Specification for a Welsh centre of excellence in user centred design by K2Tytb9

VIEWS: 1 PAGES: 13

									Informing Healthcare
National Architecture Design Board



Document Title:         Medicines Management

Document Lead:          Robin Mann
Date written:           16th November 2007
Version:                v0.4
For NADB:               12th December 2007


Summary
This document presents the strategic approach to delivering support for medicines
management across Wales.


Purpose

For approval of strategic fit.




                                                                                    Page 1 of 13
 Medicines Management programme                                                               DRAFT Version 0.3




Medicines Management
Version 0.4 16th November 2007

Dr Robin Mann, Head of Clinical Design
Cheryl Way, National Medicines Management Lead
Rhian Rice, National Project Manager


1. Executive summary
         1.1. A prescribed medicine is the most frequent treatment provided for patients
              in the NHS. Current spending in Wales is:
                 Primary care £550,000,000 p.a.
                 Secondary care £150,000,000 p.a.
         1.2. Medication errors are a major problem for the NHS:
                 Adverse drug events may cause up to 11% of hospital admissions1
                 Preventable errors cost the NHS ~£20 million every year
         1.3. Electronic prescribing is one method of reducing drug errors. An e-
              prescribing system was introduced at Brigham and Women’s hospital (1993)2
               After 2 years serious medication errors had decreased by 55%
               After 3 years, as decision support was introduced, serious medication
                errors decreased by 86%
               Cost savings over 10 years were estimated to be $28.5M
         1.4. Informing Healthcare’s e-prescribing team has visited and reported on 5
              major e-prescribing sites in the UK and one in the US. In addition, the team
              visited a chemotherapy prescribing site in Wales3
         1.5. The main conclusions of the site visits are:
               IHC should proceed to explore electronic prescribing in a defined
                programme of activity, undertaking careful and rigorous evaluation of the
                costs and benefits at specific decision points to ensure that the best value
                for money is being achieved.
               Implementation and training are major issues for electronic prescribing
                which can take up to 15 years within a single Trust. IHC should reduce
                the risks associated with electronic prescribing by implementing
                facilitative capability in advance via the Welsh Clinical Portal (e.g. test
                requests, TPR charts)
               Informing Healthcare should specifically explore two options for
                delivering e-prescribing:
                 Buy e-prescribing system (with or without pharmacy system
                     replacement)


         1
           Institute for safe medication practices, 2000
         2
           http://www.audit-commission.gov.uk/reports/AC-
         REPORT.asp?CatID=&ProdID=E83C8921-6CEA-4b2c-83E7-F80954A80F85
         3
           The Case for a Hospital Electronic Prescribing and Medicines Administration System for
         Wales, Draft, November 2007(under review)

                                                                                                    Page 2 of 13
Medicines Management programme                                                          DRAFT Version 0.3


                 Develop in-house as part of the Welsh Clinical Portal (not
                  chemotherapy)
             In addition, the site visit and published data have shown that electronic
              prescribing has proven benefits in chemotherapy and should be pursued
              without delay
       1.6. This document describes the proposed programme of activity, the aim of
            which is to:
               Deliver improved patient safety through reduction in preventable
                medication errors and adverse drug events
       1.7. The major objectives of the programme are to:
            Obj1     Identify the best approach to delivering electronic prescribing in
                     terms of value for money, where value is determined by specific
                     and quantifiable measures of patient safety. This will inform a
                     national business case for electronic prescribing
            Obj2     Deliver the products that are required to support electronic
                     prescribing, regardless of the approach
            Obj3     Deliver the facilitative technologies that will support the required
                     change management, in preparation for implementation, regardless
                     of approach
            Obj4     Deliver electronic prescribing in specific areas (chemotherapy)
                     where there are proven benefits and where this will not impact on
                     the strategic decision
       1.8. Objectives 1-3 are aligned to delivering the business case for electronic
            prescribing in Wales.
       1.9. The following projects form the initial project suite for the programme
               Chemotherapy
               dm+d mapping
               Transcribing projects
               e-Prescribing SIP
       1.10. The parallel development of the Welsh Clinical Portal, including making
            GP medicines records available in secondary care via the Individual Health
            Record (IHR), will be critical to facilitate culture change and acceptance in
            preparation for implementation.




                                                                                              Page 3 of 13
Medicines Management programme                                                                  DRAFT Version 0.3




2. Background
       The problem
       2.1. A prescribed medicine is the most frequent treatment provided for patients
            in the NHS. Current spending in Wales is:
               Primary care £550,000,000 p.a.
               Secondary care £150,000,000 p.a.
       2.2. Medication errors are a major problem for the NHS:
             They are the second largest category (after slips, trips and falls) reported
              to the NPSA, with 5000 incidents related to medication reported in the
              UK each month (~3500 p.a. in Wales)
                                                                                     4
             Adverse drug events may cause up to 11% of hospital admissions
             Preventable errors cost the NHS ~£20 million every year
       2.3. A study in Boston in 1993 found that: 6.5% of in patients suffered an
            adverse drug event (ADE); 28% of which were due to errors. 56% of the
            errors occurred at the prescribing stage and 34% at administration stage5
       2.4. The Audit Commission report ‘A spoonful of sugar’ (2001) proposed
            electronic prescribing be introduced across the UK as part of a whole
            systems approach to medicines management: ‘A standard national system for the
            coding of medicines and barcodes should be introduced across the whole of the NHS to
            support the development of electronic prescribing systems and automated dispensing systems’

       The Solution
       2.5. Electronic prescribing is one method of reducing drug errors. An e-
            prescribing system was introduced at Brigham and Women’s hospital (1993)6
             After 2 years serious medication errors had decreased by 55%
             After 3 years, as decision support was introduced, serious medication
              errors decreased by 86%
             Cost savings over 10 years were estimated to be $28.5M
       2.6. Over the last 10-15 years, electronic prescribing has been introduced into
            several hospitals in the UK and abroad. Some evaluation work has been
            published, which indicates that e-prescribing is most successful if part of a
            whole systems approach to patient safety
       2.7. Electronic prescribing comprises 9 elements, all of which are required for
            end to end medicines management:
             Medicines lists – the current list of medications that a patient is taking
              (this includes in-hospital medications and take home medications)
             Transcribing medications lists from paper to electronic systems on
              admission and discharge (this includes pharmacist reconciliation of
              primary and secondary care medicines)
             Pharmacy systems to maintain stock and run pharmacy departments


       4
         Institute for safe medication practices, 2000
       5
         Bates et al. JAMA, 1995
       6
         http://www.audit-commission.gov.uk/reports/AC-
       REPORT.asp?CatID=&ProdID=E83C8921-6CEA-4b2c-83E7-F80954A80F85

                                                                                                          Page 4 of 13
Medicines Management programme                                                             DRAFT Version 0.3


             Information standards
             Decision support to provide active guidance on prescribing practice
             Drug orders to pharmacy
             Medications administration records in hospital (the record of medications
              that a patient has been given)
             Complex instructions (e.g. intravenous infusions, Warfarin dosing,
              chemotherapy)
             Production to administration tracking of medicines
       2.8. The available publications generally report substantial benefits from
            electronic prescribing; however the publications report benefits in different
            areas and there are many sites where there is no evaluation data available at
            all. There is also the possibility of publication bias where negative findings
            have either not been submitted for publication or have not been selected for
            publication
       2.9. Rough calculations based on Scottish figures indicate that electronic
            prescribing could be procured for Wales for around £25 million. After 5
            years lead in time, the net savings could be £15 million per annum. This
            implies that electronic prescribing could pay for itself within 8 years and
            save £15 million revenue thereafter. These figures do not include
            implementation costs and are not robust, but they do suggest that electronic
            prescribing has the potential for reducing costs as well as improving patient
            safety and they do support further exploration of costs to determine the
            actual business case for e-prescribing across Wales.
       2.10. Informing Healthcare’s e-prescribing team visited and reported on 5
            major e-prescribing sites in the UK and one in the US7
               Chelsea and Westminster Hospital, London
               Arrowe Park Hospital, Wirral
               Queens Hospital, Burton
               Montagu Hospital, Doncaster
               Queen Elizabeth Hospital, Birmingham
               Brigham and Women’s Hospital, Boston, Massachusetts
       2.11.    In addition, the team visited a chemotherapy prescribing site in Wales.
       2.12.    The main conclusions and recommendations from the site visits are:
             The site visit and published data have shown that electronic prescribing
              has proven benefits in chemotherapy and should be pursued without
              delay
             Documentation of benefits and costs in e-prescribing sites is inadequate
              and insufficient to support a business case for the full implementation of
              e-prescribing across Wales without further detailed work
             IHC should proceed to explore electronic prescribing in a defined
              programme of activity, undertaking careful and rigorous evaluation of the
              costs and benefits at specific decision points to ensure that the best value
              for money is being achieved
             Implementation and training are major issues for electronic prescribing
              and can take up to 15 years within a single Trust. IHC should reduce the

       7
        The Case for a Hospital Electronic Prescribing and Medicines Administration System for
       Wales, Draft1, November 2007 (under review)



                                                                                                 Page 5 of 13
Medicines Management programme                                                          DRAFT Version 0.3


              risks associated with electronic prescribing by implementing facilitative
              capability in advance via the Welsh Clinical Portal (e.g. test requests, TPR
              charts)
             Informing Healthcare should specifically explore two options for
              delivering e-prescribing:
               Buy e-prescribing system (with or without pharmacy system
                  replacement)
               Develop in-house as part of the Welsh Clinical Portal (not
                  chemotherapy)
       2.13. The remainder of this document concerns the proposed programme of
            activity to deliver electronic prescribing in an incremental and phased
            manner to reduce risks and ensure value for money for Wales.


3. Aims and objectives
       3.1. The aim of the electronic prescribing programme is to:
               Deliver improved patient safety through reduction in preventable
                medication errors and adverse drug events
       3.2. The major objectives are to:
            Obj1      Identify the best approach to delivering electronic prescribing in
                      terms of value for money, where value is determined by specific
                      and quantifiable measures of patient safety. This will inform a
                      national business case for electronic prescribing
            Obj2      Deliver the products that are required to support electronic
                      prescribing, regardless of the approach
            Obj3      Deliver the facilitative technologies that will support the required
                      change management, in preparation for implementation, regardless
                      of approach
            Obj4      Deliver electronic prescribing in specific areas (chemotherapy)
                      where there are proven benefits and where this will not impact on
                      the strategic decision
       3.3. Objectives 1-3 are aligned to delivering the business case for electronic
            prescribing in Wales.


4. Outline plan
       4.1. The outline plan is illustrated in figure 2.

       Current position (November 2007)
       e-Prescribing
       4.2. The Pharmacy system has been migrated from an unsupported and
            distributed MUMPs platform to a supported and centralised Cache
            platform. This upgrade is expected to be sufficient to meet pharmacy needs
            for 3-5 years.




                                                                                              Page 6 of 13
Medicines Management programme                                                        DRAFT Version 0.3


       4.3. Transcribing projects in C&D and C&V Trusts are underway. The C&V
            Trust project is managed by the IHC e-prescribing team and is under IHC
            control. There an opportunity to learn from the C&D project.
       Facilitative technologies
       4.4. Test requesting and results reporting (TRRR) is being developed within
            version 1 of the Welsh Clinical Portal. Doctors who use the Welsh Clinical
            Portal to request tests will require less training to request medicines in the
            future than colleagues who do not use the portal.

       Next steps (November 2007 – November 2008)
       e-Prescribing
       4.5. The following projects are described in more detail in section 5.
               Chemotherapy
               dm+d mapping
               Transcribing projects
               e-Prescribing SIP
       4.6. The availability of GP medicines records via the Individual Health Record
            (IHR) to Welsh Clinical Portal users will be an important factor in the
            usefulness of transcribing systems.
       Facilitative technologies
       4.7. Implementation of Welsh Clinical Portal clinical communications functions
            will encourage routine use of the portal for common clinical tasks. Version
            2(a) will enable referrals to be created by nurses and discharges to be created
            by doctors. Version 2(a) will offer significant communications capability but
            also highlight the value of capturing and re-using clinical data. Version 2(b)
            will further support clinical handover, which will allow doctors to maintain
            medicines lists (checked by pharmacists), and allow nurses to maintain bed
            status, which will support accurate location and transfer information.
       4.8. Clinical communications, whilst important, are not as risky to patient safety
            as prescriptions: an error in a clinical letter is unlikely to result in direct
            harm. Introducing Version 2 components before full e-prescribing is
            implemented will significantly de-risk the electronic prescribing
            implementation. Doctors and nurses who use Version 2 will be greatly
            advantaged in their skills are more likely to be ready for electronic
            prescribing and recording of medicines administration.

       Major decision point (December 2008)
       4.9. The results of the evaluation of the e-prescribing SIP and analysis of
            progress with the Welsh Clinical Portal should enable a decision to be made
            as to the preferred approach. This will inform the business case (see below)

       Medium – longer term activity
       e-Prescribing
       4.10. The two major options are the procurement route (e-prescribing system
            (with or without pharmacy system replacement)), and the Welsh Clinical
            Portal route:


                                                                                              Page 7 of 13
Medicines Management programme                                                         DRAFT Version 0.3


             The procurement route will need to be aligned to the IHC procurement
              methodology. The detail of how a supplier system will interact with the
              Welsh Clinical Portal will need to be defined.
             WCP development route will require further work to develop
              functionality for hospital electronic prescribing (requests to supply and
              administer medicines), administration records and tracking.
       Facilitative technologies
       4.11. Implementing the ability for nurses to capture observations (temperature,
            pulse, respiration (TPR), and other readings) and clinical assessments will
            provide them with the skills and routines required to record medicines
            administration safely. The use of the Welsh Clinical Portal to capture
            observations will de-risk the introduction of medicines administration.
            Observation recording will include the use of alerts to indicate when patients
            are at risk of sepsis, which will introduce nurses to these concepts in a
            controlled and safe way.

       Out of project activity (May 2008 - December 2008)
       4.12. A business case will be required for spend on e-prescribing across Wales.
            Timescales need to be worked through in more detail; however, work on the
            strategic case with high level options could start from May 2008. The
            preferred option for the OBC would be available following the evaluation of
            the e-prescribing pilot.
       4.13. The business case will need to include options for the pharmacy system
            replacement regardless of which e-prescribing route is taken.
       4.14. A revision of the electronic prescribing programme plan including
            project mandates for activity required to deliver the preferred approach
            would be needed for the decision point in December 2008.




                                           Figure 2
                        Outline electronic prescribing programme plan




                                                                                             Page 8 of 13
Medicines Management programme                                                            DRAFT Version 0.3


          (Dark green boxes are ‘systems’, light green boxes are Welsh Clinical Portal
          prescribing related ‘services’, red boxes are facilitative technologies delivered
                                through the Welsh Clinical Portal)


5. Initial Project Suite
       5.1. This section provides details for the initial projects identifies in section 4.5
            above:
                Chemotherapy
                dm+d mapping
                Transcribing projects
                e-Prescribing SIP



                 Project      Chemotherapy prescribing
             Background       Chemotherapy is a discrete area of practice governed by
                              complex guidelines and pathways. Wales’ cancer groups
                              support the need for a common system across Wales and each
                              of the 3 cancer networks in Wales have the Chemocare system
                              in at least one site. There is an immediate need to support this
                              specialised area of practice and work to look at options for
                              Wales should start immediately
                    Status    Mandated
                              IHC has appointed a clinical pharmacist with expertise in
                              chemotherapy systems to lead this work. A project initiation
                              document is required.
                 Objectives    Identify the approach to supporting chemotherapy in Wales
                               Gain agreement of this approach from Cancer services
                               Produce business case
                               Deliver the approach
                     Scope    Includes both cancer treatment centres and satellite
                              chemotherapy provision.
             Deliverables      Medicines lists for chemotherapy
                               Decision support to provide active guidance on prescribing
                                  practice
                               Medications administration records in cancer treatment and
                                  associated centres
                               Complex instructions (chemotherapy)
              Exclusions      Anything outside chemotherapy
              Constraints     tbc
            Dependencies      Interfaces with WCP and PCR
         Outline Business     Obj4 Deliver electronic prescribing in specific areas where
                    Case               there are proven benefits and where this will not
                                       impact on the strategic decision
              Customer's      An implemented chemotherapy prescribing system that is
                  quality     being used across Wales to support cancer care. The system
             expectations
                              must ‘interface’ with the Welsh Clinical Portal in an agreed
                              manner.
                Acceptance    tbc
                  Criteria


                                                                                                 Page 9 of 13
Medicines Management programme                                                            DRAFT Version 0.3


              Known risks     tbc




                   Project    dm+d mapping
               Background     Pharmacy systems currently used in Wales contain information
                              about local hospital formularies and local medicines stock.
                              This information is needed by transcription and e-prescribing
                              systems to limit the number of available medicines for
                              prescription. It is also needed for reporting purposes (Medusa).
                              A common coding system is required to support these needs.
                              The strategic option is the dictionary of medicines and devices
                              (dm+d), which is mapped to SNOMED-CT8
                    Status    Agreed but not mandated
                 Objectives   To map the current Medusa codes to dm+d
                     Scope    tbc
               Deliverables    Information standards
                Exclusions    tbc
                Constraints   tbc
           Outline Business   Obj2 Deliver the products that are required to support
                      Case            electronic prescribing, regardless of the approach
              Dependencies    tbc
                Customer's    The current pharmacy systems will be able to interact with
                    quality   current and future transcribing and e-prescribing systems using
               expectations
                              dm+d
               Acceptance     tbc
                 Criteria
              Known risks     Ongoing maintenance of dm+d codes must be supported
                              (HSW are currently funded by WAG to £8k pa for coding
                              updates)



                   Project    Transcribing projects
               Background   Transcribing systems in are based on the best practice
                            ‘Shrewsbury approach’ where pharmacists maintain medicines
                            lists and use these to maintain ward and bedside stocks. Direct
                            interfacing with the pharmacy system may not be essential (to
                            be proven) but will increase utility and reduce patient risks.
                            Decision support helps pharmacists in their role to check
                            doctors’ prescriptions for errors.
                   Status C&V transcribing SIP in progress
                 Objectives To deliver a system that pharmacists can use to maintain
                            medicines lists and stock.
                            Use of decision support that reduces medicines error rates
                    Scope Pharmacist use on up to 6 wards only
                            Interim system will be developed into WCP compliant system

       8
           Coding paper

                                                                                                 Page 10 of 13
Medicines Management programme                                                          DRAFT Version 0.3


             Deliverables   Phase 1
                             Medicines lists in hospital (including take-home medicines)
                             Transcribing medications lists from paper to electronic
                                systems on admission and discharge (incorporating
                                medicines reconciliation)
                             Decision support to provide active guidance on prescribing
                                practice
                            Phase II
                             Drug orders to pharmacy
                             Information standards
                             System evaluation
              Exclusions    The system will not be developed further outside the WCP
                            development programme
              Constraints   tbc
            Dependencies    dm+d mapping project for full functionality
         Outline Business   Obj1 Identify the best approach to delivering electronic
                    Case             prescribing in terms of value for money, where value is
                                     determined by specific and quantifiable measures of
                                     patient safety
                            Obj2 Deliver the products that are required to support
                                     electronic prescribing, regardless of the approach
                            Obj3 Deliver the facilitative technologies that will support
                                     the required change management, regardless of
                                     approach
              Customer's    A system for maintaining and reconciling medicines lists that
                  quality   provides the TTO medication confirmation at discharge. The
             expectations
                            system is being used and has been approved by all Pharmacists
                            who operate in the deployment areas.
                            The user interface will be incorporated into the WCP and there
                            is an agreed convergence plan to use the WCP in the future
              Acceptance    Non portal compliance will be considered acceptable under
                Criteria    agreed circumstances
            Known risks     tbc



                 Project    ePrescribing SIP
             Background     One of the major options for e-prescribing is to procure a
                            pharmacy system with an e-prescribing module. The only
                            opportunity to do this in Wales is in Swansea where there is a
                            JAC pharmacy system in Morriston Hospital and an ASCribe
                            pharmacy system in Singleton Hospital. The ASCribe-
                            prescribing system is less well established than JAC’s and use
                            of the JAC prescribing system will provide better data.
                 Status     Mandate
               Objectives   To evaluate specific aspects of electronic prescribing in Wales
                            to inform the business case and to inform the decision on
                            buy/build at the programme checkpoint.
                   Scope    Maximum 2 clinical areas in Morriston Hospital, Swansea
             Deliverables    Pharmacy systems to maintain stock and run pharmacy
                                departments
                             Decision support to provide active guidance on prescribing


                                                                                               Page 11 of 13
Medicines Management programme                                                                         DRAFT Version 0.3


                                  practice
                                 Drug orders to pharmacy
                                 Medications administration records in hospital (the record
                                  of medications that a patient has been given)
                Exclusions    The e-prescribing module of JAC will not be rolled out across
                              Swansea, even if successful, unless IHC has agreed this as part
                              of a convergence path with the Welsh Clinical Portal.
                Constraints   Pilot must completed in 6-12 months. IHC funding will not
                              continue beyond the evaluation period.
            Dependencies      JAC support for e-prescribing implementation
         Outline Business     Obj1 Identify the best approach to delivering electronic
                    Case              prescribing in terms of value for money, where value is
                                      determined by specific and quantifiable measures of
                                      patient safety
              Customer's      The outputs of the baseline testing and evaluation to be agreed
                  quality
             expectations
              Acceptance      Quantitative and qualitative data against the evaluation criteria
                Criteria
             Known risks      Swansea may not be able to switch off the e-prescribing
                              functionality even if it proves the wrong approach


6. Evaluation plan
       6.1. ‘We have delivered great results but if you get something wrong it is possible to kill a
            patient inside 5 minutes’ (Brigham and Women’s Hospital, Boston).
       6.2. Electronic prescribing introduces streamlining of clinical processes and
            enhanced decision support, but these can result in over reliance on systems
            and less time to notice if things are going wrong.
       6.3. The safety critical nature of electronic prescribing and the need for actual
            statistics on cost and benefits to support the overall business mean that a
            rigorous evaluation plan is needed.
       6.4. The overall evaluation will be of the products of the projects not the
            projects themselves (these can be undertaken separately). Evaluation should
            minimally include:
                 Baseline measurements
                 Post implementation measurements
                 Controls
       6.5. Measurements of impact should minimally include:
                 Cost
                 Patient safety
                 Patient satisfaction
                 Clinician performance
                 Clinician satisfaction
       6.6. Evaluation could be outsourced to specialist / academia (for discussion).
            This would ensure independence and create less demand on IHC resources.
       6.7. IHC should publish the findings of the evaluation irrespective of outcome.
            It should aim to publish in relevant academic journals to increase the validity
            of the findings.

                                                                                                            Page 12 of 13
Medicines Management programme                                               DRAFT Version 0.3


7. Governance arrangements
       7.1. TBC – to include Project boards, NADB, Professional groups, 3M, PRM,
            etc.


8. Resource plan
       Human resources:
       8.1. IHC e-prescribing team (core team highlighted)
             Clinical
               Cheryl Way, National Medicines Management Lead
               Colin Powell, Chemotherapy Lead, Pharmacy
             Clinical Design
               Robin Mann, Head of Clinical Design
               David Rose, Clinical Design Lead - Pharmacy
             Project management
               Rhian Rice, National Project Manager
             Technical
               Proposal to use Robin Burfield for technical support
       8.2. Evaluation team
               Robin Mann
               Dan Warm
               ?? external

       Financial resources
       8.3. TBC




                                                                                   Page 13 of 13

								
To top