requests to Pharmacy.
• Access to the system for prescribing for in-patient, out-patient and theatres.

Aspects that are not included for delivery with this business case (but may be developed as a part of future phases of implementation) are:

• Barcode recognition of medicines
• Medicines stock control
• Electronic transmission of medicines supply requests to the Pharmacy automated dispensing system
• Chemotherapy.

Project Deliverables

The greatest benefits to be derived from implementing an EPMA system are those related to improving the safe provision of care to patients. EPMA achieves this through:

1. Mandated field to capture allergies and sensitivities
2. Legible prescription and doses, with no crossing out.
3. Pre-populated order sets
4. Mandated fields when manually generating an order set to ensure all minimum prescription data entered
5. Promotion of our Medicines Formulary
6. Medicine database with alert functionality for drug – allergy and drug – drug interactions
7. Alert functionality for patient – drug interaction
8. Ability to restrict prescribing access to certain drugs
9. Reduction in the need to transcribe (no need to re-write prescription, transcribe at discharge, and transcribe at admission)
10. Medicines started, stopped and changed during admission captured in the discharge prescription
11. Electronic access to GP records
12. Elimination of the use of inappropriate decimal points, abbreviations, unit measures.
13. Clear audit trail in terms of identifying prescriber, administrator, checker rather than determining illegible signatures
14. More timely supply of medicines facilitated by electronic ordering on the ward and transmission to Pharmacy
15. Alert system to highlight ‘critical medicines’ to ensure timely administration
16. Alert system for missed / late doses
17. Automated reports to provide accurate data highlighting issues with aspects of medicines management (e.g. non-formulary prescribing, missed doses, duplicate ordering) so that support can be provided to address the issues.

Additional benefits of implementing an EPMA system include:

1. Patient experience – reduction in prescribing and administration errors, more timely supply of medicines (including medicines for discharge)
2. Work processes for staff – eliminate looking for misplaced drug charts, eliminate rewriting drug charts because out of space, automated transcription of medicines into the discharge prescription, reduce duplication of workload due to ‘right first time’, automated transmission of medicine order from ward to dispensary.
3. Infection prevention and control – promote formulary compliance (eg duration of treatment), alerts for at risk patients, administration alerts, targeted antibiotic ward rounds, restricted access to certain antibiotics.
4. Cash releasing efficiencies – no purchase of paper prescription charts, improved formulary compliance, reduced misappropriation.
5. Electronic Patient Record – better data quality and real time information.
6. Reputation – demonstrating that we are a forward thinking organisation that utilises modern technology to improve care for patients.

Project Management

The EPMA Programme Board was established in January 2014

Name	Role on Programme Board	Title
Gareth Price	Pharmacy Lead / Chair	Chief Pharmacist
Graham Jones	Clinical Lead	Consultant Anaesthetist
Nital Panchal	EPMA Project Lead	EPMA Pharmacist
Katie Swarbrick	Programme Nursing Lead	Associate Nursing Director
Vikki Lewis	Operations Lead	Head of Performance, Capacity & Business Planning
Helen Cobb	Finance Lead	Assistant Finance Director
Nick Millband	IT Lead	Senior IT Manager

The Programme Board is supported by a Project Team, which has a flexible membership so that staff with key skills and knowledge can be engaged at appropriate times through the life of the project. A key role of the Board and Project Team will be to work with the wider clinical teams to promote full engagement with the process of EPMA roll-out and ensure successful implementation, embedding new work processes in to practice.

The first stage of the project will be to develop the Quadramed EPMA system to meet our needs, including the creation of pre-populated order sets (prescriptions). It is anticipated this phase will take 10 to 12 months. A full roll-out plan will be developed by the EPMA Project Team. A pilot phase will take place on a small number of wards, followed by a phased roll-out to all wards and clinical areas. A period of assessment will be built in to the plan after each phase of implementation so that lessons learnt can be taken in to the next phase. The Team must be empowered to delay the implementation of the next phase if there are issues remaining to be resolved in a particular clinical area, for example additional training required to fully embed new working practices due to a limited level of staff IT capability.

Finance

The financial investment required to support this business case is detailed in the table below:

	2014-15	2015-16	2016-17	2017-18
License, Installation, Project Costs, Contingency	£428,000	£58,000
Maintenance contract		£82,000	£89,000	£89,000
IT Hardware and Infrastructure	£120,000	£479,000	£605,000
Staff		£256,000	£256,000	£198,000
Total	£548,000	£875,000	£951,000	£287,000

Cash releasing benefits from implementing an EPMA system have been calculated as follows:

Benefit Description	Rationale	Cash Releasing Value
Reduction in stationary costs	Based on 2013 / 14 expenditure on drug prescription kardexes	£40,000
Improved medicines optimisation processes	Improved adherence to the medicines formulary	£544,000
Reduction in misappropriation of medicines	Greater visibility of medicines usage in clinical areas	£35,500
Total	£619,500

 

Non cash releasing benefits from implementing an EPMA system have been estimated as follows:

Benefit Description	Rationale	Non-Cash Releasing Measure
Reduction in medication errors.	Savings based on reductions in litigation (paid by insurance), reduced length of stay, and reduced costs of corrective treatments.	£888,641
Reduction in adverse drug reactions (ADRs)	Savings based on reduced admissions and bed occupancy	£100,000
No need to look for misplaced prescription charts*	Based on saving each member of staff 20 minutes per shift through not searching for prescription charts: Pharmacy staff Nursing staff Medical staff	£90,000 £445,000 £217,000
Rewrite prescription charts	Medical staff time saved	£15,000
Reduction in staff time transporting prescriptions to Pharmacy*	Electronic transmission of prescription / supply requests	£30,000
Reduction in drug wastage	Reduction in duplicate prescriptions, duplicate ordering and supply and duplicate administration.
Support the Trust achieve HCAI targets	Optimising antibiotic use

Conclusion

There are clear benefits of implementing EPMA in terms of safety and quality of services provided for patients, and quantitative and qualitative efficiencies. Without investment into an EPMA solution the following problems will continue to apply;

• Wastage of drugs
• Lack of adherence to formulary
• Limited control and accountability in an area of significant expenditure
• Less than the best treatment for a patient.
• Extended bed stays and higher levels of unnecessary re-admission.
• Patient safety incidents through poor legibility of prescriptions
• Errors in prescribing and medicines management which could have been avoided with clinical decision support, impacting on patient safety.

Implementing EPMA will require significant organisational change.

To implement this change we will engage staff at all levels throughout the organisation, and most importantly senior managers and health care professionals. 

An EPMA solution will demonstrate to patients, staff and visitors to the hospital that we are determined to offer the best level of care patients can receive, and will support us to achieve our corporate delivery strategies and strategic aims. 

*For further details see http://www.england.nhs.uk/ourwork/tsd/sst/tech-fund/