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EPrescribing at University Hospitals Birmingham NHS Foundation Trust Ann Slee Director of Pharmacy ann.slee@uhb.nhs.uk.

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Presentation on theme: "EPrescribing at University Hospitals Birmingham NHS Foundation Trust Ann Slee Director of Pharmacy ann.slee@uhb.nhs.uk."— Presentation transcript:

1 ePrescribing at University Hospitals Birmingham NHS Foundation Trust Ann Slee Director of Pharmacy

2 Presentation Outline The system System functionality Benefits
Ongoing work

3 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

4 Prescribing Information Communication System

5 PICS - Overview

6 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

7 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 Users logging in per week 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

8 Presentation Outline The system System functionality Benefits
Ongoing work

9 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 So what is it…

10 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

11 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

12 Password-level warnings ignored 6 month period
Lower (red) histograms show the number of times the user ‘backed off’ when presented with a password level warning

13 Drug dictionary (04/02/10) Created and maintained in-house
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) 7029 1231 Drug-drug interactions (active drugs) 18,207 2230 Individual dose limits (active drugs) 1949 Daily dose limits (active drugs) 2093 Created and maintained in-house All dm+d drugs included in 2006 BNF contraindications included in 2006

14 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

15 Presentation Outline The system System functionality Benefits
Ongoing work

16 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 16

17 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 This is a rule that monitors the doctors’ compliance with earlier advice provided by another set of rules. Every patient must be assessed for risk of DVT as part of the PICS admission process, and the system then gives advice that in some cases includes the use of prophylactic drugs. Where such advice does not appear to have been followed 24 hours later, the system will query this apparent omission. We have been looking again at the prescribing of enoxaparin on PICS in relation to the recommendations from the thrombosis screen and in particular at whether the introduction of the reminder on the day after admission has had any effect. The reminder was introduced on 25th March and so we have compared the periods 01/12/08-25/03/09 and 26/03/09-24/05/09. Where enoxaparin was recommended: a) the proportion of surgical cases where enoxaparin was prescribed has risen from 68% in the first period to 72% in the second b) the proportion of non-surgical cases where enoxaparin was prescribed has risen from 57% in the first period to 71% in the second Reminder led to a 4% increase in prescriptions for surgical patients, 14% increase for medical patients

18 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 18

19 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! 19

20 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 distribution Ad-hoc reports (clinical audits) Modelling impact of proposed changes

21

22 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

23 The Execs Review

24 Trend in Missed Doses – April 2008 – July 2010

25 Stock Look up in PICS

26

27 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

28 Presentation Outline The system System functionality Benefits
Ongoing work

29 Ongoing Work Increased use of data – for example DDDs for antibiotics
NPSA warfarin requirements Counselling Monitoring Rx verification Renal injury

30 447 patients who had NSAID and  2 creatinine measurements
Overall Mean LOS = 20.9 days Rise > 50% Rise to > 150 38 19 13 Mean LOS = 27.5 days Mean LOS = 34.0 days Mean LOS = 31.3 days

31 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

32 Ongoing Work System being marketed - CSE Ongoing benchmarking
UK specific functionality UK specific rules and policy interpretation Ongoing benchmarking Cleveland clinic Other English Trusts with systems Research to demonstrate benefits

33 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


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