Anne Jacklin

Chief Pharmacist,

Hammersmith Hospitals NHS Trust
Du Cane road
London, W12 OHS

It is fascinating to hear that systems are sophisticated enough to deliver what has just been discussed in the previous presentation. We hear lots about what technology is theoretically able to deliver but when you work in the NHS it does not seem that this is possible. I am going to describe a pilot on a single ward. There is probably a single-ward pilot in a hospital in every health authority in the country and most of these are not being evaluated. People are gaining experience whilst finding that they cannot continue to fund the pilot. I am going to recount our experiences picking up Tony's points about when is implementation actually implementation and Martin's points about affordability and how you prove things.

My talk is about piloting a novel drug prescribing and administration system that is at the beta testing stage. I did not then know the term 'beta' but now believe that it describes software that is not yet fit-for-purpose. We were attracted because the system was free; the project was small scale and developed by a small start-up company. We believed that we really would be able to learn with them and we had independent academic evaluation from the LSE. Nick Barber and Bryony Dean-Franklin tell me that that whilst electronic prescribing is said to reduce errors actually this assertion is not proven and is the subject of much debate at present. I run drug medication incident reporting and I can tell you that most errors are due to misadministration in my hospital. Apparently an electronic prescribing system will be of little help and will not make any difference to my dispensing. Whilst electronic prescribing will remove errors due to illegibility I do not believe that there are many errors of this kind. The company claimed that the system would reduce medication errors that we thought was possible because the system was more complete than just prescribing and many of our risks are in administration. The company also said that the system would make more efficient use of our nurses. Our nurses spend much time administering drugs (30 - 50% of their work) so this claim was very attractive. The claim was also made that the system would reduce leakage i.e. theft although we suspect that this is completely insignificant in my hospital. Finally the system would produce good audit data (which I like).

The system is a combination of: computerised prescribing, physician order entry and ward-based workstation software. This sorts out the drug administration that shows all the drugs due at, say, two in the afternoon & removes the need to check every chart & round as nurses do now. There are three unusual features: a computerised medication cabinet (the magic cupboard), a mobile smartcart and it also barcodes! 

The system verifies the identity of the patient and relies on the right drug being in the right part of the smartcart verified by a barcode. 

Perhaps because the design is Israeli & does not reflect NHS practice there is no clinical pharmacist's review. This what the kit looks like - there is the magic cupboard with the smartcart docked infront.  

The Cabinet has a touch screen so when a nurse does the drugs round she enters her password and gets a list of the patients due for the round, she then touches on the patient's name and for each drug a drawer opens and only the drawer for that drug. The drawer in the trolley opens only for that patient so she puts the right drug in the right drawer for the right patient and in this way collects all of the drugs for the patient. 

If the patient is not there on the system or doesn't have a barcode the nurse cannot access the drugs. So, a pretty neat idea but what is it replacing? What we do in hospitals is we have drug administration charts, the doctor and then the pharmacist writes on it and then the nurse administers however then we give nurses whole bottles of drugs from which to select the individual dose - quite risky these days. 

The system in the States is completely different because the pharmacist gives the individual tablet, properly labelled for each patient every 24 hours - very nice. However we view the American practice of writing the prescription on a bit of paper beforehand and then entering the details on a computer as very risky. Lockable bedside cabinets have begun to replace the trolley. Recent advice from the DOH is that these cabinets solve medication error problems. We have not seen any supporting paper but Bryony has shown that the cabinets make no difference to the error rate but just change the nature of the error, making it worse in some areas and better in others. The unpublished findings at Harrow Park show that the medication error rate is reduced by 70% - which is not our experience. So, what we are replacing is a drug trolley full of tablets from which the nurse selects the dose and drug combination for each patient. This is an accident waiting to happen particularly when the tablets are in sealed strips. When most of the strip has been used the printed dose can be very hard to read.

Now back to the project - we undertook a 6 - 9 month pilot, the company provides the product, a nurse and a researcher while we do all the local project management. The most amazing thing was that we had a proposed and an achieved timetable of which we are very proud because this was quite unusual for such pilots. We went live in June, after installation, trainer-training etc. There were teething problems at the beginning, necessitating some redesign & we had to retrain people, then the system settled down by September. A single-ward pilot with complete reengineering - how could this possibly work? Not surprisingly we had some outstanding issues in September and nothing has changed in the last six months. I have been told by others who have done single-ward pilots in the UK that this is absolutely classic. The problem that we have seems to be systemic, rooted in the structure of software development companies in the UK. These are small organisations that do not seem to work through user groups to aid software development. I and others have encountered similar difficulties with other systems such as the one in our pharmacy.

The remote tablets PC's still do not work properly. We would like to raise the orders in pharmacy now that we can electronically order. We do lots of discharge medicines in this country and once prescribing is done electronically, the big advantage for junior doctors is that they can tick the discharge medicines on the screen. However we have been waiting since September for this to be available. We have a potentially fantastic advantage that allows you to order what you need on wards because you know what patients are taking what medicines. However the design only allows a fixed replacement order when the stock has reached a critical level - which is what we do at present. In other words there is no decision support for intelligent ordering. The company did not think about drug reporting which, on our view, is common to most systems. We should give audit information to our prescribers so that the ward pharmacists could prioritise their work. Decision support is very slow and hasn't improved.

Ten years ago we were warned that pharmacists would be out of a job if they did not pilot electronic prescribing. David Cousins (Director of Medicines Management at the N.P.S.A.) gave this warning, tried this at Derby and later the system was removed. Where was the shared learning? Where was the development? We didn't get round to that did we? I know of similar experiences in other hospitals and we think there are lessons to be shared. I am not sure that our learning and evaluation to date will be translated into product improvements.

The system does have faults but it does have advantages over the existing and unsatisfactory arrangements in our hospitals. It looks lovely, it barcodes, the drug round is seemingly quicker and nurses love not having to look for a bit of paper which a major distraction. Some nurses like the system, others like the traditional methods on other wards. The consultants are indifferent, the registrars were initially worried about their juniors who, despite some concerns about mispicking (Penicillamine instead of Penicillin), deskilling & allergies think that there are advantages. The pharmacists like it although the process takes longer but they get to see all the patients, all the charts, all the time that did not happen previously because at any one time some patients are in theatre or X-ray.

We plan to keep going till November if the software development happens because this is what we want to evaluate. Bryony has done much pre-evaluation and we have some early data that suggests a substantial reduction in prescribing errors but we do not have a denominator and we have not yet done the proper work on severity. We also think that nurse administration time is much reduced. However unless we can confirm these advantages and get timely development of needed changes to the software then I fear that this may just be another pilot that falls by the wayside.

Questions

DB Why is it slow because this is the single most important determinant of satisfaction?

AJ Software design. For example, the screens, which worked fine on a care-of-the-elderly ward in Israel, do not work fast enough for the workload in an NHS surgical ward. However I believe these problems have now been resolved. Everyone in the hospital was shocked that the project started on time but not surprised at subsequent difficulties because they know about I.T. in the NHS.

DB Speed really matters.

AJ Doctors who prescribe on the system all the time do not see speed as the critical issue and just want the system to be everywhere because their main problem is that this is a single-ward-pilot. So they have first to take information off paper and then later back onto paper. I thought that the biggest problem would be the junior doctors because they are a big problem in the UK but they have taken to the system.

OH I assume that this system receives prescriptions electronically from the Patient Record System?

AJ We do not have proper electronic patient records. Doctors prescribe either through a pen tablet or a keyboard on the ward.

OH Could the same kind of problem with allergy alerts that Tony described occur with this system? Note for the reader: the detail is in the following 'A GP prescribes penicillin, presses the 'Enter key' and the prescription is printed. If however the GP knows to record this under the reactions & allergies part of the database then an adverse reaction flashes up when the prescription is attempted.'

AJ The decision support is at present too cumbersome to be acceptable and so is not used. Our rule of thumb in going from the existing systems that are used elsewhere in the hospital is that the new system should not be worse. So if you type in an allergy whether coded correctly or free-typed it comes up red on the screen. This is better than our drug charts that are only 70% filled in or were before we did modern things to the pharmacy. We have a very poor rate of allergy recording in the hospital and so far this system has made no difference at all. I know that decision support is a problem that remains unsolved in the NHS.

BF Does the nurse use the barcode scanner at the bedside to confirm that the right patient has popped open the smartcard? If a patient refuses a dose how is that handled?

AJ Yes and when the drawer opens the nurse has a message screen on her cart where that information can be entered and sent back to the nursing station.

BF Do nurses do several other assessments such as heart-rate monitoring?

AJ They do not do that very much in the UK. Nurses just go around and do drugs although they claim to be doing these other assessments. There are some cultural issues here because although nurses are very unhappy about their inability to undertake new tasks, there is no evidence (certainly from Bryony's pre-observational work) that they have undertaken other extra tasks in the past.

RD There are some interesting joint issues that have emerged from these two presentations, which tie in with ideas in economics. This is something to do with how technology is procured by the public sector. What we have here is something that is intensely reactive, depending on these small-scale cottage industry start-ups that have to relentlessly hype the product in order to keep the venture capital flowing. There is also the point at which the enthusiasm of the prospective purchasers wears off. Such hyping has been around for 10 - 15 years. I seem to remember that the GP computerised prescribing systems were written by GP's writing software for their own practices and for their own interest. The products may not have had all the bells and whistles now wanted but because the developers were both architects and users they produced crude, simple things that worked.

It seems to me that one of the interesting problems here is the unchanging reactiveness of the NHS. The model of the public-private partnership seems very much that the public sector sits on its hands and a bunch of Arthur Daley characters pitch up on your door and try to sell you something. We do not have a body that starts with the users, develops a specification based on what people really need. Only then do we go out and tender for a supplier. So genomic screening tests work very well in the lab but do not work will once they are turned over to the poor bloody infantry in the NHS.

TC One of the doctors that we interviewed at the beginning when the system was being installed very much expressed this view - 'We should be designing these systems and we should not be having these systems imposed upon us'. A bone of contention was the question of whom this system was for and has not been resolved in this case.

RD It has been portrayed as a pharmacist-doctors struggle when it seems to me that the real users are the nurses.

AJ At the senior level the nurse director and the consultant surgeon are completely supportive, stay in the background but will come out and bat when needed.

LF This is the classic situation where you introduce one change that flags all the other major problems. For example why aren't the nurses assessing the patients and taking the their vital signs before administering medication? However no one wants to look at that.

TC Nurses do not object to the system but they are very clear that they do not like the process of implementation. 'There are too many people on this ward, coming to visit, wandering around and then there are the technicians and they get in your way.' You can tell that when you are there just from their sighs and the way they will walk round you. They feel manipulated and experimented upon.

AJ If they had asked the question 'Why us?' The answer would have been that they had a good ward sister and were in the right place.

LF They want time for their patients an then there are issues about being looked at as part of the pilot's evaluation.

AJ We have had nurses on the project team from the start and they have had the opportunity to contribute and if only they had done so then the solution would have been better designed from a ward perspective. Their major contribution came later when things started to go wrong and then they were very very creative. Now they come up with really good ideas but the better time for these would have been at the earlier stage of preparation.

TC One of the things that you talked about was the question would another ward volunteer had you asked the sisters.

AJ The project went to rest of the surgical wards when we were at the height of disenchantment with the system to ask for a ward to volunteer. Every ward did so.

MB Does that say something about the reward system in the hospital or the system itself? Do you get promotion if you agree to participate?

TC You cannot make that distinction - the reward system is the technology. You should understand the project not in terms of the quality of a piece of kit but in terms of motivations, peoples' jobs and rewards. The technology is socially embedded.

RD The point about an inadequate piece of kit say in terms of software speed is the way it disrupts the work.

IW You mentioned that David Cousins tried and then abandoned electronic prescribing. So have we done any stocktaking of all the attempts to introduce electronic prescribing?

NB We did a one in five survey of all hospitals in England and 33% had a computerised prescribing system on one ward. However there was no coordination, evaluation or sharing of experiences and data.

AJ Most of these are prescribing systems and we are interested as much in administration. Because one prescription generates multiple administrations so naturally that is where the greatest risk lies. Electronic prescribing does not help us with trolleys and bedside cabinets. This is my biggest problem in the hospital.

IW Your point underpins the importance of shared learning and stocktaking and which may inform the agenda of the Metanetwork.

ENDS