Electronic prescribing

Articles recommending the use of electronically generated prescriptions can be traced back in the literature to the early 1980s (53). Relatively sophisticated systems were employed by the early 2000s to facilitate ePrescribing and CDS. In more recent years, there have been widespread national and international initiatives to implement ePrescribing, these systems having the potential to significantly improve the quality and safety of patient care through facilitating evidence-based prescribing and reducing medication errors (13)(14)(24)(54)(55)(56). ePrescribing can also facilitate extensive improvements in dispensing and administration processes, including shorter process turn-around times, enhanced communication among healthcare professionals, reductions in paperwork, and improved audit trails and drug utilisation reviews (14).

There is no universally agreed definition of ePrescribing, this term having the potential to denote different meanings depending on the context in which it is applied. Various definitions have been put forward by governing bodies internationally for both hospital and community settings. The Centre of Medicare and Medicaid Services in the USA defines the ePrescribing process as:

“the transmission, using electronic media, of prescription or prescription-related information between a prescriber, dispenser, pharmacy benefit manager, or health plan, either directly or through an intermediary, including an ePrescribing network...” (57).

The National Health Service (NHS) Connecting for Health in the UK define ePrescribing as:

“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 through knowledge and decision support and providing a robust audit trail for the entire medicines use process” (58).

The Department of Health (DoH) and Ageing’s Pharmacy and Government Arrangements in Australia define ePrescribing as:

“an electronic prescription which is generated in accordance with a process by which a prescription is electronically generated by a prescriber, authenticated (electronically signed), securely transmitted (either directly or indirectly) for dispensing and supply, and seamlessly integrated into the pharmacy dispensing software...” (59).

For the purpose of this doctoral research, ePrescribing encompasses the latter definition, a technology framework that facilitates a prescriber to securely generate and transmit prescriptions to a pharmacy dispensing software electronically. This definition was thought to relate the most to the content of this thesis which explores the facilitators and barriers to electronic systems for medicines management with a focus on ePrescribing, robotic pharmacy systems, and medication storage and retrieval systems. ePrescribing systems which integrate with pharmacy systems have also been found to have the greatest benefits to improve patient safety and quality of care through better access to data, exchange of data, and enhanced communication (60).

An illustration of an ePrescribng interface is provided in Figure 1.2.

Figure 1.2: Example of the design of an ePrescribing interface

Components that need to be considered when implementing an ePrescribing system are illustrated in Figure 1.3. These comprise the technology itself, the healthcare providers who interact with it, and where this exchange takes place.

Figure 1.3: Components of an ePrescribing system

Evidence of ePrescribing effectiveness can be found in a UK study by Donyai et al in 2008 which highlighted a significant reduction in both prescribing errors and pharmacists’ clinical interventions for hospital inpatients following implementation (60). Another UK study by Shulman et al in 2005 comparing the impact of ePrescribing with handwritten prescribing on the frequency, type, and outcome of medication errors also found medication errors were significantly lower with ePrescribing (61). Franklin et al in 2007 assessed the impact of a closed-loop ePrescribing and automated medication storage and retrieval system on prescribing errors, administration errors, and staff time in a UK hospital and found a reduction in prescribing errors, medication administration errors, and increased confirmation of patient identity before administration (62).

A literature review by Niazkhani et al in 2009 on the impact of ePrescribing on inpatient clinical workflow identified 51 publications with workflow advantages of legible orders, remote accessibility of systems, and shorter order turnaround times (63). Another systematic review by Eslami et al in 2009 on the impact of ePrescribing in hospitalised patients identified 67 articles with overall positivity in the category of adherence to guidelines, cost, organisational efficiency, usability, and satisfaction (63). A study by Mitchell et al in 2004 evaluating an ePresciribing and electronic medication administration record (eMAR) system in a

Technology ePrescribing

technology

Location Ward Pharmacy

Office People

Doctors Nurses

Allied healthcare professionals

UK hospital found omissions of patient and drug information were less frequent with system implementation (64).

From a time efficiency perspective, prescription monitoring and alterations were reduced to less than 10% in a UK hospital with system implementation which facilitated pharmacists to spend 70% of their time on direct patient care (65).

This is a significant advancement considering the report A Spoonful of Sugar:

Medicines Management in NHS Hospitals, published by the Audit Commissioner in 2001 found pharmacists only contributed 5-20% of their time to direct clinical care (66). A USA study by Murray et al in 1998 found pharmacists spent 46%

more time problem solving and 34% less time filling in prescriptions with system implementation (67). Other studies have also demonstrated an increase in time for direct and indirect patient care and a reduction in pharmacist interventions for prescriptions (68)(69). The main advantages of implementing ePresribing for the benefit of key stakeholders are summarised in Table 1.3 adopted from the Health Information and Quality Authority (HIQA) (70).

Table 1.3: Benefits of ePrescribing for key stakeholders adopted from HIQA (70) Receiver Benefits

Patients  Reduced transcription errors

 Improved legibility and precision of prescriptions

 Accuracy and speed of dispensed prescriptions through more efficient processes

Doctors, nurses, other prescribers

 Reduced interruptions from pharmacies querying prescriptions and fewer prescriptions returned to prescribers for non-compliance with legal or subsidy requirements

 Better clinical decision-making leading to safer and higher quality of care through timely access to patient information

Pharmacy staff

 Use of a common list of medicines in both prescriber and pharmacy systems to improve efficiency

 Improved quality of prescription information and a reduction in time spent contacting prescribers to clarify or correct prescriptions

 Ability to download prescription details facilitating efficiency with less potential for error

Organisations  Improved health information flow efficiency and a reduction in duplicate prescribing

 Efficiency gains enabling pharmacists to provide other patient-centered services

 Improved consistency with the adoption of ePrescribing standards

 Better understanding and control of policies, processes, and mechanisms that ensure the privacy of ePrescribing

Even with such potential benefits, digital transformation in health service delivery is not realised in many countries. The Prescription for Excellence report by the Scottish Government in 2013 states ePrescribing and related CDS has only been implemented in a select few acute hospitals in Scotland and not to its full potential (71). Based on the European Hospital Survey: Benchmarking Deployment of eHealth Services (2012-2013) report published by the European Commission (EC) in 2014, Ireland lags behind many European states with ePrescribing implementation (Table 1.4) (72). No Irish hospital in the public sector and only a small number of UK hospitals have introduced hospital-wide integrated ePrescribing systems between prescribers and dispensers (73).

Table 1.4: European hospital survey: benchmarking deployment of eHealth services (2012-2013) adopted from the EC (72)

Country ePrescribing CDS

Contributory factors to implementation delay may be due to financial constraints, lack of product offerings to deliver benefit, and regulatory barriers. Beyond those challenges, prescribers have also been slow to embrace new systems that require changes in workflow and investment in training. A perception that systems are technically challenging, that other systems need to be in place before these systems are rolled out, or that the culture change required for adoption into clinical practice is too complex can lead to resistance (73)(74).

implemented ePrescribing in England, the report Electronic prescribing in hospitals: challenges and lessons learnt published by the NHS Connecting for Health in 2009 conveys ePrescribing is achievable and beneficial with careful planning and a multidisciplinary team effort (73).