Health Informatics (formerly Computers in Health Care) Kathryn J. Hannah Marion J. Ball Series Editors For other titles published in this series, go to www.springer.com/series/1114 0000774976.INDD i0000774976.INDD i 7/11/2008 4:17:04 PM7/11/2008 4:17:04 PM Stephen Goundrey-Smith Principles of Electronic Prescribing 0000774976.INDD iii0000774976.INDD iii 7/11/2008 4:17:04 PM7/11/2008 4:17:04 PM Stephen Goundrey-Smith, MSc, Cert Clin Pharm, MRPharmS Pharmaceutical Informatics Specialist SGS PharmaSolutions Banbury Oxfordshire UK ISBN 978-1-84800-234-0 e-ISBN 978-1-84800-235-7 DOI: 10.1007/978-1-84800-235-7 British Library Cataloguing in Publication Data Goundrey-Smith, Stephen Principles of electronic prescribing. - (Health informatics) 1. Drugs - Prescribing - Data processing I. Title 615.1¢4¢0285 Library of Congress Control Number: 2008928766 © Springer-Verlag London Limited 2008 Apart from any fair dealing for the purposes of research or private study, or criticism or review, as permitted under the Copyright, Designs and Patents Act 1988, this publication may only be reproduced, stored or transmitted, in any form or by any means, with the prior permission in writing of the publishers, or in the case of reprographic reproduction in accordance with the terms of licences issued by the Copyright Licensing Agency. Enquiries concerning reproduction outside those terms should be sent to the publishers. The use of registered names, trademarks, etc. in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant laws and regulations and therefore free for general use. Product liability: The publisher can give no guarantee for information about drug dosage and application thereof contained in this book. In every individual case the respective user must check its accuracy by consulting other pharmaceutical literature. Printed on acid-free paper Springer Science + Business Media springer.com Series Editors Kathryn J. Hannah Adjunct Professor, Department of Community Health Science Faculty of Medicine The University of Calgary Calgary, Alberta T2N 4N1, Canada Marion J. Ball, Ed.D Fellow, Center for Healthcare Management IBM Research Professor Emerita, Johns Hopkins University School of Nursing 7506 Coley Court Baltimore Maryland 21210 USA 0000774976.INDD iv0000774976.INDD iv 7/11/2008 4:17:05 PM7/11/2008 4:17:05 PM Series Preface This series is directed to healthcare professionals who are leading the transformation of health care by using information and knowledge to advance the quality of patient care. Launched in 1988 as Computers in Health Care, the series offers a broad range of titles: some are addressed to specific professions such as nursing, medicine, and health administration; others to special areas of practice such as trauma and radiology. Still other books in the series focus on interdisciplinary issues, such as the computer- based patient record, electronic health records, and networked healthcare systems. Renamed Health Informatics in 1998 to reflect the rapid evolution in the disci- pline now known as health informatics, the series continues to add titles that con- tribute to the evolution of the field. In the series, eminent experts, serving as editors or authors, offer their accounts of innovation in health informatics. Increasingly, these accounts go beyond hardware and software to address the role of information in influencing the transformation of healthcare delivery systems around the world. The series also increasingly focuses on “peopleware” and the organisational, behavioural, and societal changes that accompany the diffusion of information technology in health services environments. These changes will shape health services in the new millennium. By making full and creative use of the technology to tame data and to transform information, health informatics will foster the development of the knowledge age in health care. As coeditors, we pledge to support our professional colleagues and the series readers as they share the advances in the emerging and exciting field of health informatics. Kathryn J. Hannah Marion J. Ball v 0000774976.INDD v0000774976.INDD v 7/11/2008 4:17:05 PM7/11/2008 4:17:05 PM Preface The purpose of this book is to provide electronic prescribing (EP) systems imple- menters with an overview of the clinical and professional issues involved with the use of EP systems, and a discussion of the key systems design principles involved. The book does not assume any detailed clinical or IT knowledge on the part of the reader; as such, it provides general guidance on possible applications of EP sys- tems. However, the book should not be used a substitute for detailed analysis of a specific EP system by analysts with appropriate domain expertise within a health- care setting; the author accepts no liability for issues arising from the use of the book inappropriately in this way. This book is the result of several years of reflection and work in the area of electronic prescribing and medicines management. It represents a major project for me, as a pharmacist, a health informatician and as a writer. However, in my experi- ence, major undertakings such as this are rarely the sole work of one person. I would therefore like to make a number of acknowledgements, and to thank a number of people whose assistance and support has been invaluable in the produc- tion of this book. I would like to thank those hospital staff who were willing to be interviewed and to share their experiences of electronic medicines management with me: ● Pete MacGuinness, Senior Clinical Pharmacist at the Shrewsbury and Telford NHS Trust. ● Damien Kelly and Joyce Bould at the Royal Hampshire County Hospital, at Winchester. I am also grateful to those who were of assistance during the course of writing this book: ● Hillary Judd, Polly Shepherdson and colleagues from First Databank Europe Ltd, for their input in the area of data support for electronic prescribing. ● Julie Randall from the Hull & East Yorkshire NHS Trust for her assistance and advice concerning drug charts. ● Eric Smith for his work on illustrations. ● Eddie Smith for his comments concerning pathology systems. ● Grant Weston and colleagues at Springer Verlag for their editorial support. vii 0000774976.INDD vii0000774976.INDD vii 7/11/2008 4:17:05 PM7/11/2008 4:17:05 PM viii Preface I am especially indebted, however, to those people with whom I have worked most closely on electronic prescribing, pharmacy and medicines management projects over the past five years. In a sense, my expertise reflects theirs. They are (in no particular order): George Brown, Tom Bolitho, Clive Spindley, Tim Botten, Sue Braithwaite, Julie Randall and Raghu Kumar. I would also like to thank my wife, Sandra, and my children, Edward and Archie, for their patience and support during the writing of this book. Stephen Goundrey-Smith Charlton, Banbury, Oxfordshire January 2008 0000774976.INDD Sec1:viii0000774976.INDD Sec1:viii 7/11/2008 4:17:05 PM7/11/2008 4:17:05 PM Contents Series Preface v Preface vii 1 Philosophical and Social Framework of Electronic Medicines Management 1 Introduction 1 Defi nitions and Terminology 3 The Benefi ts of Automated Systems 5 EP and the Individual 7 EP and the Organisation 10 EP and the State 12 Legal Requirements for EP Systems 15 EP Systems and Professional Liability 16 Confi dentiality and Consent 17 Ethical Issues 18 Conclusion 19 Notes and References 19 2 History and Context of Electronic Prescribing in the US and UK 21 The Development of Information Technology in Healthcare 21 Development of EP Systems in the United States 23 Development of EP Systems in the United Kingdom 25 Case Study 2.1 26 The Winchester & Eastleigh NHS Trust 26 Case Study 2.2 30 Shrewsbury & Telford NHS Trust 30 Development of EP Systems: A European Perspective 32 Integration of EP Systems with Pharmacy Systems 32 Development of Medicines Information Services and Their Integration with EP Systems 34 ix 0000774976.INDD Sec1:ix0000774976.INDD Sec1:ix 7/11/2008 4:17:05 PM7/11/2008 4:17:05 PM x Contents EP Systems and Oncology Systems 35 The Development of Consolidated Electronic Medicines Management Systems in Hospitals 36 Barriers to Implementation of EP Systems 36 Conclusion 39 Notes and References 39 3 Organisation Benefi ts of Electronic Prescribing 41 Principles of Business Process Redesign 41 Medicines Management in Hospitals: Existing Business Processes 44 Organisational Benefi ts of EP 47 Workfl ow Management for Clinical users of EP Systems 48 Prescribing Workfl ow Design 48 Medicines Administration Workfl ow Design 50 Facilitation of a Seamless Pharmaceutical Supply Chain 52 Reduced Use of Paper and Consumables 54 Clinical System Intraoperability 54 Improvement in Hospital Business Processes due to Electronic Dissemination of Prescriptions 55 Contribution of Workfl ow Improvement to Professional Practice Development 56 Conclusion 57 Notes and References 57 4 EP Systems as a Risk Management Tool 59 Principles of Risk Management in Therapeutics 59 Reduction in Medication Error Rates With EP Systems: Experience From US Implementations 63 Reduction in Medication Error Rates With EP Systems: Experience From UK Implementations 65 Increases in Medication Errors Due To the Introduction of EP Systems 69 Reduction of Medication Errors Due To the Availability of Electronic Decision Support Tools At the Point of Prescribing 70 Problems With Evaluating Risk Reduction Aspects of EP Systems 74 Conclusion 75 Notes and References 75 5 Data Support for Electronic Medicines Management 77 Coding Systems for EP Concepts 78 The Development of Medicines Information Reference Sources 82 Sources of Drug Databases, and Their Implementation Within EP Systems 84 0000774976.INDD Sec2:x0000774976.INDD Sec2:x 7/11/2008 4:17:05 PM7/11/2008 4:17:05 PM Contents xi Requirements of Drug Databases for Supporting EP Systems 86 Medicine Nomenclature 87 Synonyms 88 Product Mapping 88 Pharmaceutical Forms 88 Routes of Administration 89 Dose Information Management 89 Admixtures 90 Non-indexed Products 90 Data for Decision Support Tools 91 Legal Issues with EP Data 93 Conclusion 93 References 94 6 Electronic Medicines Management: Support for Professional Practice 95 Modernisation of Healthcare Working Practices 95 EP Systems: Support for Professional Practice 97 Audit Logs in EP Systems 101 Use of EP Systems for Clinical Audit 102 EP Systems and Patient-Centred Medicines Reviews 105 Involvement of EP Systems in Clinical Research 108 EP Systems: Support for Continuing Professional Development (CPD) 109 Integrated Care Pathways and Clinical Guidelines 111 EP Systems: A Gateway to Medicines Information Reference Sources 111 Conclusion 112 References 113 7 Electronic Medicines Management and Non-medical Prescribing 115 Background to Non-medical Prescribing 115 Experience of Non-medical Prescribing 117 Benefi ts and Risks of Non-medical Prescribing 117 Patient Safety 118 Training of Non-medical Prescribers 118 Clinical Governance 119 Role of EP Systems in the Management and Support of Non-medical Prescriber-Led Services 119 EP Systems and Role-Based Access (RBAC) 120 Records Management and Multi-user Systems 121 Workfl ow for Different Prescriber Types 123 Prescribing Permissions 123 Structured Prescribing and Care Plans 124 Specialist Formularies 124 0000774976.INDD Sec3:xi0000774976.INDD Sec3:xi 7/11/2008 4:17:05 PM7/11/2008 4:17:05 PM xii Contents Information Support for Different Non-medical Prescriber Types 125 Support for Patient Group Directions (PGDs) 126 Support for Training and CPD for Non-medical Prescribers 127 Adverse Drug Event (ADE) Reporting 128 Non-medical Prescribing: Management and Clinical Governance 130 Conclusion 131 References 131 8 Electronic Prescribing and Future Priorities 133 The Challenge of Device Integration 133 Hardware Platforms and Infrastructure 137 Assistive Technology 139 Identifi cation and Communications Technologies 143 Issues and Limitations with Quantitative Research on EP Systems 145 Political Issues with EP 146 Notes and References 148 Conclusion 148 Appendix Worldwide Experience of Hospital Electronic Prescribing 151 Index 153 0000774976.INDD Sec4:xii0000774976.INDD Sec4:xii 7/11/2008 4:17:05 PM7/11/2008 4:17:05 PM [...]... Framework of Electronic Medicines Management A review of experience of EP applications in the UK8 has demonstrated that EP implementations have resulted in the following benefits: • Availability of a fully electronic prescribing history • Improvement in legibility and completeness of prescriptions • Improvement of hospital business processes due to electronic dissemination of prescriptions • Availability of. .. requirements of the UK data protection legislation Ethical Issues As EP systems will be operated by healthcare professionals, the ethical principles followed by healthcare professionals (which are made explicit in the codes of ethics published by professional bodies) are of significance when considering the use of EP systems It is well established in many legal systems that a health professional has a “duty of. .. an indiscriminate manner A recent UK definition of electronic prescribing is as follows: 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 0000774968.INDD Sec8:3 7/11/2008 3:35:01 PM 4 1 Philosophical and Social Framework of Electronic Medicines Management through knowledge... prescriptions • Availability of electronic decision support tools at the point of prescribing • Comprehensive audit trail of prescribing decisions made • Reduction in the rate of medication errors Some of these benefits have also been reflected in the major quantitative studies of systems in the US These benefits will be discussed in detail in subsequent chapters The benefits of EP systems are far-reaching... the process of change itself is often a slow one, and will become impatient at the amount of low-level detail that needs to be considered with an EP system implementation Other hospital managers may see the implementation of an EP system as a means of achieving their targets at the expense of the working practices of other professional groups in the hospital, or may see the system as a way of imposing... to maintain registers of the receipt and supply of controlled drugs In recent years, this requirement has enhanced to include the recording of: (a) Running balances (b) The name of the supplying pharmacist (c) The name of the person collecting the medicine These enhancements enable a more fuller audit trail of the supply of controlled drugs to be established The future use of electronic controlled... for prescribing the drug Consequently, it is desirable for EP systems to indicate clearly to a prescriber if a product is unlicensed EP Systems and Professional Liability Medicine is one of the most highly regulated areas of professional practice and, with an increasingly litigation-conscious culture and a corresponding increase in defensive practice on the part of health professions, awareness of professional... healthcare professional, and the use of electronic systems as prescribing, dispensing and decision support tools does not detract from this Indeed, software vendors should include a disclaimer in their documentation to the effect that EP software is a tool and is not intended to replace the clinical judgement of the practitioner However, while clinical users must still use their clinical judgement when prescribing. .. Connecting for Health Electronic Prescribing Baseline Specification.3 This is a useful working definition for an EP system because it takes into account the capacity of an EP system to add value to the patient’s prescribing history through use of clinical decision support tools, and also the process of storage and communication of medicine orders It is an appropriate description of some of the EP systems... average acute hospital Hospitals are larger, comprising of a number of distinct wards and departments There are a range of clinical and non-clinical professions in a hospital and, historically, the working practices of each profession have been governed by the profession itself, rather than engagement in multidisciplinary teams, and this fosters professional segregation and rivalry, rather than multidisciplinary . Availability of electronic decision support tools at the point of prescribing. • Comprehensive audit trail of prescribing decisions made. • Reduction in the rate of medication errors. Some of these. 113 7 Electronic Medicines Management and Non-medical Prescribing 115 Background to Non-medical Prescribing 115 Experience of Non-medical Prescribing 117 Benefi ts and Risks of Non-medical Prescribing. Availability of a fully electronic prescribing history. • Improvement in legibility and completeness of prescriptions. • Improvement of hospital business processes due to electronic dissemination of