Background
Objectives
Materials and methods
Results
Number of acute hospitals | Number of EP systems | Types of systems | Integration between clinical & information technology services | Interviewees | |
---|---|---|---|---|---|
Site A | 1 | 6 | All commercial | No | 3 senior pharmacists |
Site B | 1 | 3 | Two commercial, one in-house | Yes | 2 senior pharmacists 2 senior doctors 1 senior nurse (super-user) |
Site C | 1 | 2 | One commercial, one in-house | Yes | 1 senior pharmacist |
Site D | 2 | 3 | All commercial | Yes | 1 senior pharmacist |
Reasons for having multiple electronic prescribing systems
Models of EP system adoption
Organisation-led systems adoption | Clinician-led systems adoption | Strategic clinical network-led systems adoption |
---|---|---|
• Large scale use • Driven by local necessities and/or national drive • Governed by IT department • Example: A hospital wide discharge system or ePMA system | • Limited use (area or group of patients) • Driven by speciality needs • Supports a complete clinical pathway (not only prescribing) • Governed by the speciality • Example: ICU system | • Limited use (area or group of patients) but shared between hospitals • Driven by strategic clinical network • Supports a complete clinical pathway (not only prescribing) • Governed by speciality across hospitals • Example: Cancer System |
The third model of EP adoption was strategic clinical network-led EP adoption. All systems that fell under this category were cancer systems. These were similar in function to clinician-led systems, but shared between multiple hospitals. The choice of system was dictated by the specific cancer networks that hospitals were linked to.‘….. they [speciality systems] all bring benefits in addition to the prescribing abilities, so their systems are bespoke and built for that speciality. So for example the orthopaedic one will collect data for the bone registry and populate the letters, you can do bits in theatres and it will populate the letters for the stuff that’s relevant to that speciality rather than being a ‘does all’ but does a lot very well as that speciality would like it done, I guess. So, the systems have e-prescribing as a part of the package but that’s not the only thing that they do, so like an add-on I guess’Interview 2, pharmacist, site A
System governance and strategic IT planning
‘I think if you were to ask we would say that we were going for a best of breed approach where we pick the best piece of software but the reality is that it’s evolved as time has gone by so we’ve sat there and we’ve thought we need a renal information system and we’ve bought one and then we’ve thought we need a discharge letter and we’ve bought one. So it’s been the way that nobody’s ever really had a strategic plan about how we develop things I think, it’s just happened and then it’s been a question of trying to get things to talk to each other at the end’Interview 4, pharmacist, site A
Effects of having multiple EP systems
Positive effects
‘…….having bespoke systems, so if we think about the chemotherapy systems it does do a lot more and it is very set up to manage chemotherapy protocols which would be very difficult to do within [system 1; electronic prescribing and medicines administration system], so it really has been built to deal with that kind of prescribing. It also has a lot of other functionality around scheduling and making appointments so that the day unit can keep their diaries. Then again, that would be quite hard for us to build into [system 1] in a way that works as well as it does for [system 2; ICU system] so bespoke systems will always do, will always work really well for that bespoke area and I think that is probably the key benefit’Interview 1, pharmacist, site B
Negative effects
There were challenges related to training on systems managed by other hospitals such as cancer systems, as often staff had to travel to other organisations for training.‘It’s two things you have to learn, I think the more information you have to learn the more chance there is of mistakes and given that we have a high turnover of junior staff I think it’s a lot easier if they just have to learn one thing once’Interview 7, senior doctor, site B
Locum staff were also affected by access and competence issues. Interviewees mentioned practices such as sharing passwords with locum staff and shifting IT related tasks to substantive staff if locums were unable to handle multiple systems.‘We have become dictators. We give the order then it’s not our problem anymore, it’s someone else’s problem. Junior doctors will have to sort out the orders while earlier I could have done some prescribing myself’Interview 8, senior doctor, site B
‘It’s apparent now if we have locums that really if they don’t know the hospital and the systems they are essentially fairly useless because somebody else has to look after all the IT input. IT is actually quite an important part of our working lives and the simpler and more error free it is, the better it is and I think two systems doesn’t really promote that.’Interview 7, senior doctor, site B
Although rare, workflow issues were more serious when data for the same patient were spread between two electronic systems. Staff had to log in to two different systems and locate the same patient’s records to prescribe, which was not only cumbersome but also risky as this may introduce errors.‘People have had to change their way of working. So you might do something in a particular order but actually now that we’ve got [multiple] systems in place you might have to do it in a different order or you might have to approach your tasks in a slightly different way. So, where possible we have tried to outline ways to do that but what you find is that users actually find their own way to do it.Interview 1, pharmacist, site B
‘You would prescribe your anaesthesia in [anaesthesia system] and when you want to give a bolus of a drug post-op [post-operative] you have to go and login into ePMA [electronic prescribing and medicines administration]’Interview 7, senior doctor, site B
‘The other obvious disadvantage with the bigger systems is that you’re having to maintain multiple catalogues and that’s going to be an issue between the ITU [intensive therapy unit] system and the main electronic prescribing system when we have it, that you’re going to be having to update and maintain the catalogue twice with your formulary decisions twice’Interview 9, pharmacist, site D
Procedures to allocate and renew passwords had to be created in order to guarantee all staff were able to access systems when required. Hardware requirements also had to be assessed carefully to meet demands of accessing multiple EP systems:‘The passwords I have at the hospital, I have my NHS password, my hospital password, my [system 1] password, my [system 2] password, we were counting, might get a university password, I have about 7 passwords in the hospital. I make notes on my [smartphone] of my current passwords and I now I tend to cross-populate, I used to have separate ones for all of them and now I tend to … the first one I change, I just change them all to the same password and then when it’s triggered again do the same thing, which I’m sure is not what you’re meant to do’Interview 7, senior doctor, site B
‘…then making sure that the right people have got the passwords at the right time to be able to get into the system. You’ve got to make sure that you have got enough equipment available for everybody and that all the programs work on the same equipment, so that you are able to do everything from the one terminal if you need to.Interview 1, pharmacist, site B
Having patient data spread across multiple EP systems hindered healthcare professionals from obtaining a complete picture of the patient journey. For instance, a doctor or nurse treating an outlier patient (a patient in another specialty’s ward due to lack of beds) might not be aware of important patient-related clinical data if they have no access credentials to a specific EP system. Some interviewees reported incidents where diagnosis of a newly admitted patient was delayed because of a ‘black hole’ in the patient prescription records:‘it is making sure people know that there is information in different places, making sure that they are trained, making sure nothing gets missed, making sure that prescribers are putting the drugs into the systems being used in that area, which I think can be difficult and then obviously if you have got a new system there are training issues and making sure that people are able to use the system effectively to deliver patient care, so I think there are definitely risks. It would be much less risky if you just had one system but we have to just find ways to mitigate those risks’Interview 1, pharmacist, site B
Duplication of patient data in various systems was identified as another potential clinical risk. Slightly different information may be documented in each system:‘I think we’ve had a couple of occasions where a patient has been admitted, they’re generally unwell and it’s taken a little while for everybody to piece together the puzzle to say actually this patient’s getting this type of care and therefore there is a prescription and this is what they’re being prescribed and it’s happening somewhere else in our organisation but we can’t readily see that record’Interview 9, pharmacist, site D
In some instances, systems were not completely paperless as supplementary paper-based records were also required. Therefore, healthcare professionals were faced by a mixture of paper charts and data spread across multiple EP systems.‘I think also there is another issue actually around duplication of information, so do people need to record things across different systems or can they put it in one place and expect that it will be found, and actually we don’t want people to have to duplicate stuff because we might get a slightly different story in each system. You want it recorded once and then for people to know where to find It’Interview 1, pharmacist, site B
‘You may get used to a system doing a certain thing when you move to the other system and it doesn’t do it, that could create a risk because in your other system it’s automatically checking.’Interview 9, pharmacist, site D
Overcoming negative consequences of multiple systems
Challenges for system adoption
‘I think that it’s the user’s expectation that they expect the systems to talk to each other and they don’t and I think that’s hard to manage, people saying “well, why doesn’t the blood result feed into this one?” and you say that there is no link, you actually do have to look in this other place for it, so there is definitely some difficulty around managing expectation’Interview 1, pharmacist, site B
Interviewees raised some issues around EP systems’ capabilities. It was suggested that advances in HIT were not keeping up with the rapid changes of healthcare. Therefore, some systems were not able to support management of patients with complex clinical requirements.Oh yes. I think it’s really difficult with IT in the NHS because of what we know we can have just in our general day to day life and how we see systems working in everything that we do and we’re so used to IT.… when you then try to apply that standard, that expectation to what we can achieve in NHS systems it’s really frustrating that it’s so difficult to do the same thing’Interview 9, pharmacist, site D
Interviewees reported lack of sufficient expertise to manage EP systems within the NHS. While IT departments provided technical support for EP systems, clinical input was provided by end-users. The separation between technical and clinical skills may have hindered appropriate system management. Interviewees highlighted the need for people with both clinical and IT knowledge.‘… system at the moment struggles to deal with patients who have got several booked admissions for different types of care and that may be because when the system was first developed patients perhaps were only expecting them to be lining up to come and have one type of treatment. Now patients have so much co-morbidity and are living so long that we can expect them to have lots of things happening all at the same time and our electronic prescribing system doesn’t cope very well with that’Interview 9, pharmacist, site D
‘At the moment, the responsibility of the [hospital wide discharge system] kind of sits with IT. That can be problematic in terms of its good because it’s an IT system and therefore the technical aspects of what need to be done are within their remit anyway, but when you’re looking at it in terms of a clinical system that does cause a problem. We have a clinician who is nominated within the organisation as being the person who will take decisions around the [discharge] system, but again he’ll be doing it from a very clinical perspective rather than an IT […..] I feel that we will probably see a shift and maybe start to have some clinical IT posts more than pure IT posts that have got a responsibility in both areas’Interview 9, pharmacist, site D