Electronic prescribing shows quality results

It is not often that Victoria's HealthSmart roll-out receives good news, having been roundly eviscerated in a report by Victorian Auditor-General John Doyle in 2013. The report concentrated on four health services that had rolled out the Cerner electronic medical record, which one hospital is understood to have abandoned, two have rolled out fully and the other is most of the way there.

In his report, Mr Doyle makes particular reference to the complexity and difficulty of introducing electronic medications ordering and management, saying that there are significant difficulties in using the system to manage complex prescriptions.

He also highlighted the common teething problems reported by clinicians with most complex health IT roll-outs, including interruptions to workflow and tedious and time-consuming new ways of doing things.

So was he right in his criticisms? While no one denies that the roll-out has been difficult, recent data seems to show that there have been major reductions in medication errors at two of the health services that introduced Cerner through the HealthSmart program, Austin Health and Peninsula Health.

The introduction of Cerner to automate prescribing and drug administration, as well as radiology and pathology ordering and reporting – including what is claimed to be the first roll-out of electronic medications management in an emergency department in Australia – won the two health services a quality improvement award from the Australian Council of Healthcare Standards (ACHS) late last year in the clinical excellence and patient safety category.

In their submission for the award, the clinical systems project teams from Peninsula Health and Austin Health cited a number of statistics to prove their point, including:

  • A 55 per cent decrease in medication errors in sub-acute care in the 12 months after the system went live compared to the previous 12 months
  • A decrease of 77 per cent in ISR rating three (moderate severity) incidents
  • A decrease of 37 per cent in ISR rating four (mild severity/near miss)
  • A reduction of 67 per cent in missed doses, 25 per cent in prescribing errors and 72 per cent in wrong drug errors
  • No medication errors were recorded due to legibility issues
  • 99.9 per cent accuracy in allergy status
  • No incidences of lost drug charts.

In addition, the system does seem to be usable, recording a response time of 2.29 seconds to log in, a transaction time of 0.61 seconds and 7.5 clicks per order.

Austin Health and Peninsula Health worked closely together on the project, although both developed their own communication and change management strategies. They split the roll-out into two phases: the first go live, in June 2011, involved implementing the core software system with capability from electronic pathology and radiology orders, results, centralised allergy and alerts management, discharge prescriptions, discharge summaries and electronic discharge prescribing.

The phase two go live, involving inpatient medication prescribing, dispensing and administration, went ahead in June 2012 and was completed across all sites and services (emergency, acute, sub-acute and mental health) of both health services by August 2013.

In preparation, a range of computers on wheels, tablets and mobile devices were deployed and IT infrastructure upgraded including new wireless systems.

No more paper charts

Lyn Jamieson, clinical systems project director with Peninsula Health, says the major aim of the project was full electronic management of the whole medications process. “We basically don't have paper charts any more,” she says.

At Peninsula, doctors and pharmacists work on developing the electronic drug chart together, with the pharmacist usually taking care of the medications history and the doctor putting the drug chart together.

Doctors now prescribe electronically, including in the emergency department, predominantly ordering from order sets or what Ms Jamieson calls a set of order sentences. “We have a predefined set of order sentences that they will pick,” she says. “There is a drop-down box and they will pick the medication and the dosage and the frequencies from that drop-down box.

“They don't have to do that if they don't want to – they can do it from scratch if they want to – but most of them will do it from a predefined list.

“We also have what they call power plans and a lot of our doctors are now ordering from them. It is set around specific patient conditions so if a patient has got chest pains and they come into ED, there is a standardised order set that is evidence-based that we encourage the doctors to use.”

Doctors can override the power plans and pick and choose what tests and drugs they want, but most are taking advantage of the pick list and power plan functionality, she says. “We have that predefined so they just do one click and all of that will be ordered within one click.”

Peninsula first went live with the system in its sub-acute setting in July 2012, followed by mental health that August. In acute care, the service broke down the introduction into clinical areas, going live in the medicine units at Frankston Hospital in November 2013 and then at Frankston's ED in February last year.

“We think we are the first emergency department in Australia to go live,” Ms Jamieson says. “In April we went live with surgery, women's, children's and adolescent health units and theatres. August was our last go live and that was Rosebud Hospital, where we went live with that whole hospital.”

Peninsula Health has been slowly gathering benefits and outcomes data, the most mature coming from sub-acute care. Ms Jamieson says her last analysis showed a 34 per cent decrease in medications incidents in sub-acute.

While Mr Doyle's report did mention problems with the system for pharmacists, Ms Jamieson says it has proved otherwise for nursing staff. “Overwhelmingly, the majority of our nurses love medication administration electronically and that's because they can read the drug charts and they know which doctor has ordered the drugs. Sometimes before they couldn't work out the signature. They can also access the drug chart so there's no fighting over that one paper drug chart.

“The nurses are mainly administering off [tablet PCs]. They were given a choice of devices and what we had available at the time … so most of them are using a Motion C5 tablet. The majority of them will use that while other nurses prefer the WOW, the workstation on wheels. Some of them like the larger screen.”

The data from pharmacy is also proving positive, with the latest analysis showing that pharmacy had a 62 per cent decrease in the number of medications omissions and a 19 per cent increase in the time that pharmacists now have to do therapeutic interventions. “That's what they really enjoy doing and what we should have pharmacists doing.”

With antimicrobial stewardship, there is now 92 per cent compliance, as opposed to 48 per cent in the past, Ms Jamieson says. “We also have decision alerts on the system and it can allow you to structure clinical pathways better so your work processes could be more structured.

“We can actually force the clinicians into a certain way of practice which is good, although sometimes they may not think it's good. The majority of the junior doctors do need that assistance and this is where an electronic clinical system can really help them out.”

Electronic prescribing in ED

At Austin Health, executive director of acute operations Fiona Webster says her service is now in the position to be one of the best implemented medication systems in Australia.

All medications ordered in the emergency department are done through Cerner, with medications management now highly visible throughout all departments.

“We can connect the whole drug chain,” Ms Webster says. “We all know exactly what drugs have been ordered, what drugs have been given to the patient, we know every dose of the drugs in the hospital. With a paper system you would never have had that visibility. It's giving you a much better sense of prescribing patterns and there is a lot of data that sits underneath it that we are just starting to understand.”

While it is not unusual for doctors and nurses to be very suspicious of electronic systems, Ms Webster believes that as a lot of the work in ordering and reviewing tests is done by junior doctors, they are a lot less resistant to change than older clinicians.

“They appreciate the visibility that the system brings,” she says. “They are not having to remember dose ranges and that sort of thing, so from that point of view the junior medical staff picked that really quite quickly.

“Radiology has been able to pull out the paper system long before they expected to be able to because previously we had a situation where you wrote an order, it went into a tray, someone had to come and collect it, someone had to take it to radiology and that was entered into the radiology system, where they couldn't read the order so they had to track the doctor down.

“Junior doctors didn't know when the test might be scheduled so they were ringing the radiology department. None of that happens any more. They put the order in the computer, they can see when the tests are scheduled in the system and as soon as the results are available they are available for them to review.”

Ms Webster says it this this visibility of the whole process that is the most beneficial. “We now have visibility of every drug whereas before when you looked at the drug chart you couldn't necessarily tell when people were given the drug, to see if it was given on time.

“Now we know when drugs are not given on time and we know when antibiotics are ordered. A lot of medication errors are due to legibility but all of that is gone now. Documentation of allergies has improved dramatically and clinicians can now see things on the system that they hadn't been able to see previously.”

An edited version of this story appeared in the July 2014 issue of Pulse+IT Magazine.

Posted in Australian eHealth

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