Benefit Description Quantification/KPI
Reduction in medication errors. Comparison with prescribing and medicines use errors.
Reduction in omitted medicines. Comparison of pre and post data sets.
More efficient use of medicines. Reuse of patient’s medicines, reduced repeat dispensing. More efficient use of staff time
Medical Nursing Pharmacy
Impact on ward round, prescribing time for inpatient, outpatient and discharge; order turnaround and administration turnaround time.
Support safe, accurate, effective prescribing.
Comparison with prescription and administration audits/ errors.
Support safe, accurate and timely patient discharge.
Complete, accurate and timely discharge prescriptions. Increased compliance with the standard of information related to discharge medications.
Audit of discharge information and comparison against data from Easynote.
Improvement in information given to patient, data collection of medication information sheets printed and given patients. Comparison with manually generated information.
Efficient automated reporting on prescribing and medicines use.
Accurate accounting of tariff and non-tariff/high cost drugs and use eg reconciliation, review and delay/omission of medicines.
Improved information relating to medication use.
Ability to collect and analyse prescribing information of medicines including abusable drug and reconcile with pharmacy issue information.
Reduction in prescribing stationary
9 Financial summary
9.1.1 A bid should be placed with the technology fund in 2015 to gain capital investment to offset Trust liabilities. Additional capital funding should be sought from commissioners in view of the significant benefits delivered to the CCG and GPs. 2015/16 2016/17 2017/18 2018/19 2019/20 Capital investment £384,400 £100,000 £25,000 £25,000 £25,000 Staffing Costs £296,129 £296,129 £183,364 £183,364 £183,364 Operating Costs £148,400 £98,400 £98,400 £98,400 £98,400 Variable Costs £150,000 Estimates savings £30,000 £270,000 £786,000 £786,000 Net Impact £978,929 £464,529 £37,264 -£478,736 -£478,736
10 Bibliography
1. National Advisory Group on the Safety of Patients in England. A promise to act - A
commitment to learn. Improving the Safety of Patients in England . 2013.
2. Frontier Economic. Exploring the costs of unsafe care in the NHS. s.l. : Department of Health, 2014.
3. NHS England. http://www.nrls.npsa.nhs.uk/resources/type/data- reports/?entryid45=135304. NRLS. [Online] NHS England , October 2014.
4. National Reporting and Learning System. Organisation Patient Safety Incident Report
Kettering General Hopsital. s.l. : National Reporting and Learning System, 1 October 2013 to
31 March 2014.
5. Trust, Pharmacy Department Kettering General Hopsital NHS Foundation. Pharmacy
contributions to care audit report. November 2013.
6. Dornan, Time and et, al. An in depth investigation into causes of prescribing errors
byfoundation trainees in relation to their medical education. EQUIP study. 2009.
7. Insider, eHealth. Better NHS IT could avoid 16,000 deaths. eHealth Insider. [Online] 18 October 2011. http://www.ehi.co.uk/news/acute-care/7247.
8. 2011. Rodriguez and et al.
9. ScHARR. Journal of Health Services Research and Policy,. 2008, Vol. Vol 13, No 2. 10. Ascribe. Benefits and Cost Improvement Nomogram Kettering General Hospital. 2011. 11. Nicholls, Jane. Contributions to improving safety of patients at discharge from secondary care to other care settings. Patient Safety First. [Online] 2 October 2014.
11 APPENDIX 1 – FINANCIAL BREAKDOWN
Item 15/16 16/17 17/18 18/19 19/20 EPMA Purchase £ 300,000 Server Capacity £ 59,400 Hardware £ 25,000 £ 100,000 £ 25,000 £ 25,000 £ 25,000 Infrastructure Interfacing £50,000 Total Capital £ 434,400 £ 100,000 £ 25,000 £ 25,000 £ 25,000 Licenses £ 98,400 £ 98,400 £ 98,400 £ 98,400 £ 98,400EPMA lead Pharmacist (1WTE x band 8b) £ 60,357 £ 60,357 £ 60,357 £ 60,357 £ 60,357
EPMA Pharmacy Technician (1WTE band 5) £ 29,067 £ 29,067 £ 29,067
Project Manager (1WTE x band 7) £ 43,543 £ 43,543
Clinical Facilitators (3 WTE x band 6) £ 108,917 £ 108,917
Clinical Facilitators (1 WTE x band 6) £ 36,306 £ 36,306 £ 36,306
IT technical support (1 WTE x band 5) £ 29,067 £ 29,067 £ 29,067 £ 29,067 £ 29,067
Information Analyst (1WTE x band 5) £ 29,067 £ 29,067 £ 29,067 £ 29,067 £ 29,067
IT trainer (1 WTE band 4) £ 25,178 £ 25,178
Total Staff Costs £ 296,129 £ 296,129 £ 183,864 £ 183,864 £ 183,864
Deployment £ 150,000
Avoiding medication errors (reduced
length of stay) -£ 10,000 -£ 150,000 -£ 250,000 -£ 250,000 Reduced Drug expenditure -£ 10,000 -£ 50,000 -£ 100,000 -£ 100,000 Printing savings -£ 10,000 -£ 20,000 -£ 50,000 -£ 50,000
Forecast cash releasing savings £ - -£ 30,000 -£ 220,000 -£ 400,000 -£ 400,000
Releasing nursing time to care -£ 200,000 -£ 200,000 Pharmacy efficiency -£ 36,000 -£ 36,000 Junior doctor efficiency -£ 50,000 -£ 50,000
Forecast productivity savings £ - £ - £ - -£ 286,000 -£ 286,000
Reduced litigation cost
Printing savings
Forecast quality savings £ - £ - £ - £ - £ -
Q ua lit y Comm ission er Staffing breakdown Savings Pr od uc tiv ity Ca sh
Reduced Drug expenditure -£ 50,000 -£ 100,000 -£ 100,000
Invoice reconciliation savings
Forecast commissioner savings £ - £ - -£ 50,000 -£ 100,000 -£ 100,000
Total Savings £ - -£ 30,000 -£ 270,000 -£ 786,000 -£ 786,000
Total impact £ 978,929 £ 464,529 £ 37,264 -£ 478,736 -£ 478,736
Comm ission
12 APPENDIX 2 - Benefits realisation case from Royal
Cornwall Hospital Trusts
12.1.1 The following pages are from the EPMA benefits realisation case published by Royal Cornwall Hospitals Trust
Electronic Prescribing and Medicines Administration (EPMA)
Interim Benefits Realisation Paper
1.0
Introduction
In October 2011 the Trust signed off the Electronic Prescribing and Medicines Administration (EPMA) business case. The implementation of eDischarge ran from February 2012 to November 2012 and the implementation of inpatient EPMA began in December 2012 and was completed in December 2013.
This paper is an initial analysis of the benefits realisation of these deployments compared to the original business case and will help to inform the Trust on whether the project has delivered on these efficiency and income objectives (section 2.5 of the original business case).
As the project moves out of the capital deployment phase and into the ‘business as normal’ revenue expenditure it is important that the project can evidence the benefits of EPMA.
2.0
Efficiency and Income Objectives (from the original
business case)
2.1 Improved Formulary Control and Adherence
The original business case stated:
Interim Benefits Realisation Analysis: ACHIEVED
Electronic outpatient prescribing has yet to be implemented (planned for 14/15). Most inpatient clinical areas have not been live with inpatient EPMA long enough to
have meaningful data. So this analysis just looks at those clinical areas that have been live for over 6 months.
There are many other confounding influences on inpatient drug expenditure including activity, inflationary cost pressures, new drugs, ward closures and changes in ward functionality. However, the areas in this analysis are probably less prone to such factors.
The Trust spends in the regions of £23.5million/ annum on all drugs. £9million of this is cancer drug expenditure and is excluded from the calculations in this business case, as it is prescribed through the Aria cancer prescribing system. Therefore, for the purposes of this business case a figure of £14.5 million will be used to base the savings on.
E-Prescribing can improve formulary control by:
Forbidding the prescribing of certain drugs on the system.
Restricting the prescribing of certain drugs to specific individuals/ specialities.
Building certain drugs into easy to prescribe ‘script’ regimens e.g. ‘Chest infection’ script- would automatically prescribe the correct antibiotics.
A reduction in drug expenditure of 2.5% would seem an achievable target. This must be offset against an annual rise in drug expenditure of 9% (figure for 10-11).
It should also be noted that approximately 65% of £14.5million drug spend is PbR excluded and therefore the savings will be across the healthcare community.
2.1.1 Child Health
Table 1: Comparable 8 month period pre and post EPMA deployment in Child Health (went live in Dec 12)
April May June July Augus t
Sept Oct Nov Total (£) 201 2 38,704 46,24 4 31,67 0 38,96 5 42,360 27,36 9 54,26 4 40,39 7 319,97 3 201 3 33,150 42,07 8 29,77 0 37,86 2 33,725 29,75 4 37,97 0 32,38 4 276,69 3
This is a reduction of £43,280, a 13.5% reduction in drug expenditure.
2.1.2 Marie Therese House
Table 2: Comparable 8 month period pre and post EPMA for Marie Therese House (went live Feb 2013)
April May June July August Sept Oct Nov Total (£) 2012 4,964 5,031 1,880 4,772 6,104 5,639 4,011 2,572 34,973 2013 3,360 3,629 1,590 3,839 4,670 3,413 2,581 6,775 29,857
This is a reduction of £5,116, a 14.5% reduction in drug expenditure.
2.1.3 St Michaels Hospital Wards
Table 3: Comparable 5 month period pre and post EPMA for St Michaels Hospital (went live in May 2013)
July August Sept Oct Nov Total (£) 2012 744 1,827 1,483 2,093 696 6,843 2013 786 1,404 567 1,593 1,891 6,242
This is a reduction of £601, an 8.8% reduction in drug expenditure.
2.1.4 West Cornwall Hospital
Table 4: Comparable 6 month period pre and post EPMA Med 1 at WCH (went live in April 2013)
June July August Sept Oct Nov Total (£) 2012 4,454 6,696 4,790 4,671 4,986 4,447 30,044 2013 2,777 5,633 4,841 5,163 5,494 5,197 29,105
This is a reduction of £939, a 3% reduction in drug expenditure.
Med 2 was closed for part of the year in 2012 and therefore comparisons pre and post implementation are difficult.
2.1.5 Summary
The total drug expenditure in the comparable period pre implementation was £391,232 and post implementation was £342,498. This is a difference of £48,734 or 12.5%.
The drug expenditure savings target for 13/14 was £2.5million on a budget of approximately £28.5m- or 8.8%. So correcting for the drug saving expenditure there remains a saving of 3.7% which could be attributed to EPMA. However, this figure needs to be treated with caution as there are many other confounding factors that influence drug expenditure. Further analysis will be undertaken once EPMA has been embedded for longer within the Trust.
2.2 Improved TTA Turnaround- Reduction in Length of Stay
The original business case stated:
Interim Benefits Realisation Analysis: TO BE ASSESSED
The elements (1-3 above) of EPMA that will speed up the processing time have all been implemented.
A further development of electronic transfer of TTAs to the pharmacist is being worked on and we hope to pilot in January 2014.
A repeat audit will be undertaken in mid-2014 to establish whether the turnaround time benefits have been realised.
2.3 Drug Charts- saving on stationary
The original business case stated:
Interim Benefits Realisation Analysis: ACHIEVED
Child health order their drug charts via Collector Set Printers.
Table 5: Collector Set Printers Expenditure 8 month pre and post EPMA implementation (implementation Dec 12)
‘Collector Set Printers’ Expenditure (£) Saving (£)
April 2012- Nov 2012 4,950 3,036
Dec 2012- Aug 2013 1,914
The savings pro rata in child health for 12/13 are £4.5k. It would appear that the stationary savings across the Trust will be realised.
A recent audit on the TTA process showed that a TTA takes an average of 5 hours to reach the patient from the moment of decision to discharge. Over half of this time is waiting for the TTA to be prescribed and then for it to reach pharmacy.
ePrescribing will speed this process up by:
1. The drugs will already be prescribed electronically, to transfer these to the TTA form is a simple tick box exercise.
2. The pharmacist can automatically be made aware a TTA is on the system and not rely on being called by the ward staff to be informed. The pharmacist can then screen the TTA remotely if they are unable to attend the ward.
3. For wards that don’t have a regular ward pharmacist, the TTA can be screened by the dispensary pharmacist without the need for the ward to bring the drug chart and TTA down to the dispensary.
ePrescribing should be able to deliver a 60mins reduction in the turnaround time of a TTA and the pharmacy department dispenses approximately 1,800 TTAs/ month, equating to 2.4 beds/ yr. The NHS Institute for Innovation costs an average bed at £300/day
Annual saving= £300 x 2.4 x365= £256K/ annum
The Trust spent £18K/ annum on drug charts between Sept 09 and Oct 10
2.4 NHSLA level 2 Attainment
The original business case stated:
Interim Benefits Realisation Analysis: ACHIEVED
NHSLA level 2 for medicines management was indeed achieved with no comments back from the auditors. During the audit the inspector viewed the electronic
‘pharmacist friend’ tool, developed from EPMA, and used this as evidence for our medicines reconciliation completion rates.
2.5 Reduction in Patient harm
The original business case stated:
Interim Benefits Realisation Analysis: PARTLY ACHIEVED
There has been no occurrence of a patient being administered a drug they have a documented allergy on an EPMA ward since its implementation.
EPMA can restrict prescribing roles to improve safety e.g. Foundation Year 1 doctors are not able to prescribe cytotoxic agents on EPMA to ensure compliance with Royal College guidance.
The Trust now has a much better understanding of missed dose rates in each clinical area and is working on robust plans to reduce their occurrence.
2.6 Writing and Rewriting of Drug charts
The original business case stated:
NHSLA level 2 and subsequent reduction in insurance premium requires the Trust to give assurance that the accuracy of prescribing is being checked. Currently some inpatient drug requests are not checked against the patient drug chart by a pharmacist as this would require the drug chart to be taken to pharmacy and increase the risk of missed doses. Although the drug is checked for appropriateness of dose it is not checked against the rest of the chart, this is not best practice and may not be deemed as meeting the criteria by NHSLA for level 2 status. The availability of electronic drug charts would mean all requests could be screened against the patients drug chart and level 2 would be easily achieved.
The reduction in patient harm will have financial benefits to the wider community and reduce the risk of extended stays and litigation against the Trust. Examples of reducing harm are:
Allergy status- this can be made a mandatory requirement before prescribing takes place and the system will also flag is a patient is prescribed a drug they are allergic to.
Prevention of prescribing by non-prescribers- the recent Airedale report highlighted a case of nurses prescribing inappropriately for patients under their care, resulting in patients’ death. Electronic prescribing would only allow approved prescribers access to the prescribing function.
Reduction in missed doses, as these are highlighted by the system and must be actioned by the nursing caring for the patient.
Doctors would no longer be required to rewrite drug charts saving considerable junior Dr time.
When a patient is readmitted, the Doctor would have immediate access to their medication record from their previous admission and can quickly represcribe these items by simple mouse click.
Interim Benefits Realisation Analysis: ACHIEVED
Audit data shows that 8 hours a week on Dr time is saved by not having to rewrite drug charts.
The Dr can use reactivate a drug chart from a previous admission.
2.7 Improved Medicines Reconciliation
The original business case stated:
Interim Benefits Realisation Analysis: ACHIEVED
Medicines reconciliation by pharmacy is not formally recorded within paediatrics, St Michaels Hospital or Marie Therese House.
West Cornwall hospital is the only go-live area with sufficient data for this indicator. The results are shown in chart 1.
Chart 1:
The average medicines reconciliation rate pre-implementation was 77%, the average medicines reconciliation rate post implementation is 90%.
2.8 Remote prescribing
The original business case stated:
Interim Benefits Realisation Analysis: ACHIEVED
This is now possible, though there has been no measure of what efficiencies this has produced to date.
When a patient is readmitted, the medication record from their previous admission is available and can allow for faster and more accurate medicines reconciliation
Doctors will be able to prescribe for patients remotely where appropriate rather than attending the ward, reducing the need for telephone orders (against NMC guidelines) and homely remedies. This could help to drive efficiencies in the hospital at night teams and off-site provision
2.9 Remote Clinical Screening
The original business case stated:
Interim Benefits Realisation Analysis: ACHIEVED
Pharmacists are now able to screen remotely and the development of the ‘pharmacist friend’ tool means they can target those patients that most need pharmaceutical care.
2.10 Automatic Ordering
The original business case stated:
Interim Benefits Realisation Analysis: ACHIEVED
‘E-non stocks’ were implemented in November 2013 and have been very well received by the nurses. It also means requests are waiting for us to process from first thing in the morning.
2.5.11 Service Line Reporting
The original business case stated:
Interim Benefits Realisation Analysis: PARTLY ACHIEVED
There is now the ability to deliver full service line reporting for drugs to patient level. The EPMA system does not however, automatically provide this data and some
manipulation by an information analyst will be required to link drug usage to drug cost.
2.12 Audit
The original business case stated:
Interim Benefits Realisation Analysis: ACHIEVED
An example currently being used is the antibiotic webpage, which is used by the antimicrobial stewardship team to highlight those patients on inappropriate high risk antibiotics. This tool was commended at the recent antimicrobial peer review by Salford Hospital Trust.
Pharmacists currently have to check all drug charts on the wards when performing the clinical screen. Electronic prescribing will all redesign of the clinical pharmacy service, where some screening can happen remotely and only those patients deemed high risk are visited.
The ePrescribing system will automatically generate orders for drugs that are not stocked on a ward. This saves nursing and pharmacy time in having to transcribe these orders onto paper.
ePrescribing gives the potential for full service line reporting for drugs to patient level.
The wealth of data that ePrescribing captures facilitates clinical audit e.g. prescribing of restricted antibiotics, NSAID prescribing in the elderly, NICE compliance, formulary compliance and will drive improvements in prescribing practice.
2.13 Enhanced Reputation for the Trust
The original business case stated:
Interim Benefits Realisation Analysis: ACHIEVED
This has been a good news story for the Trust in the local news.
The chief pharmacist has been asked to present at the National Health and IT conference (HC2014) in March 2014.
We have had a number of site visits from other Trusts looking to implement EPMA.
2.14 Increased income through improved coding
The original business case stated:
Interim Benefits Realisation Analysis: Not yet tested
2.15 Increased income through improved drug usage reporting
The original business case stated:
Interim Benefits Realisation Analysis: Not yet tested The PCT are now the CCG.
Although this has yet to be tested, the indications from NHS England is certainly that this data will be required in the future.
2.16 Improved implementation of new guidance, standards and quality indicators
The original business case stated:
Interim Benefits Realisation Analysis: Not yet achieved
The VTE risk assessment will be part of the new version of EPMA to be implemented in Jan 2014. Once in place it will mandate the completion of the risk assessment before prescribing can continue.
Having electronic prescribing fully implemented in the Trust will clearly show that the Trust is committed to improving patient safety and the quality of care.
Anecdotal evidence from the eDischarge roll-out is that coding is improved and hence the Trust is more likely to recoup income for work done.
The requirements from the PCT (and the likely requirements of the GP commissioning consortia) for a minimum dataset for high cost drugs will soon be mandatory.
Eprescribing will be able to produce the reports required to secure this income, which would currently require a lengthy manual process and would be extreme pressures on our service.
Assessments such as venous thromboembolism (VTE), can be made mandatory before prescribing is allowed. This not only improves the quality of patient care but also secures CQUIN income for the trust.
3.0
Overall Summary
This interim benefits realisation paper shows that the EPMA is delivering against its objectives set out in the original business case. Further analysis will be required once EPMA has been in place for longer in Medicine and Surgery.
With the benefits being realised, this makes a strong case for the continued investment in the EPMA team post implementation as set out in the business case. An essential addition to this post implementation team is an information analyst. This
post has been part of the implementation phase and has been invaluable in the project realising many of the objectives.