On top of the pill

At one of the country’s first forums to specifically address e-prescribing and medications management, India Hardy, the head of e-prescribing at Chelsea and Westminster Hospital NHS Foundation Trust, asks people to raise their hand if they have implemented e-prescribing in some way.

Just two or three hands go up in an audience of 30; which shows just how far ahead Chelsea and Westminster really is. In 2003, the trust began using its electronic patient record, Lastword – which was supplied by IDX before its takeover by GE Healthcare – for e-prescribing in outpatients and for discharged inpatients.

During the company takeover, the trust took a backseat. Then it decided to roll-out e-prescribing for inpatients in 2008, having acquired the intellectual property around the Lastword system. Since then, the trust has trained 1,397 staff on the system and has gone live with e-prescribing across all of its inpatient wards.

Success factors

“You need to think of it like building a house,” Hardy tells an ePMA forum held by iSoft in Manchester. “The foundations are probably the most important thing, and for e-prescribing it’s your project management and governance.”

She goes on to explain that the Chelsea and Westminster implementation was based on several key pillars, the first of which was a clear definition of scope from the outset.

“You need to be able to define what meds, what wards, what timelines, what staff; right from the beginning. There’s no use in going with a huge roll-out plan if you’re not going to have the staff to support it post roll-out.”

The trust decided to go live first in orthopaedics because of the elective nature of most procedures. So although it wasn’t an ‘easy’ ward, Hardy said “the complex meds were predictable, so it was predicable chaos rather than chaos that we couldn’t size up.”

A very fine ePIG

Hardy also says it was essential to get stakeholder engagement and to make sure the ownership was right. Chelsea and Westminster had a delivery focused project board, and trust executives were key to decision making.

In addition, an electronic prescribing implementation group (ePIG) was set up to so any concerns could be voiced to the chief information officer.

Clinicians informed the project requirements and were involved in the usability testing of the software. “Once the scope was defined, another team would interpret it and break down those high level requirements into more detailed specification.

“If you’ve got a pilot ward and they are making decisions with you from the beginning, quality requirements and timelines are met.”

However, Hardy admits the trust missed one, key area. “During the go-live, we were so focused on clinical users who helped define the system that medical students were neglected. They couldn’t log-on or see what was going on; let alone interact with prescribing themselves.”

Toast versus pizza

Hardy says that the clinical engagement remained top of the agenda in relation to other aspects of the deployment. “We put all of our clinicians in a room before we went out to market for the hardware, and got product demonstrations for the doctors, pharmacists, IT staff, dieticians and everyone else who would be using it.”

The trust decided to roll out a range of options across the different wards, depending on who would be using them. COWS (computers on wheels) were implemented on the recovery wards, whereas hand-held devices were better for other users who wanted instant access.

“We had some very interesting conversations with our suppliers, as we began to call the devices you stacked on top of each other ‘the ones in the pizza oven’ whereas the ones you could see side by side were ‘in the toast rack.’ So our request was that we wanted a device we could drop on the floor and fit in the toast rack…simple.”

Big Bang

Although the roll-out took almost two years to complete, with five people dedicated to the project including pharmacists, EPR support and resource coders, elements of the project went live as a big bang.

“The go live support couldn’t be done within our team, so when we went live with a big bang in our medicines directorate in seven wards in one night, 30 pharmacy staff were brought in to transfer medications chart onto electronic charts.”

The trust provided 8am-8pm support for first month, which it said was a lot more sustainable as part of it had done the big bang roll out, this was then followed by 24/7 bleep support.

“We’ve now moved to a support and maintenance team, which we consider to be more of a development team.”

Reaping the benefits

Since the trust completed the roll-out, it has carried out a benefits realisation project that analysed data from two months before the pilot and four months after the implementation.

It found an 11% reduction in the severity of errors that were statistically significant. It also found no serious errors when e-prescribing was used, in comparison to one serious error in hand written prescriptions. And it found four moderately severe errors when e-prescribing was used, when there were 15 in paper prescriptions.

Hardy says the study also showed that e-prescribing reduced the likelihood of prescribing a medicine when the patient had a known allergy by 77%, by adding mandatory checking and decision support into the system.

The trust also recognised benefits from including decision support in dosing, which meant that lab results were needed to administer some drugs, and from the identification of medicines in drug recalls by the MHRA.

As easy as it seems

Hardy tells the audience that although it’s taken the best part of a decade to implement the sytsem, from planning though to go-live, she consider the business case to have been met.

“When we look back to our business case, the cost of implementation has been met by the decrease in length of stay, litigation costs, time spent by senior staff on incident review, and complaints, [and] increasing patient choice and income from CQUIN (Commissioning for Quality and Innovation).

“I’m not saying that this is the only way to do it. We’re all just after a system that works for each of the departments so there’s a dynamic definition for success for each programme. There’s no such thing as a gold medal for e-prescribing,” she adds.