Portland Hospital to produce PBS-compliant discharge scripts

Earlier this year, Portland Hospital in Victoria's south-west switched on medications management functionality through its TrakCare health information system in all wards of the hospital, the first facility in the South West Alliance of Rural Health (SWARH) to do so.

While implementing EMM is a difficult process that requires a lot of change management, Portland has had the benefit of using Intersystems' TrakCare as its patient administration and clinical information system for some time, meaning staff were familiar with its processes and confident in its capability.

And as the medication management functionality is already built into TrakCare, the whole process has only cost $10,000, something that SWARH's divisional manager for productivity and development, Katharina Redford, raises a few eyebrows at other hospitals weighing up the high cost of going electronic.

In addition to mobile access, the next step for the implementation is to integrate TrakCare with iPharmacy and develop the ability to produce PBS-compliant discharge prescriptions that patients can take to their local pharmacy.

Portland began planning for the roll-out in mid-2013 and went live in September, converting each department and ward over to the system incrementally. Ms Redford says the planning included devising change management strategies, evaluating workflows and conducting time and motion studies, as well as looking at any hardware upgrades that would be required.

While the roll-out has been reasonably smooth, as with all major changes there have been a few adjustments in that time, predominantly to ensure the system fits in with various workflows. Ms Redford says they were relatively minor and were more about developing a more nuanced understanding of the system and how it works.

“With the Gartner hype cycle, there is all this excitement and a honeymoon period when everyone is happy before there are troughs of disillusionment and we are coming out of that now,” she says. “We have identified things that really bug them and they are just usability things. 'Did you know that you could click here or do that and that will solve the problem?' That's what we are working through at the moment.

“This is a huge amount of change. This is saying to the doctors that you will now follow every rule based on what is set out in the system rather than what you have always done. But it is also nurses having the opportunity to clearly understand orders and follow best practice and it is pharmacists being able to interact at the time the orders are placed rather than two days later when they get to the chart. It is a huge change.”

It is early days yet but in the months since it was fully rolled out, Ms Redford says the system has improved productivity by reducing the time it takes to write a medication chart and the time that pharmacists formerly spent walking through each ward. However, it still requires that nurses spend about the same amount of time on administration.

And while the rate of errors has not yet changed, the errors are quite different to those that occurred in the past. “Instead of an error like 'I can't read what has been written', it is more 'that is out of line with our guidelines',” she says. “These errors aren't necessarily incidents: they are because more collaborative, intelligent questions are being asked.”

Ms Redford says one of the benefits of having medications management integrated within the clinical information system rather than as a bolt-on is that information can readily be drawn from other functions, such as patient allergies and pathology results.

“With a paper medication chart you have to rely on someone recording the allergies on every chart and every page on every chart,” she says. “On a paper chart you might just miss that note not to prescribe penicillin. That now gets recorded within TrakCare and it is always there, so if you order penicillin and the patient is allergic to penicillin, it won't let you do it.

“Clinicians can choose to override some things because there is sometimes good reason why you would order something that a person is allergic to, but the alert is always there.

“A difference again with a paper chart is that when the nurse checks the patient's INR, they would write that on the chart, but in TrakCare, that INR is within the pathology result so the doctor can go in and eyeball it and there's no confusion about whether it's a nine or a four. These are the sort of benefits of the patient-centred approach. You choose the person, you understand what's happening with that person.”

Bring your own network

Portland has decided against equipping nurses with tablet computers to use the medications module for the time being and instead went with computers on wheels (COWs) for practical reasons. Like the other hospitals in the SWARH alliance, the hospital has very good wireless access so laptops on a trolley proved suitable, and the nurses also like to keep their hands free and have a place to keep their thermometers, containers of Agarol or Mylanta and the like.

Portland will go down the mobile route as part of SWARH's BYOD strategy and is looking forward to the next version of TrakCare, which will enable mobile medications management. It won't matter what kind of device the system is installed on because it will detect whether it's a PC or other mobile device.

SWARH has a long-term mobile strategy in place and has moved now beyond BYOD into BYON, or bring your own network. As many hospitals are in rural areas that give GPs visiting rights, the alliance has rolled out Citrix's NetScaler application, which enables GPs and consultants to log into the network wherever they are. GPs are also able to purchase time on the SWARH high-speed, microwave broadband-based network if they so choose.

That said, Ms Redford is not convinced that clinicians will all take to BYOD, particularly nurses. As a nurse herself, she believes they are more likely to want to use a hospital-issued device rather than a personally owned one, as opposed to consultants, who need to use a device for both clinical and private business purposes.

Integration with iPharmacy

Ms Redford says most medications management systems don't have an integrated pharmacy module, so what Portland Hospital's pharmacists are using a link between TrakCare and their iPharmacy system. They can access TrakCare on one screen and iPharmacy on another.

“The pharmacists do their ward rounds in the pharmacy system, which saves a whole of time, and they will check each new drug as it is ordered because they get a notification,” she says.

“They can write their notes as they would with a coloured pen on a paper chart, they can put medications on hold, and within TrakCare they have configured messaging so the pharmacist can send a doctor a message saying 'did you really mean this dose' or 'under the antimicrobial stewardship program you can only order this for three days'.

“The message goes to the account so when I log on as a doctor I get a notification that there is a message waiting for me and then I can send it back to the pharmacist.”

Once the two systems are integrated, Portland Hospital hopes to start producing discharge prescriptions. “We can already produce discharge lists and we can put meds on the discharge summary, but what I'd like to do is to produce a PBS prescription so they can take that prescription to the community pharmacy,” she says.

In the future, there is the possibility of providing patients themselves with some sort of electronic view of their medications. At present, discharge summaries are printed out but often they don't come with instructions for the patient or carer on when they should take their new medications and whether they should continue to take their current ones.

“It's also possible that when they go home they can manage their own medications so there is proper medications reconciliation, which is the biggest safety driver,” Ms Redford says. “When you come into hospital a professional sits down with you and gets out of you or your relatives what tablets you take every day. Not what you are ordered to by the doctor but what you actually take, as they are often different things.

“You might be ordered to take four different things by the doctor but you also might take a couple of complementary therapies and you might also take Aunt Bessie's heart tablets because she had high blood pressure and you have it now and you just take hers. That happens all the time.”

As it is early days yet there are no statistics on medication misadventure, but SWARH expects to be able to provide a full account this time next year. Ms Redford is not at liberty to say when the other hospitals in the alliance that use TrakCare will also switch on EMM, but she says they are all keen to do so. They also plan to begin using TrakCare to connect to the PCEHR.

Posted in Allied Health

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