Why is ePA important?
Medicines are one of the highest causes of preventable adverse events (events resulting in harm to patients). International research suggests that across the health sector, approximately 50% of medication harm occurs during prescribing, 40% during administration, and 10% during dispensing and distribution. The Institute of Healthcare Improvement recommends automation and computerisation as one of the most effective tools for preventing medication errors.
ePA offers significant benefits over paper-based prescribing and administration, for example:
- prescriptions are easier to read
- errors made when prescribers chart medications are reduced
- time spent finding medication charts is eliminated
- much easier access to important safety information such as allergies, warnings when dose ranges are exceeded, and warnings about drug interactions
Our ePA team’s goal was to run the most successful ePA pilot implementation in New Zealand, and use the experience to begin a full-scale roll-out into the remaining beds across our organisation.
- The Institute of Healthcare Improvement (IHI) is an independent not-for-proffit organisation based in Cambridge, Massachusssets, USA. It is a leading innovator in health and health care improvement worldwide - www.ihi.org
What have we done?
Led by one of our expert pharmacists, David Ryan, the implementation of ePA began with meticulous planning. The ePA team recognised early on that one of the commonest mistakes made in implementing ePA is treating it as an information technology (IT) project. In fact, implementing ePA involves approximately 90% change management and 10% IT.
The ePA team knew from previous experience that the most significant challenge is getting buy-in from the clinical staff – they are very busy and do not need something that would slow their work day down and be difficult to use. To get this buy-in, the ePA team identified and clearly communicated to each critical professional group the benefits of ePA that the ePA team felt would ‘tip the balance’ in favour of ePA. Many of these innovative solutions were developed in-house by our ePA team.
Wins for the Doctors
- Mobile computing so access to important information such as laboratory results, x-ray images, clinic letters, discharge summaries, and the electronic medication chart is available anywhere on the ward, including at the bedside during ward rounds.
- ‘Quick-lists’ or preset orders – e.g. ‘Metoprolol CR 47.5mg tablets; dose: 1 tablet daily in the morning at 8:00am’. These quick-lists significantly reduce the time required to prescribe, while also providing guidance on the usual dose-range of the medication.
- Allowing on-call doctors to prescribe from anywhere in the hospital rather than having to walk the considerable distance to the wards to prescribe a patient’s medication or fluids after hours.
- Tailoring the ‘decision support’ to the minimum safe amounts so doctors are not plagued by screen after screen of warnings that are not relevant to the current situation. This has been one of the consistent criticisms of electronic prescribing implementations throughout the literature.
Wins for the Nurses
- An interface between the electronic prescribing system and the pharmacy, removing the need for nursing staff to fax all pages of the medication chart to pharmacy each time a medicine is changed, or something needs to be dispensed as it is not available in the Pyxis machine.
- Useful information from reference sources such as 'Notes on Injectable Drugs' so nursing staff don’t need to locate and look up the paper reference book for each administration
Implementing a 42” LED TV screen on each ward that displays each patient on the ward along with any doses of medication that are due. This removes the age-old problem where a doctor prescribes a new medication but does not communicate this, and the nurse only realises many hours later.
- Ensuring all of the computer applications nurses need to access throughout the day are available on the mobile 'Computers on Wheels' (COWs) – in particular the nursing acuity system where they record their patient updates for handover.
Wins for the Pharmacy
- An interface developed in-house that alerts the dispensary when medications are prescribed, changed or ceased, and that allows nursing staff to electronically request a medication when it is not stocked in the Pyxis machine. This significantly reduces duplication of work in the pharmacy as well as resulting in a large reduction in the number of phone calls related to the supply of medication.
- Configuring the electronic prescribing system to automatically add many of the standard annotations to the medicine chart that are currently hand-written by clinical pharmacists – e.g. ‘Take with food’, or ‘Do not crush’. As they are also added as soon as the medicine is prescribed, the warning / advice is available immediately as opposed to when the pharmacist next sees the chart.
- The ability for clinical pharmacists to instantly see which medications have changed, thereby removing the requirement for them to physically review every patient’s medicine chart every day.
- The ability for pharmacy staff to view what has been prescribed and administered in the dispensary when they are clinically reviewing medicine charts for profiling and validation onto the Pyxis system.
Our ePA team knew that other critical success factors included the availability of computers and mobile devices, the reliability and coverage of the wireless network, and the ‘fit’ of the system compared with current practice. They put a huge amount of effort into ensuring the workflow of the electronic system matched the requirements of the clinical staff.
The ePA team ran an extremely rapid, well executed project to implement electronic prescribing into 60 beds in two older adult wards, with approximately three months of preparation and a three week go-live period.
Given the goal was to build the experience to allow us to rapidly roll-out to the other wards and departments following the pilot, the ePA team spent considerable time training up six nurses so they were able to provide ongoing support after the go-live period rather than relying on the IT vendor’s training resource.
The ePA team put a huge amount of effort into training and support, and also in developing resources that staff could access quickly and easily via an intranet site. They produced a set of ‘how to’ guides, for example; ‘How to prescribe fluids’, ‘How to prescribe warfarin’, ‘How to prescribe a syringe driver’. The feedback from doctors and nurses has been overwhelmingly positive and we are sharing these guides with other DHBs who are planning to implement electronic prescribing.
Examples of ePA training and support documents developed
The biggest difficulties the ePA team needed to overcome were shortcomings in the design of the software. Waiting for the vendor to re-develop the areas of the software that didn’t meet the needs of the clinical staff would have delayed the project indefinitely, so the ePA team worked collaboratively with the doctors, nurses and pharmacy staff, developing innovative solutions including our own in-house software.
One valuable innovation developed by the ePA team is a medication interaction alert system. Certain medications interact and should not be prescribed at the same time or require extra monitoring. But if an ePA system has too many interaction alerts, clinicians get ‘alert fatigue’ – they skip or ignore warnings because they are frequently irrelevant. The default interaction alert system for the ePA software came from MIMS (a national medication information publication) but this results in too many interactions and alert fatigue.
The ePA team created an interactions checker system using another national publication, the NZ Formulary, and feedback from prescribers is that they think the level of alerting is ‘about right’. This is a major step forward for patient safety and is a unique innovation.
Did we make a difference?
The ePrescribing implementation was an outstanding success in a field where previous attempts both in New Zealand and overseas have been fraught with difficulty. All 60 patients on the two older adult wards were transitioned onto the electronic prescribing system over a two week period, something that has not been done successfully on this scale in New Zealand before. The critical success factors that the ePA identified prior to implementation provided the incentive necessary to win support from the clinical staff.
The system has made a substantial contribution to medication safety, and has led to improved efficiency and clinical effective care, for example:
- 100% of prescriptions are legible and the individual prescriber can be identified
- transcribing errors have reduced due to paper medication charts no longer needing recharting when they are full
- nursing staff no longer have to constantly fax medication charts to pharmacy and the percentage of medicines removed from the Pyxis machines on ‘override’ (without a clinical pharmacist check) has reduced from an average of 25% to 10%
- the considerable time and energy spent developing ‘quick lists’ has paid off with 82% of the 11,000 prescriptions being written using the quick list pre-defined orders in the first five months since go-live
- all medicines, blood products, intravenous fluids, oxygen, and special foods are prescribed on the electronic chart, ensuring there is an efficient single system in which clinicians prescribe and administer medicines
- all clinical systems can now be viewed at the patient’s bedside so that staff no longer have to return to the nursing station or doctors’ office to retrieve information
- nursing staff have unrestricted access to computers particularly at the patient’s bedside with immediate access to reference material for information such as administering infusions
- an improved allergy alert system with allergies having to be entered only once against a substance. If a user attempts to prescribe a medicine that a patient has a documented allergy to, the system automatically warns and requires the user to enter in a reason if they attempt to override the warning. In the paper-based system, patients were frequently administered medication that they had a documented allergy to because the system was reliant on a clinician double-checking the allergy box on the medication chart every time they were administering a medicine. Given that approximately 4.7 million doses of medication are administered each year at Waitemata DHB hospitals alone, the scope for error is high
The feedback from the consultants, registrars and house officers has been positive, despite the huge change that goes with learning to use a new system while continuing to provide care to patients without any additional resource.
Where to from here?
Following the very successful ePA implementation project, the senior leadership team and the Board approved funding for a second stage roll-out to an additional 330 beds. Our long-term vision is for ePA to be available across the DHB. Currently the ePA system now covers more than 200 beds at the DHB, with the number set to rise further next year with the planned introduction to six more wards at North Shore Hospital. The roll-out makes Waitemata the first DHB with such an extensive plan for ePA expansion.