The main aim of Electronic Prescribing and Medicines Administration (EPMA) systems is to improve patient safety by reducing prescribing and administration errors that could result in medication errors and adverse drug events.
At its simplest level, E-prescribing can be defined as “the utilisation of electronic systems to facilitate and enhance the communication of a prescription or medicine order, aiding the choice, administration and supply of a medicine through information and decision support and providing a robust audit trail for the entire medicines use process”.
E-prescribing has been identified by Connecting for Health as a core service for all Trusts in England and, in Scotland, the NHS is now considering a national approach to hospital E-prescribing and medicines administration.
EPMA also facilitates wider improvements in clinical practise: reductions in paperwork and transcriptions; improved audit trails for medication; performance monitoring and intelligence; reporting for PbR; greater consistency and continuity of care between primary and secondary care settings; and more enhanced communication between hospital departments and pharmacies.
EPMA system functionality includes
- Capture of patient demographics, including:
- Information collected during admission, discharge, transfers and pre-admission
- Allergy information for clinical checking
- Height and weight
- Inpatient prescribing, including:
- Prescribing of individual drugs
- Protocol prescribing
- Changing the prescription
- Re-prescribing of previous treatments
- Clinical pharmacist verification
- Prescribing for outpatients
- Decision support using the Multilex Drug Data File provided by First Databank
- Nurse administration
- Discharge prescribing with discharge letter
- Short-term leave prescribing
- Formulary management
- Clinical notes
- Integration with pharmacy management system
- A reduction in the risk of medication errors.
- Accurate and up-to-date locally defined drug databases.
- Access to clinical decision support and medicines information aiding the choice of medicines, with alerts such as duplications, drug-drug interactions, etc.
- Patient-specific alerts such as overdose warnings and allergy alerts.
- Fully legible prescriptions.
- Alerts for contra-indications, allergic reactions and drug interactions.
- Guidance for inexperienced prescribers.
- Discharge prescriptions.
- Computerised entry and management of prescriptions.
- Computerised communication between hospital wards/departments and pharmacies.
- Improvements in existing work processes.
- A robust audit trail for the entire medicines process.
- Reduction in paper-based process problems.
JAC offer several options with relation to E-prescribing, and our clients are moving forward with the JAC system in a variety of ways. The options are outlined in brief as follows:
Full Inpatient Prescribing with Nurse Administration
This also incorporates functionality to support Discharge Prescribing and short-term leave.
This is a sub-set of the full solution, which supports the generation of a discharge prescription and interim discharge letter.
Functionality to produce an outpatient prescription, either as an FP10, or as a locally defined prescription for dispensing within the Trust/Hospital.
The Medicines Management module is designed to support pharmacy staff on the wards, and will allow the patient prescription profile to be entered and maintained throughout the inpatient admission.
All of the above options fully integrate with the pharmacy stock control module. As medicines are prescribed the system will immediately request supplies of non-stock, discharge, short-term leave and outpatient prescriptions. Prescriptions can be dispensed without transcription, reducing errors, and allowing workload to be prioritised.
Sites which deploy electronic prescribing in an inpatient environment will have an Admissions, Discharge and Transfer (ADT) interface running from the Trust PAS system. This is an enhancement on the demographic feed that supplies the pharmacy stock control module.
Recently JAC have developed and deployed an interface which allows discharge information to be sent outbound to a 3rd party system. Sites which have deployed this interface are able to meet Trust requirements to provide information electronically to GPs in a timely and legible manner.
Full EPMA supports the prescribing of medicines for the inpatient admission, with subsequent administration. A variety of functions are provided to support the entry and maintenance of the inpatient prescription.
Patient demographics are stored and updated automatically to support the retrieval of current and historic medication information as well as to aid clinical decision support. The JAC system also gathers detailed allergy, height and weight information during inpatient admission.
The demographic information is typically received from the Trust PAS or 3rd party system as a specified sub-set via an inbound, HL7 interface feed.
This information is immediately available when the prescriber accesses the patient record and provides further prescriber support through functionality such as dosage calculators and clinical checking of medicines selected.
Elective patients with a future admission date can also be received into the system in a pre-admission environment. This environment supports the entry of patient prescriptions in advance.
The system will then automatically schedule the prescription (subject to review based on local policies) when the patient is admitted on the appropriate date.
Prescribing of individual medicines
The prescriber will choose the medicine that they wish to prescribe from a locally defined catalogue that will reflect the hospital formulary.
Once a medicine is selected, the prescriber will be presented with a variety of default information for the drug, i.e. route, dose, and frequency of administration. Any of the defaults can be changed, as well as further information added where required.
The default information presented for any drug is locally defined. In many cases the default options allow the drug to be prescribed without any changes, requiring a single key press to confirm the request.
Prescribing of “as required” or PRN drugs such as pain relief are supported, with text boxes to indicate reasons for administration which will support nursing staff. The prescribing of once-only orders or STAT medications are also supported, with the ability to record administration immediately, or in the future.
Other notes can be added at the point of prescribing relating to a product prescribed for a patient which can be set to display in various points of the prescribing and administration processes.
It is possible to link a once-only order with a regular ongoing prescription such that a dose is given now, and the order is scheduled to continue in the future.
Treatment courses are fully supported in terms of the number of days or doses that the prescription will be active. Default information can be presented for products such as antibiotics, and the system further supports this through the optional definition of linking stop dates to indications.
Prescribing of order sets
The prescribing of order sets allows locally defined treatment protocols to be defined, e.g. Helicobacter eradication. An order set includes all of the required drugs together with information such as pre-defined dosages, administration frequencies, and duration of therapy.
When a prescriber selects an order set, they are able to modify for the patient if required, however typically the order set is constructed such that a single key press will confirm the request.
Changing the prescription
A variety of functions are provided to support the ongoing changes required to the patient prescription. The system supports modification, discontinuation, suspension and resumption of any and all items prescribed for the patient.
Re-prescribing of previous treatment
Treatment that has been stopped within the current admission may be re-initiated. This functionality is further extended to allow prescriptions from a previous admission to be renewed for the current admission. Any previous episode of care can be reviewed from the main patient profile.
Clinical pharmacist verification
Clinical pharmacist verification is a function for pharmacists to clinically check a prescription. The verification process changes the status of the prescription and this information is clearly displayed to all users of the system, regardless of the function in which they deal with the patient.
Verification provides clarity for nursing staff that the prescription has been clinically reviewed. Within the pharmacy module, verification releases the prescription to be dispensed.
Any prescription generated by a doctor is treated as unverified. Standard reports are provided for pharmacists to identify changes to patient prescriptions on the wards without having to be physically present on the ward.
The verification process includes functionality to support medicines management. This allows information such as whether the patient was admitted on the medicine, have their own supply, and whether they are self administering to be recorded.
The system incorporates an outpatient module which supports the generation of an outpatient prescription that is made available within the pharmacy department upon completion.
The outpatient prescription is dispensed by pharmacy following pharmacist clinical verification.
Clinical decision support
Drug interaction checking, therapeutic duplicate checking, allergy checking and drug monographs functionality is available and supported using the Multilex drug knowledge base provided by First Databank. This decision support is provided at the point of prescribing.
For example, where a drug is prescribed to which the patient has been marked as potentially allergic, the system will provide an alert to the prescriber. The prescriber will be given the option to continue providing they enter a reason defined by the Trust, or they may cancel and choose an alternative product.
Drugs prescribed which may interact or duplicate with drugs previously prescribed that are still active on the prescription will also display an alert. For these types of alert the prescriber may choose to discontinue a drug which conflicts in addition to the options of giving a reason for continuing to prescribe and/or cancelling the prescription.
All actions taken by prescribers relating to decision support are logged for clinical review.
The system is designed to facilitate the recording of administrations of medicine, at the patient bedside.
Whenever the administration functionality is accessed, the system will display the medicines due for the patient based on the current date and time.
Medicines are recorded as given by entering the date and time. This can be achieved by a simple double click on the relevant field. Where administrations are not given, a drop down list is available to select from a choice of Trust defined reasons for non-administration.
Reasons for non-administration can be linked to routes of administration to simplify the process of recording information for a number of medicines, e.g. if the patient is nil by mouth, all Oral medicines can be flagged in a single action.
Access to clinical monographs and the ability to add notes to the patient record are both features of the administration process.
Standard administration functionality is supplemented with the ability to define medicines where the administration requires witnessing by another nurse. Where witnessing requirements exists, an authorised user will be required to enter acknowledgment that the administration was observed through entry of their username details into the system. Typically this might occur in the paediatric environment.
Support for patients who are self administering is also provided. Those medicines which the patient is self administering are highlighted for nursing staff.
Information available from within the main administration window identifies when doses of medications were last administered, the date and time of the last dose, and who recorded the administration.
This information is provided for the entire admission, in addition to a report which is available to review the last 24 hours’ administrations. All information relating to administration is accessible from a single window.
The system supports the generation of an interim discharge letter incorporating the active medicines profile for the patient, and drugs required for dispensing at discharge.
The discharge function offers the prescriber an intuitive and simple way to choose medicines for the patient to take home in addition to dictating the quantity to supply, and indicate whether the GP should continue treatment.
Any medicines upon admission that have changed or been stopped within the admission will be automatically added to the Discharge Letter with the reasons for change.
The Discharge Letter also provides a mechanism to enter further information about the patient. Doctors, Nurses, and Pharmacists all have relevant sections which can be populated with information.
As the discharge letter is completed on the ward, any medicines that require dispensing are automatically made available within the dispensing module and scheduled based on an indicated urgency. The scheduling of dispensing requirements allows pharmacy to better manage service delivery. The prescription is dispensed following clinical verification by a Pharmacist.
In addition to the discharge prescribing functionality, a prescription may be created for a patient who is leaving the hospital for a short period of time. This functionality is known as short-term leave.
When a short-term leave prescription is generated, the prescriber will enter the anticipated date and time that the patient will both leave and return to the hospital. When the medicines are selected for the prescription, the system will calculate the supplies required for the time period that the patient will be on leave.
As the short-term leave prescription is completed on the ward, any medicines that require dispensing are automatically made available within the dispensing module and scheduled based on an indicated urgency.
When the patient leaves the ward, nursing staff mark the patient on leave, and this suspends all inpatient prescriptions and marks all doses due for administration with information that the patient is on leave. When the patient returns to the hospital all inpatient prescriptions are re-activated.
Formulary management and control
Promotion of the drug formulary is an important consideration for any Trust. The system provides comprehensive functionality which allows the Trust to implement the formulary at a variety of levels. Formulary can be managed at Directorate, Specialty, Grade and individual prescriber levels.
Where a prescriber selects a product which is non-formulary, an alert will be displayed and the prescriber will have the choice of continuing with a reason, or selecting a formulary alternative. If the prescriber selects a formulary alternative, the System will present a list of alternatives that are kept within the Trust.
Within both prescribing and administration functions, clinical notes may be added, modified, discontinued and/or viewed. Clinical notes may be added to the patient or to the drugs that have been prescribed.
Notes are grouped into categories defined by the Trust. Some of the categories have an impact elsewhere within the application, for example notes can be added to appear within the administration process.
Whenever clinical notes have been associated with a patient, they are displayed upon patient selection. Clinical notes are highlighted in different colours to represent whether a user has previously seen the information being displayed.
All notes are date and time stamped with the user who added the information. Notes can be set with discontinue dates whereby they will be suppressed, but may still be viewed upon request. Notes that are associated with drugs on the patient prescription can automatically be set to be suppressed when the prescription stops.
Integration with pharmacy management system
The electronic prescribing module is fully integrated with the pharmacy management system.
Any prescribed items that are non-stock, or required on discharge, short-term leave or outpatient prescriptions will be immediately available for dispensing within the pharmacy system. This integration allows the pharmacy to be better positioned to meet the needs of the hospital with regards to medicines supply.
The integration with the pharmacy module also eliminates prescription transcription, reducing the potential for errors in the dispensing process, as well as simplifying the process through the automated pass through of information that would otherwise have to be manually entered.