Over 50 representatives of health providers from all over Australia gathered in Melbourne in June for Electronic Medication Management 2012, to discuss the current state of play with the implementation of electronic prescribing in hospitals. International speakers described developments in their countries and those who had already embarked on the task of implementing e-prescribing at their hospitals in Australia shared their experiences of the benefits and the challenges.
The keynote international speakers were Stephen Goundrey-Smith from the UK, and Dr Andrew Bowers from New Zealand. Mr Goundrey-Smith took delegates on a virtual tour of sites where electronic prescribing had been implemented in the UK, described the current UK situation and the work done, and lessons learnt from the NHS Connecting for Health e-prescribing programme. Dr Bowers described how there had been increased impetus to move towards paperless systems in New Zealand, as a result of the earthquakes last year, in order to maintain a “business as usual” situation should there be future natural disasters. Dr Bowers described how New Zealand had developed an e-medicines programme, which would streamline medicines management across hospitals and the community in New Zealand, and that they were developing a universal database of medicines to enable this. iSOFT’s MedChart system was being considered as a national solution for electronic prescribing in New Zealand, but they had experienced problems because the law did not routinely support electronic signatures for prescriptions.
Rosemary Bowers, Chief Pharmacist from the Concorde Repatriation Hospital, Sydney, described a recently-published comparative study of two electronic prescribing systems, the iSOFT MedChart system (used at the Concorde) and the Cerner Powerchart system. Both systems had a significant effect on improving the completeness and legibility of prescriptions, although the iSOFT system was associated with fewer medication errors. However, the methodological issues associated with structuring a comparison of two systems were considerable.
Given recent experiences in the UK with national IT iniatives, UK readers will be interested to hear of initiatives in Australia where regional or state-wide medication management systems have been implemented. Dr Brent Richards from the Gold Coast Hospital, Queensland, described the implementation of a state-wide clinical information system (CIS) for intensive care. The roll-out process had been very slow – the business case for the system had been written in 2006 – and there had been many bureaucratic and procedural hurdles to surmount. However, the system was now up and running. By presenting clinical data in multiple data frames and dashboards, the system had improved the quality of care in Queensland intensive care units, and had improved the consistency of care, helping city hospitals to support rural hospitals effectively. Sarah Smith described how the same CIS solution, MetaVision, had been implemented within the intensive care departments in the ACT (Australian Capital Territory) hospitals at Canberra and Calvary.
Within Victoria, the state government had introduced a state-wide electronic health programme, HealthSmart, where electronic prescribing was available using the Cerner system. Andrew Howard, CIO of the Victorian Health Dept, described the background to this initiative. A state configuration for the system had been agreed with Cerner, and the system used standard Australian Medicines Terminology (AMT), which was linked with the Cerner Multum drug database, but enabled medicines to be listed in a way consistent with Australian costing and reimbursement.
This state configuration was not popular with all users because, in many cases, further local configuration was required, and this might be in conflict with the state configuration. Libby Owen Jones from the Austin group of hospitals in greater Melbourne, described how the state solution had been implemented in their hospitals. She indicated that, although the system had led to legible discharge prescriptions and better decision support around allergies and drug interactions, there had been considerable challenges around change management and that, at present, only 20% of discharge prescriptions were being issued with the system.
Some hospitals in Victoria had declined to go with the state’s HealthSmart system. Chris Turner, Chief Pharmacist at the Echuca Hospitals in upstate Victoria described how Echuca Regional Hospital (ERH) had implemented the iSOFT MedChart system, but had faced considerable challenges with acceptance of the system, although now use of the system was “entrenched” at ERH.
Some speakers described how electronic prescribing had been found to be of benefit in specialist environments. Calvary Healthcare, Bethehem, ACT, had implemented iSOFT MedChart for a tertiary palliative care service. While the system had benefits relating to the quality of prescribing, there were a number of scenarios specific to palliative care, which required specific work-arounds – for example, prescribing of multiple medicines in syringe drivers, flexibility in the administration of prns, and the use of functionality to support the duration of administration of opioid patches (fentanyl, buprenorphine).
Shannon Ferguson from the pharmacy department of the Royal Victorian Eye and Ear Hospital (RVEEH) described the implementation of the state Cerner-based system for electronic prescribing in this specialist hospital, which had a considerable outpatient and day surgery caseload, but only one inpatient ward. For a small specialist institution, a state-wide electronic prescribing solution offered a system built with resources that the small hospital did not have, and that would provide consistency of care with other general hospitals in the area. However, in many cases, more local configuration was required because the state solution was built with general hospitals in mind.
David Evans, e-Health Clinical Advisor for Queensland, reflected on the issues that arose with the use of connected electronic systems in healthcare. He said that many of the problems with IT in healthcare were due to fragmentation of data in “silo” based systems – but that federated (joined up) IT systems could resolve these issues. However, joined up systems led to important questions that were hard to resolve, such as: a) how could data quality be maintained, and who would be accountable for that quality, b) who was the data owner in such systems, and c) who should be the moderator of access and by what method should access be moderated?
Telecare – the use of telecommunications, video conferencing and digital messaging - has the potential to improve the process of medicines management for community-based patients, both in terms of increasing service capacity and delivering a consistent service across a large area geogrpahically. On the second morning of the conference, two differing perspectives of telecare were presented. Rod Young, CEO of the Aged Care Association of Australia gave a vision of how telecare services, and the development of the “smart home”, where the house is fitted with a range of intuitive monitoring and communications devices and electronic sensors, could optimise patient care and enable them to remain in their own homes for as long as possible in old age.
Rosemary Hogan, from the Royal District Nursing Service, whose homecare nurses already used telecare utilities, painted a more cautious picture. She indicated that, while telecare improved service capacity and potentially improved consistency and reduced errors, there was often a higher workload for staff in the initial post-implementation phase, that there were often mis-conceptions from staff about loss of jobs, and change management issues along the way. In the final session of the conference, David Ryan, Pharmacy Operations Manager at North Shore Hospital, Auckland, described the implementation of Pyxis automated cabinets and their integration with other tecnologies at the hospital, giving benefits of improved stock control, more contralled access to medicines and an improvement in the rate of selection errors.
There are various potential lessons for the UK from the Australian and New Zealand experiences with electronic medication management. Implementers should take a pragmatic view of what systems they can implement in local hospitals, and what benefits they could achieve. The process of change needs to be carefully managed in any setting, and implementers will need to be determined in surmounting barriers and working to ensure the system is appropriately configured for their settings. Regional systems, which are configurable to local providers, may leverage system use by providing a level of support that would not be possible in small hospitals and provider organisations. This may encourage the use of systems in specialist hospitals. Above all, implementers and suppliers should be prepared to have an open, honest and positive relationship, and to share experience with other centres. This conference provided a suitable opportunity to share experience on electronic prescribing and medicines management with other implementers in Australia and New Zealand.