Beyond EPMA: harnessing the benefits of information

Niall Poole presenting at HC2008Electronic Prescribing and Medicines Administration (EPMA) is a safety system. The mandating of approved drug names and complete, legible and unambiguous prescriptions has been shown in some studies to reduce medication errors by around 60%(1)…but is that enough?

The cost of EPMA is not insignificant, nor is the far reaching culture change it brings to doctors, nurses, pharmacists and other healthcare professionals. Will everyone sign up to its safety agenda alone, or does EPMA need to do more to win over the staff who use it?

Trusts should consider the added value that can be achieved by unlocking some of EPMA’s full potential. Some of this is achieved by consultation with the software house and with other Trusts using the system, to ensure the direction of development supports the Trust’s goals. However, further potential can be achieved by having access to the wealth of data on your patients which is now being stored.

The Heart of England NHS Foundation Trust (HoEFT) uses JAC Computer systems EPMA software. It is one of a number of NHS sites that meet regularly with JAC to discuss and assist the development of the software. JAC’s EPMA also allows each Trust to access their data with appropriate reporting tools and generate their own reports from it.

EPMA data can be used as powerful auditing tool. Much data that could not be either practically recorded or easily collated and analysed is recorded automatically from the existence of a particular prescription (e.g. are all my patients prescribed thromboprophylaxis?) to a detailed log of prescribing and administration actions. 

Fig 1: Handwritten prescriptionFig.1: Handwritten prescription

Consider the prescription in figure 1. What time was it given? 6pm?

The signature in the box doesn’t necessarily mean the dose was given at 6pm, it may have been early or late. What time was the prescription written; was it even possible for the nurse to give the first dose on time? EPMA records the time of a ‘signature’ automatically, giving a more accurate indication of prescription and administration time.

Using this information a report can tell you whether the first doses of antibiotics being given promptly.Combine this with information from a HISS or PAS system and it’s possible to answer the following:

  • What is the delay from a positive MRSA result to appropriate treatment being prescribed and given?

  • Are low molecular weight heparins being given at an appropriate time prior to surgery?

These questions cannot be easily answered with paper systems; doctors and nurses would need to be observed or record additional information which would need to be collated later. This could lead to either smaller audit numbers, loss of data quality or observer bias, indeed some audits might not be attempted because of the man hours required.

When a new audit question is raised, you often want to know what has happened already; because EPMA retains information for every prescription and administration, you can accurately apply your new audit criteria retrospectively.

A retrospective audit will help Trusts identify issues and improve practice in future, but it doesn’t necessarily help the current patients. Because audit data from EPMA can be generated almost instantaneously it can also be used prospectively. HoEFT have developed web based reporting tools for clinicians, particularly for ward pharmacists and microbiologists, although the principles could be extended further in the future.

Pharmacists' ward page view

Fig. 2: Pharmacists’ ward page view

Pharmacists logging on to their ward page (Figure 2) can see which patients have:

  • To take out (TTO) medication for discharge prescribed

  • Intravenous antibiotic of over 48 hour duration

  • New or changed prescriptions requiring pharmacist checking

  •  Drugs usually requiring blood levels

  • Discontinued prescriptions or missed doses in the last 24 hours

  • Outstanding pharmacy interventions

This information could not be collated every morning from paper systems in time for a pharmacist’s ward visit. The page also provides quick access to the patients’ EPMA records, lab results and the Trust’s electronic patient record (EPR) system.

Microbiologists can review current antibiotic prescriptions and histories from a web page. Alerts are included for specific antibiotics and long durations and in future this will expand to highlight multiple drug regimens and combinations considered to be inappropriate.

There is still much work to do in HoEFT to fully integrate EPMA with the other electronic systems and achieve the full potential from the patient data that is currently stored. The next step may be to extract data from multiple systems, filter it and present it in a web page where a clinician could, for example, compare discrepancies in a patient’s current antibiotic prescription with their most recent cultures and sensitivity results.

True integration will only come, however, when suitable interfaces are developed that allow patient data outside of the EPMA system to integrate with the current drug interaction based decision support e.g. warning if prescription is written for vancomycin for a patient with poor renal function. Reciprocally, an interface that allows systems outside of EPMA a mechanism of proposing appropriate treatment without the clinician having to re-key the drug into the EPMA system e.g. an appropriate antibiotic based on microbiology results or a treatment protocol from a care pathway.

There isn’t a computer algorithm for everything! It is important that a boundary between assistance and clinical judgment is maintained which allows clinicians the flexibility to make professional decisions; but, by intelligently collating data from relevant patient information systems and presenting it in one place to clinicians, IT can make it easier for clinicians to do the right thing.

Niall Poole MRPharmS

Electronic Prescribing Project Manager
The Heart of England NHS Foundation Trust

This article was presented by Niall Poole at the 2008 Healthcare Computing conference.


About the author

Niall Poole qualified from Bradford University in 1996 and following several years as a community locum, completed his clinical diploma at Derby Royal Infirmary before moving to Birmingham.

Niall has been the Electronic Prescribing Project Manager for the Heart of England NHS Foundation Trust in Birmingham since August 2002. In that time 5 surgical wards and associated theatres have gone live. With the continued support of the Trust the system is now being rolled out trust-wide.

References

1. Tatayana A. Shamliyan, Sue Duval, Jing Du, Robert L. Kane: Just What the doctor ordered. Review of the evidence of the impact of Computerised Physician Order Entry system on medication errors. Health Services Research doi:10.1111/j.1475-6773.2007.00751.x

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