Enhancing efficiency in pharmacy and patient management: The RxSolution experience at the Intermediate Hospital Oshakati, Namibia.

Transcription

1 Republic of Namibia Ministry of Health and Social Services Enhancing efficiency in pharmacy and patient management: The RxSolution experience at the Intermediate Hospital Oshakati, Namibia. February 2012 Christopher Ntege David Mabirizi Shannon Kakungulu Stanslaus Madende Edward Muchadeyi Mbayi Kangudie

2 This report is made possible by the generous support of the American people through the US Agency for International Development (USAID), under the terms of cooperative agreement number AID-OAA-A The contents are the responsibility of Management Sciences for Health and do not necessarily reflect the views of USAID or the United States Government. About SIAPS The goal of the Systems for Improved Access to Pharmaceuticals and Services (SIAPS) Program is to assure the availability of quality pharmaceutical products and effective pharmaceutical services to achieve desired health outcomes. Toward this end, the SIAPS result areas include improving governance, building capacity for pharmaceutical management and services, addressing information needed for decisionmaking in the pharmaceutical sector, strengthening financing strategies and mechanisms to improve access to medicines, and increasing quality pharmaceutical services. Recommended Citation This report may be reproduced if credit is given to SIAPS and the Strengthening Pharmaceutical Systems (SPS) projects. Please use the following citation: Ntege C, Mabirizi D, Kakungulu S, Madende S, Muchadeyi E, Enhancing efficiency in pharmacy and patient management: The RxSolution experience at the Intermediate Hospital Oshakati, Namibia. Submitted to the US Agency for International Development by the Strengthening Pharmaceutical Systems (SPS) Program. Arlington, VA: Management Sciences for Health. Key Words RxSolution, Pharmacy, information system, management, Oshakati, hospital, Namibia Systems for Improved Access to Pharmaceuticals and Services Center for Pharmaceutical Management Management Sciences for Health 4301 North Fairfax Drive, Suite 400 Arlington, VA USA Telephone: Fax: Website: ii

3 ACKNOWLEDGEMENT The MoHSS management, The United States Agency for International Development (USAID), the Strengthening Pharmaceutical Systems (SPS) program. INTERMEDIATE HOSPITAL OSHAKATI TECHNICAL TEAM Naphtali Hamata Regional Director Oshana Shannon Kakungulu, Medical Superintendent IHO Msafiri Kweba Regional Pharmacist Oshana Rogers Manyeruke, Pharmacist IHO Edward Muchadeyi stores Pharmacist IHO Stanslaus Madende Principal Pharmacist IHO ADVISORY GROUP MEMBERS Jennie Lates, Deputy Director: Pharmaceutical Services-MoHSS David Mabirizi, Country Director MSH-Namibia Jude Nwokike, Country Program Manager Namibia Jean-Pierre Sallet Regional Technical Advisor MSH-South Africa Douglas Keene Vice President Centre for Pharmaceutical Management Mbayi Kangudie HIV/AIDS Care and Treatment Advisor USAID-Namibia Evans Sagwa Deputy Country Director MSH-Namibia TECHNICAL IMPLEMENTING TEAM Chris Ntege, Senior Program Associate: MSH-Namibia Ernst Sigl, Senior Program Associate: MSH-South Africa (IT support) Kate Dambudzo MSH-South Africa (IT support) Sifiso Mahlaba MSH-South Africa (IT support) Misheck Dudzai MSH-South Africa (IT support) iii

4 CONTENTS ACKNOWLEDGEMENT... iii ACRONYMS... viii EXECUTIVE SUMMARY... 9 PART I: RxSolution implementation and results Introduction Background Location of Intermediate Hospital Oshakati (IHO) Challenges High number of patients Long patient queuing times Large inventory list of more than 1200 items Loss of revenue due to delayed claims to medical aid schemes Inadequate data for evidence-based decision making Limited human resources Un-streamlined workflow processes and weak controls Un-necessary loss of resources due to expiry of products Strategies implemented to improve efficiency The RxSolution pharmacy management software tool Illustrative implementation and training time requirements Interventions Training on the use of RxSolution Pre-implementation assessment and installations Procurement and installation of equipment The Launch of the Rx Solutions in IHO Performance monitoring Post-implementation assessment of pharmaceutical management indicators Installation of biometric access to stores with link to server iv

5 7 Results Usage of RxSolution in IHO, Namibia Patient queuing time at reception Reduction in wastage due to expiry of medicines Improvement in stock management and stock level accuracy Improvement in rational ordering of medicines and reduction in interim/emergency orders Expenditure on pharmaceuticals and related items Improvement in ordering time from the CMS Enhancement of Therapeutic Committee discussions and improved reporting of PMIS data Reports from the system and availability of data ABC analysis reports Observations from the ABC analysis data Availability of information on prescriptions and data on rational use of medicines Other management information reports generated from RxSolution at IHO Prescription reports Patient visits captured on the system Part II: Taking RxSolution forward Areas of emphasis in RxSolution training Lessons learned Conclusion and way forward Annexures Annexure 1: Baseline assessment of patient queuing time at reception (August 2009) Annexure 2: Post-implementation assessment of queuing time at reception (Dec. 2011) v

6 TABLES Table 1: List of initially trained cadre staff Table 2: Assessment results patient waiting time Table 3: Wastage due to expiries over five financial years Table 4: Data on interim/emergency orders placed to the CMS, FY 2007/ / Table 5: Main orders placed and receipts at IHO Table 6: ABC analysis reports done since installation of RxSolution in November Table 7: Sample prescriptions: two prescriptions dispensed on 1 June Table 8: Sample prescription dispensed on 1 June Table 9: Potential revision of sample prescription dispensed on 1 June Table 10: Outpatients prescriptions at the paediatric pharmacy and main pharmacy Table 11: Dispersion of private patients in IHO among the different medical aid schemes and payment options FIGURES Figure 1: Map of Namibia indicating the location of Oshakati Figure 2: Main entrance to the hospital, with patients waiting outside (September 2009) Figure 3 Patients queuing in the Intermediate Hospital Oshakati for services- April Figure 4: A group of pharmacy staff being trained on RxSolution at IHO by Chris and Ernst Figure 5: Pill-counting machine procured with funding from USAID Figure 6: Dr Richard Kamwi, the Minister of Health and Social Services, officiating at the launch of RxSolution system at IHO (November 2009) Figure 7: Dr Richard Kamwi, the Minister of Health and Social Services, cutting the ribbon at the main pharmacy on the occasion of the launch of the RxSolution tool at IHO (November 2009) Figure 8: Medicine boxes 'before' and 'after' Figure 9: Use of cardboard boxes (before), and installation of shelving (after) Figure 10: Fingerprint biometric access system Figure 11: Patient queuing time assessments Figure 12: Trend of wastage due to expiries in main store Figure 13: Trend in HF5 indicator (balancing of stock cards) assessment in IHO over time Figure 14: Trends of placement of interim orders by IHO in the past 4 years vi

7 Figure 15: Expenditure on pharmaceuticals and related clinical sundries Figure 16: Data trends before RxSolution implementation Figure 17: Data trends after RxSolution implementation Figure 18: Relationship between items ordered and received from the CMS Figure 19: Trends in the variance between items ordered and received from the CMS Figure 20: Workload indicator of average number of prescriptions/month handled per pharmacy staff as of May Figure 21: Prescriptions entered on the system from May 2010 to April Figure 22: Trend in number of visiting patients captured onto the system, from November 2009 to November Figure 23: Trend of registration of private patients Figure 24: Distribution of private patients in IHO among the different medical aid schemes Figure 25: Distribution of private patients in IHO among the medical aid schemes Figure 26: RxSolution in use at IHO private ward vii

8 ACRONYMS ART CMS EWI IHO INRUD MoHSS MSH PMIS SPS TB USAID WHO Antiretroviral Therapy Central Main Stores Early Warning Indicators Intermediate Hospital Oshakati International Network for the Rational Use of Drugs Ministry of Health and Social Services Management Sciences for Health Pharmacy Management Information System Strengthening Pharmaceutical Systems Tuberculosis United States Agency for International Development World Health Organization viii

9 EXECUTIVE SUMMARY The Intermediate Hospital Oshakati (IHO) is located in the northern part of Namibia where approximately 60% of the population lives and receives about 1,500 patients every day. Until November 2009, IHO pharmacy was using a manual system to manage its inventory. This, coupled with high patient loads, long patient queuing times, and limited human resources, resulted in unnecessary financial losses due to expiry of products, excessive pharmaceutical expenditures, delays in claiming reimbursement from 3 rd -party payers, lack of accurate and reliable data for management decision-making, long patient queues and patient dissatisfaction. In 2009, with funding from the USAID, the Ministry of Health and Social Services implemented a pharmacy management software tool (RxSolution) to improve on patient and the inventory management. PMIS (Pharmacy Management Information System) Retrospective data was collected over five years, three of which were prior to the implementation of RxSolution tool. Data on key pharmaceutical management indicators; inventory and patient management (patient queuing time, stock card balancing and number of emergency orders) and financing (expenditure on pharmaceuticals and losses due to expiries of medicines), was collected and analyzed (in Microsoft Excel ). Analysis of the data showed that after two years of implementation, the average patient queuing time was reduced by 65% from 41 to 14 minutes, the expiries on shelf reduced from 81,289N$ per quarter to 18,779N$ per quarter in the 2 years before and after RxSolution, expenditure on pharmaceuticals has reduced by 45% from 38 to 20 million N$, balancing of stock cards has increased by 57% from an average of 36% to 93% and the number of emergency orders placed has reduced by 56% from an average of 8.25 to 4 orders per quarter. The pharmacy and hospital management now has available a resource of information that is being used for good decision making. Data from the tool is used for discussions in the hospital therapeutic committee meetings and also generation of information on PMIS indicators. The RxSolution tool has significantly improved patient and pharmacy management in the hospital by reducing the patient queuing time, improvement in inventory management, reduction in waste due to expiry of pharmaceutical products on the shelf, rationalization of expenditures and has provided the hospital management team with valuable information for improving on the rational use of medicines and guiding decision making. davidmabs@yahoo.com 9

10 PART I: RxSolution implementation and results 1 Introduction Pharmaceutical management systems in many developing countries are challenged by ineffective procedures in selection, procurement, distribution and use of medicines and other pharmaceutical products. The current trend of increasing burden of chronic infectious diseases especially HIV/AIDS, tuberculosis (TB), and Non Communicable Diseases in addition to persistent acute infections like malaria have compounded these challenges in ensuring universal access to medicines. The situation has worsened due to limited human resources, increasing patient overload at the health facilities. Management Sciences for Health (MSH) has been at the forefront in strengthening pharmaceutical systems in many developing countries, and successes have been reported. In 2008, The Intermediate Hospital Oshakati, the main referral hospital in the northern part of Namibia, was faced with many challenges in the management of pharmaceutical supplies. Coupled with high patient overload and associated long waiting times at the pharmacy, necessitated a more efficient way of managing and handling the pharmaceuticals and patients in the pharmacy. Through the Oshana regional directorate and Permanent Secretary of the Ministry of Health and Social Services, the hospital management requested support from Management Sciences for Health's United States Agency for International Development - funded Strengthening Pharmaceutical Systems Program. In order to develop a structured approach to improve efficiency in the IHO pharmacy, The INRUD medicine-use indicators adopted by the WHO as the standard methodology for assessing medicine use, and published as the Action Programme on Essential Drugs manual How to Investigate Drug Use in Health Facilities were adopted. The International Network for the Rational Use of Drugs (INRUD) is a network promoting rational drug use of medicines in developing countries, involving many African and Asian member countries. Coordinated by MSH, with additional technical support provided by the Harvard Drug Policy Research Group, the Karolinska Institute, University of Newcastle, and the World Health Organization (WHO) Action Programme on Essential Drugs, These indicators also form the core of the medicine use assessment indicators elucidated in Part II of this report, in addition to which institutionspecific performance indicators have also been included. In order to strengthen the collection and analysis of medicine use indicators, MSH developed the Rx Solutions tool. This is a tool used in medium size district level hospitals to large referral hospitals to enhance efficiency in patient and pharmacy management. In November 2009, The IHO computerisation initiative, which comprised a series of activities including; 10

11 training, support supervision, infrastructure improvement, installation of equipment, and technical assistance in data compilation and analysis was started. The cornerstone of this approach was the RxSolution pharmacy management software system that had been in use in South Africa and Swaziland to improve management of the pharmaceuticals and, registration and storage of patient data. After implementation of the tool in the hospital pharmacy several changes were made in the workflow activities of the pharmacy staff in order to enhance the efficiency and functioning of the tool. Over past two years of using the tool, the hospital pharmacy has realised many successes and major improvements in patient and pharmacy management. Assessment of a selection of pharmacy management indicators show the progress attained since the implementation of the system. These indicators include: inventory management, rational medicine use and pharmaceutical financial management indicators. This report describes the pharmacy management indicators that can be obtained from the ardent and efficient use of the software and how an electronic tool can enhance efficiency in patient and pharmacy management. 11

12 2 Background 2.5 Location of Intermediate Hospital Oshakati (IHO) Figure 1: Map of Namibia indicating the location of Oshakati ( IHO is located in the northern part of Namibia, close to the border with Angola, and is the main referral hospital for the northern part of the country. Approximately 60% of the whole Namibian population resides in the northern regions of the country (Ohangwena, Oshana, Omusati, Oshikoto, Caprivi and Kavango). The hospital is well complemented with most of the medical specialties required of a referral hospital. 12

13 Figure 2: Main entrance to the hospital, with patients waiting outside (September 2009) 3 Challenges 3.1 High number of patients Due to the fact that the IHO is the only referral hospital in the northern part of the country and the high catchment population, this has resulted in chronically high numbers of patients visiting the hospital daily, not only for referral services but also for basic medical services. Pharmacy Management Information System (PMIS) data between 2008 and 2011 show that the hospital receives on average patients a month about 1700 patients per 1. This results in great strain on the limited human resources in many areas of the hospital, including the pharmacy. 1 MoHSS PMIS reports 13

14 3.2 Long patient queuing times As a result of the high patient overload, limited human resources and use of a paper-based manual system, there were always long queues at all service points, especially at the main reception where patients have to be registered and pay service fees, and also at the pharmacy where medicines are collected. Figure 3: Patients queuing in the Intermediate Hospital Oshakati for services- April Large inventory list of more than 1200 items On a 6-week reorder cycle, the pharmacy staff needed to go through an inventory of more than 1200 individual items as they prepared to order stock from the Central Medical Stores (CMS) located 700 kilometres away from the IHO. These items included the clinical sundries, pharmaceutical products and diagnostic products. The inventory for the pharmaceuticals also included the patient pre-packs that are routinely prepared prior to dispensing. The pharmacy previously used stock cards to manage the inventory. This was a very tedious job that took a lot of time and yet wasn t even accurate enough to provide good information for decision-making. Management of this entire inventory system required, for example, the calculation of maximum and minimum stock levels for each individual stock item that would in the end provide guidance when ordering for additional stock. However, because of the large inventory, high workload at the pharmacy and the manual paper based systems, the accuracy and reliability of this information was questionable and resulted in over or under stocking and a high risk of expiry of medicines of lack of medicines for patients. A shortage in any of the medicines meant that an interim order had to be made and medicines collected 700 kms away in the capital Windhoek. 14

15 3.4 Loss of revenue due to delayed claims to medical aid schemes The hospital has a private ward where all private patients are managed and pay for their treatment through the different medical aid schemes available. These medical aid schemes have a 3-month cut-off for submission of claims by the hospital for reimbursement. However, the paper-based system that was (and is still partially) in use for managing these claims meant it took the hospital on average 7 months to process these claims, and this resulted in losses in revenue. There were challenges in aggregating the consumables (pharmaceuticals and clinical sundries) used for private patients, since this required going through hard copy files and getting the data into claim forms. 3.5 Inadequate data for evidence-based decision making The pharmacy managers and hospital administration did not have enough and reliable data at hand that could effectively enable them to make informed and suitable decisions relating to rational use of medicines and inventory management, among others. The hospital has a Therapeutic Committee where staff and management discuss issues related to therapeutics and design targeted interventions to enhance efficiency in patient management. This committee needs reliable information and in a short time, in order to be able to make decisions timeously and meet challenges as they arise. The pharmacy had a PMIS data collection tool, which is a paper-based system that provides data and reports for discussions in the Therapeutic Committee meetings. These data have been very useful in guiding the Therapeutic Committee meetings and providing the necessary agenda. 3.6 Limited human resources The issue of limited human resources has been and is still a chronic, recurring issue within the MoHSS and affects all cadres, including pharmacy staff, and especially pharmacists. The ever-increasing number of patients further compounds the problem. 3.7 Un-streamlined workflow processes and weak controls The pharmacy had a workflow system that needed improvement in order to be more efficient. Issuing of supplies from the stores to the wards was being done on a daily basis, and this together with the dispensing to both in- and outpatients put a lot of strain on the staff. Management of the patient pre-packs wasn t allowing for reconciliation and accountability of the packs made. Issuing of items from the main store wasn t streamlined and stock cards were not updated. There wasn t a specific person in charge of the stores; any staff could get to the stores, remove items and refill shelves at the dispensing area. Management and supervision of staff and their activities was a challenge. 15

16 3.8 Un-necessary loss of resources due to expiry of products Because of a manual paper-based inventory system, especially in a high-volume hospital with a large inventory of items to procure, there were unnecessary losses due to expiry of pharmaceuticals that could easily have been avoided with a more efficient/computerized inventory management system. Due to lack of accurate, reliable and easily retrievable information, data used for making procurement decisions were based on estimates, since maximum and minimum values for the stocked items were not being calculated. This scenario resulted in overstocking of some products that ended up expiring on the shelves in the pharmacy. 16

17 4 Strategies implemented to improve efficiency With the approval of the Permanent Secretary of the Ministry of Health and Social Services, MSH in partnership with the IHO management decided to implement a phased approach to reduce the challenges IHO was facing in providing efficient services to patients. The approach was to provide IHO with Rx tool that would automate several processes within the pharmacy as well as providing data and management reports. In addition to the tool, pharmacy workflows needed to be changed to suit a computerised system, while not creating more work for staff. There was also a need to procure tablet-counting machines and to encourage the hospital to buy and maintain them as a means of speeding up the process of dispensing to patients; pills were still being counted manually and this process took a lot of time and manpower. Phasing in of the implementation of the tool was to start with the pharmacy and then roll out to the different prescribers, who would ultimately have to prescribe on the system. Because of the difficulties usually experienced in implementing a computerised system, the team decided that training of users would involve first the training of all staff needed; from among these trainees super users would be trained further to train others. These super users were selected based on their aptitude in the use of software and general computer basics. They were responsible for training any new staff that joined the hospital and for continuous training of the rest of the staff while liaising with SPS technical staff. Phases Phase 1: Installation of RxSolution at the main reception and main pharmacy Training of users in data capturing and inventory management Review and reorganisation of the workflow processes Reshelving of the pharmacy dispensing area and stores Regular support supervision and continuous on-site support by an IT technician Phase 2: Installation of RxSolution in the administration areas and clinical sundries store Installation of RxSolution in the private ward Training of new users and refresher training Regular support supervision and continuous on-site support by an IT technician Technical assistance for data extraction, analysis and reporting Transfer of equipment to the hospital management Transfer of data management to hospital staff Phase 3: Extension of the Rx system to the prescribers in the specialised clinics and the theatre 17

18 Phase 4: Provision of technical assistance on data migration and reporting Provision technical assistance in carrying out a medicine use surveys in the hospital Roll out of the tool to two additional hospitals in the Capital, Windhoek 4.1 The RxSolution pharmacy management software tool RxSolution is an integrated computerised pharmaceutical management system. The software supports best practices for procurement, storage, distribution and dispensing of pharmaceuticals and medical supplies to ensure availability of critical products at all times. It can also manage and track stock transactions and product usage, and has modules for budgeting, procurement, receipts, requisitions, dispensing, down referrals and reports. It was designed for pharmacists by pharmacists. It is specifically designed to manage pharmaceuticals and medical supplies, from the stage of procurement to dispensing to patients. The system is used to manage inventory; handle issues to wards, out/in-patient pharmacy and satellite clinics; dispense medications to patients; and prepare repeat prescriptions for downward referral at facility level. RxSolution supports best practices for procurement storage, distribution and dispensing of pharmaceuticals and clinical supplies, helping to ensure the availability of critical supplies at all times. Rx Solution has a patient registration module or software linked to it called Rx PIMS (Patient Information Management System). The Rx PIMS is located at the patient reception area where all patient identifier data are captured. The main reception area is where all outpatients data are captured and the Casualty Department captures that of most of the inpatients. Users at these points enter the patients names, date of birth, referring centre, gender, etc., then the system automatically issues a unique patient identification number that is printed and encoded on a barcode sticker which is then placed on the patients passport. For managers in a health care facility this is a very important tool that guides decision making with regard to pharmaceutical commodity management, patient management and the rational use of medicines. Software features include: Monitoring of stock and recording of quantities requested, ordered, received and distributed Recommends quantities to be ordered based on usage rates. Automatically assigns min/max values to each item based on the usage rates Tracks batch/lot and expiry date for commodities being consumed 18

19 Includes a dispensing module that allows management of prescribers, dispensers, patients and prescriptions Has a downward referral module to assist with monitoring and control of stock movement between institutions and patients. Data generated are used for improving pharmaceutical use, stock availability and financial and logistical accountability. RxSolution can be used either as a single user (one computer) or on a multi-user basis. Rx Solution is used in over 200 hospitals and clinics in South Africa, Swaziland, Lesotho, Uganda and Haiti. At the beginning and through the implementation of this project, MSH Namibia received extensive support from an experienced team from MSH South Africa. 4.2 Illustrative implementation and training time requirements A typical implementation requires the steps shown below; the schedule can be adjusted for each installation site depending on its size and how busy it is: Install software 1 hour Update demand table 1/4 day Update supplier table 30 minutes Update product table 1/2 day Capture stock on hand information 1 day Update prescribers and dispenser tables 1/4 day Transfer existing patient data, if electronically available 1/2 day Review report requirements 1 day Estimated time per site ± 4 days. 19

20 5 Interventions 5.1 Training on the use of RxSolution The RxSolution interface is almost identical from module to module, so once users can use one module, learning the others is much easier and faster. Training is optimal when participants from the various institutions who will use the program are jointly trained in a computer laboratory session. Assuming that the participants have at least basic computer skills, with experience it has been shown that training super users on site works better since these individuals take on the responsibility of training and supporting other staff. # Cadre No. trained 1 Pharmacists 12 2 Pharmacist Assistants 8 3 Workhands 3 4 Hospital administration staff 7 5 Reception area staff 12 Total 42 Table 1: List of initially trained cadre staff Figure 4: A group of pharmacy staff being trained on RxSolution at IHO by Chris and Ernst 20

21 6 Pre-implementation assessment and installations In April 2009 a team of technical officers from SPS Namibia and South Africa visited IHO to carry out a baseline and pre-implementation assessment and establish requirements for this computerisation project. After the visit an implementation plan was developed to guide the whole process; this included specifications and quantities of different types of hardware required. The task procurement, installation and networking of hardware was outsourced to a local company, SALT Essentials. Between August and October 2009 the computer and networking hardware was installed and staff was trained on the software. 6.1 Procurement and installation of equipment With funding from the USAID, SPS Namibia procured equipment for the enhancement of pharmacy activities. These included a tablet-counting machine to quicken the process of dispensing medicines to patients, 30 computers and Uninterruptible Power Supply (UPS) two servers, and a biometric limited-access system for the main storage areas in the pharmacy. This was part of the process of improving effectiveness in the pharmacy workflow processes under the computerisation project. Figure 5: Pill-counting machine procured with funding from USAID 21

22 Re-shelving and reorganization of workflow to suit RxSolution processes The pharmacy area was reorganised to make it look neater and tidier, with procurement and installation of shelves and cupboards in areas that were previously open. (Pictures of these areas can be seen in Chapter 3 of this report.) The SPS team also worked with the hospital administration and pharmacy staff to redesign the workflow process to ensure that the system worked to the best of its capacity. 6.2 The Launch of the Rx Solutions in IHO On 17 November 2009 the Hon. Minister of Health and Social Services, Dr Richard Nchabi Kamwi, officially launched the RxSolution system, and staff have continued to use it to date. Figure 6: Dr Richard Kamwi, the Minister of Health and Social Services, officiating at the launch of RxSolution system at IHO (November 2009) 22

23 Figure 7: Dr Richard Kamwi, the Minister of Health and Social Services, cutting the ribbon at the main pharmacy on the occasion of the launch of the RxSolution tool at IHO (November 2009) 6.3 Performance monitoring Technical support supervisory visits Support visits were made to the hospital initially on a monthly basis and then on a quarterly basis to ensure the smooth running of the system and also to encourage staff to enter data accurately. During these visits several bugs and fixes were done to the system to ensure that it was functioning properly. Emphasis was put on data input. Off-site back-up setup MSH/SPS entered into a contract with a private IT service provider to support the hospital with continuous on-site support for basic IT-related issues and also provide an off-site back-up mechanism for the data generated. A virtual network system was created with a live link to the databases off-site to enable SPS 23

24 technical staff to regularly review the quality of data generated on a daily basis and provide guidance remotely to staff on the ground. In other words, the system was continuously monitored off-site on a daily basis to ensure that it was being used correctly. Including tracking who is using or not using the system regularly. 6.4 Post-implementation assessment of pharmaceutical management indicators Between August and December 2011 a post-implementation assessment was done to gauge the improvement in practices and provide a measurement of the effectiveness of the tool in improving pharmaceutical management. The assessment of these indicators (pharmacy management indicators) forms the gist of this report. BEFORE AFTER Figure 8: Medicine boxes 'before' and 'after' Figure 9: Use of cardboard boxes (before), and installation of shelving (after) 24

25 6.5 Installation of biometric access to stores with link to server A biometric access system was also installed in the pharmacy area to limit access to the medicine storage areas to only authorized staff. This was done also to limit possible pilferage and provide accountability for access to these areas. This system required use of fingerprint identification to access the medicine storage areas. The system is also used to monitor clock-in and clock-out times for pharmacy staff, since it registers all entries and exits to and from the pharmacy. Access to the main stores was limited to only two staff, who are responsible for managing the system in those areas. Figure 10: Fingerprint biometric access system 25

26 7 Results 7.1 Usage of RxSolution in IHO, Namibia In the IHO the RxSolution system is installed in all reception areas, the main pharmacy, paediatrics, outpatients, private ward, TB unit, medical sundries store, main administration block and Casualty departments. Over 40 hospital staff has been trained so far, and at the moment the existing staff are responsible for training new staff. Currently the number of pharmaceuticals listed on the system is 1200 items (of which about 200 are frequently procured), but with the inclusion of the medical sundries there is a total of 2047 items. All of these items are now being managed electronically in the system for all inventorying actions. With this in place the hospital management is in a far better position to manage pharmaceuticals and related commodities, which weren t easy to track when using a manual, paper-based system. 7.2 Patient queuing time at reception Patients visiting the hospital have all got to get to a reception point where their demographic details are captured and fees paid before they can access the treatment areas. IHO has two main reception areas; the casualty reception, where inpatients are registered and get admitted to a ward, and the main reception right at the entrance of the hospital, where mostly outpatients are registered. The patient queuing time is the total time spent at the reception area, including the time taken while being attended to at the counter/teller. A data collection tool (attached) was developed and handed out to the patients as they entered the hospital, with the time indicated as it was being handed over to them. When a patient reached the counter at the reception, they handed over the form (tool) to the receptionist, who filled in the time in the required box and handed it back to the patient afterwards. The tool captured how much time it took the patient to reach the counter (in the queue) and how much time the receptionists/attendants took to process the patient. The forms were then collected and analysed afterwards. The baseline assessment for patient queuing time was done in August 2009, two months before the RxSolution was implemented. A similar post-implementation assessment was done two years later in December 2011 in order to gauge if there were any improvements realised. In both situations the assessment was done before 09h00, when the queues are longest. 26

27 Table 3 below shows a summary of the assessment results on patient queuing time at the main reception before installation of RxSolution (August 2009) and after (December 2011). PATIENT WAITING TIME AT RECEPTION Before RxSolution August 2009 After RxSolution, Dec % Improvement Average time spent in queue before reaching counter (minutes) Average patient processing time at counter (minutes) Average total time spent at reception (in queue and at counter) (minutes) Table 2: Assessment results patient waiting time The data show that there was a significant reduction (88%) in the time it took to process patients at the reception counter (recording patient details and payment of fees). Previously, when a patient arrived at the reception counter they had to hand in their treatment passport, and then the patient s demographics would be handwritten into a register book. The patient would then be prescribed a specific fee to pay depending on the type of consultation sought or their category (private/state patient). The amount paid would then be entered into another register and a receipt written out and handed over to the patient. This process took an average of 25 minutes, dependent on how many staff was available at reception. With installation of RxSolution the same patient data were entered into the computer with more details, and the system would then print out a bar-coded sticker that would be stuck onto the patient s treatment card/passport. Whenever the patient returns to the hospital, this sticker code is scanned to retrieve the patient information, and a visit date would then be the only entry into the system. This automated retrieval of patient information greatly shortened the process at the reception counter and also the overall queuing time (reduced by 65%). 27

28 Time (Minutes) Enhancing efficiency in pharmacy and patient management Below is a graphic representation of the data from Table Comparison of patient queuing time at reception before (Aug. 2009) and after (Dec. 2011) installation of RxSolution Average time spent in queue before reaching counter Average patient processing time at counter Average of total time spent at reception (in queue and at counter) BEFORE AFTER Figure 11: Patient queuing time assessments The average patient queuing time was reduced by 65% from 41 to 14 minutes, a clear indicator of improved patient services management. 7.3 Reduction in wastage due to expiry of medicines The IHO being a referral hospital, it holds large stocks of pharmaceutical supplies: on average the hospital receives supplies worth US$ 300,000 in every 6-week cycle. With the manual, paper-based system it was previously almost impossible to track each and every item correctly with regard to maximum and minimum stock levels, track expiries and make accurate orders to replenish stock. This resulted in higher losses/wastage due to goods expiring on the shelf. A five-year trend analysis was done with data collected from hard copy medicine expiry registers on site and from RxSolution. The purpose of this analysis was to determine whether the use of the electronic pharmacy management tool had any effect on losses due to expiries. 28

29 Value of expired items (N$) Quarter Enhancing efficiency in pharmacy and patient management Pharmaceutical Expiries/damages (Stores N$) Year 2007/ / / / /2012 Q1 19, , , , Q2 22, , , , , Q3 93, , , , , Q4 3, , , Total 139, , , , , Table 3: Wastage due to expiries over five financial years The data in the table above shows the losses due to expiries from the main pharmacy stores (products that expired in the pharmacy store). The data clearly show a steady downward trend in products expiring on the shelves in the store. Figure 11 below shows the trend of these same expiries on a quarterly basis throughout the 5-year period assessed. 350, , Trend of wastage due to expiry in main store 250, , RxSolution introduced 150, y = x Auto-ordering activated 100, , Figure 12: Trend of wastage due to expiries in main store The equation from the graph above shows that the losses due to expiries are reducing by about 4,000N$ every quarter, which is a significant saving for the hospital (7.56N$=US$1.00). 29

30 % of stock cards balancing Enhancing efficiency in pharmacy and patient management The RxSolution tool was introduced in Q3 of FY 2009/2010, and automation of the ordering of purchases was done in Q1 FY 2010/2011. This was necessary so as to gain at least four months of usage data for the system to be able to calculate and estimate accurate usage rates for each store item. The expiries on shelf reduced from 81,289N$ per quarter to 18,779N$ per quarter in the 2 years before and after RxSolution. 7.4 Improvement in stock management and stock level accuracy The PMIS tool has been used in capturing data on the balancing of stock cards (HF5). Data available from FY 2007/8 to 2011/12 were obtained and analysed to show the trend in this health facility indicator. Data for this indicator were collected by randomly picking 30 stock cards and comparing the physical stock on the shelf with the stock indicated on the card. There has been a marked improvement in the accuracy of the stock cards used in the IHO main store. Figure 10 and Table 5 below show the trend and impact that RxSolution has had on this particular indicator. 100 Stock card balancing 75 y = x Rx Introduced /2008 Q2 2007/2008 Q4 2008/2009 Q2 2008/2009 Q4 2009/2010 Q2 2009/2010 Q4 2010/2011 Q2 2010/2011 Q4 2011/2012 Q2 2011/2012 Q4 Figure 13: Trend in HF5 indicator (balancing of stock cards) assessment in IHO over time Note: There were no data available for FY 2009/10 Q4. Data representing 2011/12 Q4 were collected on 16 December The balancing of stock cards has increased by 57% from an average of 36% to 93% a key indicator of improved inventory management. 30

31 Quarter Enhancing efficiency in pharmacy and patient management 7.5 Improvement in rational ordering of medicines and reduction in interim/emergency orders The ordering of medicines and other related pharmaceutical supplies is done in a 6-week cycle, i.e. it is intended that an order is made once every 6 weeks. Before each order is placed staff in the pharmacy have got to do an accurate stock take of all items in the store and estimate usage rates (by calculating maximum and minimum stock levels per product) before actual quantities are ordered. This meticulous process can be evaluated for its effectiveness by looking at the rate occurrence of stock outs or by just observing the number of interim/emergency orders placed in between the reorder cycles. While gauging possible improvement in the rational ordering of medicines in the IHO, it was decided to observe the number of interim/emergency orders placed, and trend these over time. Similarly, a 5-year (five financial years) period was chosen, with two years showing data for when the RxSolution was in use. In the data presented below in FY 2007/08 only data from Q4 could be obtained, and so FY 2007/8 was omitted from Table 5. Number of Interim orders to the Central Medical Stores Year 2007/ / / / /2012 Q1 No data Q2 No data Q3 No data Q Total Table 4: Data on interim/emergency orders placed to the CMS, FY 2007/ /12 Below is a graphic representation of the data in the table above, showing the trend of interim/emergency orders placed by the IHO. The trend depicts a steady decline in the number of these orders, which highlights an improvement in or rationalisation of the ordering system. It is probable that before the installation of the electronic system the pharmacy managers didn t have accurate and reliable stock information to be able to place appropriate orders with the right quantities, and this necessitated the placing of interim orders to fill gaps in stock. With implementation of an electronic system with automated ordering calculated and based on actual usage rates, actual quantities needed were being ordered - hence the decline in the number of interim/emergency orders. This is a substantial improvement in the system for the ordering of medicines and good inventory management. 31

32 Number of interim orders Enhancing efficiency in pharmacy and patient management Trend of interim orders per quarter RxSolution Introduced y = x Figure 14: Trends of placement of interim orders by IHO in the past 4 years The equation from the graph above shows that the number of interim orders placed per quarter is reducing. The number of emergency orders placed has reduced by 56% from an average of 8.25 to 4 orders per quarter, indicating a more robust and precise ordering system than before. 7.6 Expenditure on pharmaceuticals and related items In the absence of a robust pharmaceuticals inventory management system there is bound to be a higher occurrence of wastage resulting from procurement and accumulation of unnecessary quantities of products in the store. This raises the stock-holding value, some of which will certainly expire or could even be used irrationally. As such the expenditure on goods procured will rise. Expenditure on pharmaceuticals and related items used in the IHO was explored looking at retrospective data (before RxSolution was implemented), and comparing it with data post-rxsolution implementation. Both data sets are show general linear trends in expenditure. 32

33 Expenditure (N$) Expenditure per capita Enhancing efficiency in pharmacy and patient management Expenditure per capita on pharmaceuticals (N$) y = x Figure 15: Expenditure on pharmaceuticals and related clinical sundries 7,000, Trend of Expenditure on Pharmaceuticals Before RxSolution 6,000, ,000, ,000, y = 93254x + 5E+06 3,000, ,000, ,000, /200 9 Q1 2008/200 9 Q2 2008/200 9 Q3 2008/200 9 Q4 2009/201 0 Q1 2009/201 0 Q2 2009/201 0 Q3 2009/201 0 Q4 Series1 4,625,20 6,114,34 5,276,34 4,144,78 3,230,30 4,345,84 6,038,15 6,328,10 Figure 16: Data trends before RxSolution implementation The equation in the Figure 15 above shows that expenditure on pharmaceuticals and related items in the IHO on average was on a slight upward trend, with an increment of about 93,000N$ per quarter. 33

34 Expenditure (N$) Enhancing efficiency in pharmacy and patient management Trend of expenditure on pharmaceuticals after RxSolution 9,000, ,000, ,000, ,000, ,000, ,000, y = x + 3E+06 3,000, ,000, ,000, /201 1 Q1 2010/201 1 Q2 2010/201 1 Q3 2010/201 1 Q4 2011/201 2 Q1 2011/201 2 Q2 2011/201 2 Q3 2011/201 2 Q4 Series1 4,187,354 2,798,566 45, , ,524,628 32, ,340,179 2,000,000 Figure 17: Data trends after RxSolution implementation The equation from Figure 16 above shows that expenditure on pharmaceuticals and related items in the IHO after implementation of RxSolution on average was declining, with a significant reduction of about 58,000N$ per quarter. On the overall, the eexpenditure on pharmaceuticals has reduced by 45% from 38 to 20 million N$ in the review period considered before and after implementation of RxSolution. 7.7 Improvement in ordering time from the CMS It was also observed and noted after interviews with pharmacy staff that it took 5-7 days to obtain an order of pharmaceutical and related items from the CMS. This process included a stock take of all items in the stores and then writing the actual order out in a hard copy book. This exercise was very tedious, time-consuming, and many times not done in a systematic and accurate way. Since the CMS is the main supplier of pharmaceuticals and related items for the hospital, an assessment on the performance of the CMS in supplying products was done. Information from January 2009 detailing number of items ordered and those received from the CMS was done. The aim was to assess if there was a correlation between supply rate in a manually managed management system and in a computerised and more efficient system. It was envisaged that the computerised system would make supplies ordered from the CMS 34

35 more accurate, and that the CMS would supply accordingly as requested based on the fact that they were sure that the hospital requirements were justified and not just estimates based on individuals orders. Outcomes after RxSolution implementation The average percentage of medicines ordered that were received from CMS before installation of RxSolution was that an estimated 29% (April 2009-March 2010); of the items ordered were received from CMS. After installation and usage of the computerised system (as assessed in December 2011), IHO was receiving 67% (March 2010-September 2011) (table 5) of ordered items from the CMS. Automation of the ordering system, which also simplifies the stock taking process, has reduced the time taken to make a purchase order from 5-7 days to from just a few hours up to a day. The system, with updated stock levels, will auto-generate an order in just a few seconds based on the last 6 months average usage rates for each item in the store. Previously these purchase orders were sent to the CMS as filled hard copy books through the post, would took a day or more to get there. With the RxSolution software these orders are now sent electronically by to the CMS, making it easier and faster for the CMS to process an order. Month Ordered Received Difference % Received Apr % Jun % Jul % Sep % Oct % Nov % Jan % Mar % May % Jun % Aug % Oct % Dec % Jul % Sep % Table 5: Main orders placed and receipts at IHO 35

36 Number of items Enhancing efficiency in pharmacy and patient management Relationship between items ordered and received Odered Received Figure 18: Relationship between items ordered and received from the CMS In Figure 17 above, assuming an ideal situation, the two curves (blue and red) are expected to be as close as possible to each other or tending to merge, meaning that quantities ordered should be equal to what are received. As noted in the graph above, there was a great disparity between ordered and received items before installation of RxSolution (between April and November 2009). This disparity can be attributed to several inherent challenges that the pharmacy experienced then for example, lack of accurate stock records for all items at the time of ordering and inaccurate usage rates for each ordered item (maximum/minimum stock levels). These, coupled with limited human resources, made it difficult for staff to have updated information needed for placing accurate order quantities for items needed in the hospital. With RxSolution (after November 2009), where more precise orders were made using the computerised system, there was improvement and better correlation between ordered and received items. 36

37 Apr-09 May-09 Jun-09 Jul-09 Aug-09 Sep-09 Oct-09 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Number of items ordered Enhancing efficiency in pharmacy and patient management Variance between items ordered and received from CMS 800 RxSolution introduced y = x Figure 19: Trends in the variance between items ordered and received from the CMS From Figure 18 above, ideally the variance between items ordered and received should be tending towards zero, when the number of items ordered begins to approximate to the number of items received. This is also a measure of the service delivery of the CMS. 37

38 7.8 Enhancement of Therapeutic Committee discussions and improved reporting of PMIS data Empowered with data and information from the RxSolution, the pharmacy in Oshakati is currently using this for Therapeutic Committee meetings. Recently a complaint came from doctors in the oncology department in Oshakati to the pharmacy, where they stated that anticancer medicines were not being adequately procured by the pharmacy. The pharmacist in charge obtained ordering and stocking information from the RxSolution, that indicated that all the anticancer medicines were available on a monthly basis and had even expired due to the fact that no or few prescriptions were coming from the oncology department. The pharmacy has also since July 2010 produced monthly reports from RxSolution for presentation to the Therapeutic Committee meetings. Discussions in these meetings helped in making strategic decisions for the hospital, for the betterment of the services to patients by the pharmacy. The hospital pharmacy is now able to track expenditure on pharmaceuticals by the private ward and submit data to hospital management to speed the submission of claims from the medical insurance schemes. The pharmacy is also using data from RxSolution to collect and report on the PMIS indicators (the process of collecting the data has been speeded for selected indicators) and other pharmacy management indicators. For example, in every Therapeutic Committee meeting management is updated on costs and expenditure by each ward or department on pharmaceuticals. From one of these reports it was discovered that the casualty department consistently had very high cost drivers for pharmaceuticals. The hospital administration then realised the need for a casualty unit pharmacy or dispensary with a pharmacist assistant to rationally manage the stock there and also investigate cases of irrational use, wastage and/or pilferage. Rx Solutions has provided a range of reports, from inventory management to rational medicine use and pharmaceutical financing. Availability of these reports and data in the system has made it easier for the pharmacy to report on their PMIS indicators. The system can currently be used to obtain at least 15 out of the 21 PMIS indicators, and this has greatly improved their reporting capabilities. 7.9 Reports from the system and availability of data An assessment of basic inventory requirements in the pharmacy stores was carried out (August 2009) by assessing documentation and physical tour visits through the medicine storage rooms. Among the documents assessed were the individual item stock cards and registers for expired medicines. It was noted that the pharmacy stocked over 1000 pharmaceutical products and related clinical sundries, all of which had to have a stock card with information on maximum and minimum stocking levels and reorder 38

39 level, batch numbers for each consignment and expiry dates for each batch. In assessment of the documentation the following were noted: All products had stock cards but there were no maximum or minimum stocking levels indicated on them; neither were any reorder values indicated for any of the products. Ordering of pharmaceuticals was therefore difficult and inefficient, since it wasn t easy to know particular usage rates and hence determine exact quantities to order from the CMS. There was no system for tracking expired and near-expiry products in the store. All the medicines supplied to the pharmacy have batch numbers and expiry dates labeled on the packs; however, the CMS didn t supply this information in their delivery notes and invoices, and this rendered the pharmacy incapable of batch tracking and also unable to institute medicine recalls due to reliance on a manual system prone to errors and too cumbersome to cope with. Outcomes To date the pharmacy is able to obtain or perform the following tasks: ABC analysis (easily) see description in 6.8 below. The system automatically assigns maximum and minimum stocking rates for each product based on previous 6-month usage rates. Ordering of medicines from the CMS now takes just a day, down from 5-7 days, and is more accurate. RxSolution automatically generates purchase orders on request by the user. The system has so far registered over patients and information is available on all the medications used by those patients. Batch tracking is now possible for all medicines kept in the stores, thus making a medicine recall possible in case of serious adverse events. The tracking of batches has enabled the pharmacy to control wastage due to expiries. This is because medicines are dispensed accurately using the First Expiry First Out (FEFO) principle, and the pharmacist in charge is capable of regularly scanning for all near-to and expired medicines and advises management and clinical teams accordingly. Financial indicators related to pharmaceuticals can now be obtained, including reports on value of wastage due to expiries, expenditure reports for all products and individual items on a monthly, daily or annual basis, and expenditures per capita. 39

40 7.10 ABC analysis reports ABC analysis is a term used to define an inventory categorisation technique often used in commodities management; it is also known as selective inventory control. ABC analysis provides a mechanism for identifying items that will have a significant impact on overall inventory cost, while also providing a mechanism for identifying different categories of stock that will require different management and controls. The ABC analysis suggests that inventories of a store are not of equal value. Thus, the inventory is grouped into three categories (A, B, and C) in order of their estimated importance. 'A' items are very important for an store, and because of their high value, frequent value analysis is required. In addition, an organisation needs to choose an appropriate order pattern to avoid excess capacity. 'B' items are important, but less so than A items, and more important than C items. Therefore B items are intergroup items, and 'C' items are marginally important. There is no fixed threshold for each class; different proportions can be applied based on objective criteria. ABC analysis is similar to the Pareto principle, in that 'A' items will typically account for a large proportion of the overall value but a small percentage of number of items. Examples: A items: 20% of the items account for 70% of the annual consumption value of items. B items: 30% of the items account for 25% of the annual consumption value of items. C items: 50% of the items account for 5% of the annual consumption value of items. Data below show the ABC analysis reports done on a quarterly basis since installation of RxSolution in November Period: November 2009-January 2010 Number of items: 262 Value: N$ 1, 995, # Item description Value N$ Quantity % of Total issued value 1 Cefuroxime 250mg Tablet; 10Tablet 76, Rabies Vaccine Single Dose Injection; 5Vial 73, Co-Trimoxazole 480mg Tablet; 500Tablet 50, Perindopril 4mg Tablet 28 Tabs 47, Azithromycin Suspension 200mg/5ml 30ml 42, Lamivudine, Zidovudine 150/300mg tablet 60s 38, Total

41 Period: February-April 2010 Number of items: 382 Value N$ 2,761, # Item description Value N$ Quantity % of Total issued value 1 Metronidazole 5mg/mL 100mL Vial; 50Bag 217, Kanamycin 1g/3mL Injection; 1Vial 153, Cefuroxime 250mg Tablet; 10Tablet 120, Rabies Vaccine Single Dose Injection; 5Vial 84, Azithromycin Suspension 200mg/5ml 30ml 80, Fluphenazine Decanoate 2.5mg/ml 1ml inj 73, Total 26.4 Period: May-July 2010 Number of items: 358 Value: N$4, 140, # Item description Value N$ Quantity % of Total issued value 1 Chlorpromazine 100mg tablet 56s 852, Azithromycin Suspension 200mg/5ml 30ml 280, Rabies Vaccine Single Dose Injection; 5Vial 268, Metronidazole 5mg/mL 100mL Vial; 50Bag 231, Fluphenazine Decanoate 25mg/mL 1mL Injection; 5Vial 119, Chlorpheniramine maleate 4mg tablet 30s 96, Total 44.7 Period: August-October 2010 Number of items: 719 Value: N$7,103, # Item description Value N$ Quantity % of Total issued value 1 Clobetasol proprionate 0.01% cream 100g (extemporaneous prep) 1,487, Betamethasone 0.03% oint/cream 100g (extemporaneous prep) 337, Fluticasone % cream 100g 270, Azithromycin Suspension 200mg/5ml 30ml 204, Lamivudine, Zidovudine 150/300mg tablet 60s 188, Fluphenazine Decanoate 25mg/mL 1mL Injection; 5Vial 147, Total

42 Period: November 2010-January 2011 Number of items: 502 Value: N$ 7,261, # Item description Value N$ Quantity % of Total issued value 1 Chlorpromazine 25mg tablet 84s 1,537, Fluticasone % cream 100g 524, Rabies Vaccine Single Dose Injection; 5Vial 496, Fluphenazine Decanoate 25mg/mL 1mL Injection; 5Vial 229, Tetanus toxoid adsorbed single dose inj 1vial 213, Azithromycin Suspension 200mg/5ml 30ml 176, Total 43.7 Period: February -April 2011 Number of items: 502 Value: N$ 6,483, # Item description Value N$ Quantity % of Total issued value 1 Syringe Disposable BCG 25Syringe 727, Clobetasol proprionate 0.01% ointment cream 100g 638, Lamivudine, Tenofovir tablet 300/300mg 30s 491, Rabies Vaccine Single Dose Injection; 5Vial 335, Metronidazole 5mg/mL 100mL Vial; 50Bag 329, Benzylpenicilline Na 5MU 50vials 234, Total 42.6 Table 6: ABC analysis reports done since installation of RxSolution in November Observations from the ABC analysis data Items highlighted in pink in each quarter in the ABC analysis tables above had a value of 20% or more of the total expenditure on pharmaceuticals. Clinical items were not included in the inventory until March 2011 when the system was expanded to that store and other areas like the private ward. Steroidal preparations (clobetasol, fluticasone, betamethasone and fluphenazine) are frequently coming up in every quarter as high cost drivers. Data from the rational use indicators, where more information is obtained on the actual preparations, shows that these are used by the manufacturing unit for making extemporaneous preparations. Rationalising of this activity will greatly reduce costs 42

43 on these preparations. The Therapeutic Committee can bring it up as an issue to discuss and find a way of limiting prescriptions with steroids. Data from the rational use indicators also shows that usually 2-3 steroidal preparations appear on a prescription a sign of poly-prescribing of steroids. The Rabies Vaccine Single Dose Injection; 5 vial, is also appearing frequently (5-6 times) in the top 6 cost drivers. This phenomenon appears elsewhere throughout the country. The IHO Therapeutic Committee could come up with initiatives geared towards reducing the need for this vaccine by establishing strategies to reduce animal bites and a risk-based screening of patients to assist in rational prescribing of this product. Other Therapeutic Committees elsewhere in the country have already started to come up with initiatives to curb this problem, which could be shared in available forums for mutual improvement. Data show there is a very high use of psychotropic medicines, that may or may not be justified because IHO has a specialized Psychiatry Unit, but this could be a good point for discussion by the Therapeutic Committee to determine reasons for this. The clearest examples among these are chlorpromazine tablets and the fluphenazine injection Availability of information on prescriptions and data on rational use of medicines The RxSolution presents for the MoHSS central (NMPC-National Medicines Policy Coordination) managers and off-site assessors a quick and more cost-effective way of conducting a medicine use survey, by simply accessing the data collected and analysing them. This reduces the cost of travel and other logistics that would otherwise be needed to make a trip to the hospital. Table 7 below shows two sample prescriptions of the total of more than 280 handled on the RxSolution system on 1 June The aim is to highlight rational dispensing and prescribing among the health care professionals in Oshakati. The names of the prescriber and dispensers have been excluded for confidentiality purposes. 43

44 Date Prescription 1 Item cost 01/06/10 Clobetasol Propionate 0.01% (Ointment) [100 grams] Fluticasone 0.05% 15g (ointment) [1 tube] Hydrocortisone 1% 15g (ointment) [1 tube] Multivitamin (tablet) [28 tablet] 0.64 Paracetamol 500mg (tablet) [20 tablets] 1.07 Promethazine 10mg (tablet) [10 tablets] 4.09 Prescription 2 01/06/10 Aspirin 300mg (tablet) [14 tablets] 1.40 Ferrous Fum, folic acid 200mg/100mcg (tablet) [28 tablets] 2.19 Furosemide 40mg (tablet) [28 tablets] 2.06 Ibuprofen 400mg (tablet) [42 tablets] 4.15 Multivitamin (tablet) [28 tablets] 0.64 Spironolactone 25mg (tablet) 6.01 Table 7: Sample prescriptions: two prescriptions dispensed on 1 June 2010 The table above shows a sample of two prescriptions from more than 280 that were dispensed on 1 June These clearly indicate or suggest the existence of polypharmacy and irrational prescribing among the prescribers. In prescription 2, the use of two non-steroidal anti inflammatory medicines (Aspirin and ibuprofen) increases the risk of peptic ulcers. The dispensers went ahead and dispensed as prescribed, without looking critically at the rational use of medicines. On the dispensers side this could be an indication of patient medicine overload, or need for continuous training in rational dispensing and use of medicines. This also indicates that continuous training is also needed for the prescribers. These training interventions could greatly reduce costs spent on each prescription and also increase patient adherence by reducing the pill burden, as well of the chances of patients having adverse events from the medications. For example, looking at prescription 1 again below, a patient who probably had an inflammatory skin condition was given three corticosteroids in the form of creams, where only one would have sufficed. Additionally, the inclusion of paracetamol and multivitamins in the prescription may not have been necessary. 01/06/10 Clobetasol Propionate 0.01% (ointment) [100 gram] Fluticasone 0.05% 15g (ointment) [1 tube] Hydrocortisone 1% 15g (ointment) [1 tube] Multivitamin (tablet) [28 tablets] 0.64 Paracetamol 500mg (tablet) [20 tablets] 1.07 Promethazine 10mg (tablet) [10 tablets] 4.09 Total cost N$ 44

45 Table 8: Sample prescription dispensed on 1 June 2010 Relief for the patient could probably have been obtained with the prescription below and would have saved the pharmacy 40% of the original cost. Fluticasone 0.05% 15g (ointment) [1 tube] Promethazine 10mg (tablet) [10 tablets] 4.09 Total cost 82.78N$ Table 9: Potential revision of sample prescription dispensed on 1 June 2010 Such information is currently used by the pharmacy in providing discussion points in the Therapeutic Committee meetings within the hospital. Managers can also use the information to determine which individuals require training in rational use. It was noted during the extraction of the information on prescriptions that these example prescriptions were from two prescribers who had just joined the hospital on an exchange programme from another country. 45

46 Number of prescriptions Enhancing efficiency in pharmacy and patient management 8 Other management information reports generated from RxSolution at IHO 8.1 Prescription reports Managerial reports have been generated from the Rx Solutions. All prescriptions received at the pharmacy are intended to be entered into and dispensed on the system. IHO has 21 dispensers, who include pharmacists and pharmacist s assistants. Prescriptions are entered onto the system at all pharmacy dispensing points, except the ART clinic where ARVs are dispensed on the Electronic Dispensing Tool. Pharmacy staff do rotations in the different dispensing areas, stores and manufacturing area. Below is a sample graphic indication of how many prescriptions have been handled by each pharmacy staff member as of May DISPENSER ACTIVITY Ph: Pharmacist, Pa: Pharmacist Assistant, Wh: Workhand Figure 20: Workload indicator of average number of prescriptions/month handled per pharmacy staff as of May 2010 The data above are an aggregate of all prescriptions entered on the system between May 2010 and March 2011 by the available pharmacy staff in IHO. RxSolution includes a module for dispensing of prescriptions and captures information on the medicines dispensed, the prescriber, the dispenser, cost, time and dates, etc. The prescription module was part of the second phase of implementation, and thus the users did not start dispensing on the system immediately. Below is a graphic representation of the volume of prescriptions entered onto the system from the pharmacy in the 12-month period from May 2010 to April It should 46

47 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 Number prescriptions Enhancing efficiency in pharmacy and patient management be noted that formal training on the prescription module was not done until March 2010, which explains the low volumes in the months before. Prescription entered on system Figure 21: Prescriptions entered on the system from May 2010 to April 2011 Average No. of prescriptions /month dispensed on RxSolution Average No. of staff dispensing on RxSolution /month (pharmacists and pharmacist assistants) Average No. of prescriptions /month/staff entered on RxSolution Average No. of prescriptions /day/staff entered on RxSolution Table 10: Outpatients prescriptions at the paediatric pharmacy and main pharmacy The prescriptions shown in Table 10 are only outpatient prescriptions at two units: the paediatric pharmacy and main pharmacy. All inpatients and TB and ART outpatients are excluded. Inpatients normally receive their supplies from the ward stock that is currently not captured on the system for each individual patient. 47

48 Nov-09 Dec-09 Jan-10 Feb-10 Mar-10 Apr-10 May-10 Jun-10 Jul-10 Aug-10 Sep-10 Oct-10 Nov-10 Dec-10 Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Dec-11 Jan-12 Feb-12 Number of patients Enhancing efficiency in pharmacy and patient management 8.2 Patient visits captured on the system New patients registered on the Rx Solutions system Server y = x Figure 22: Trend in number of visiting patients captured onto the system, from November 2009 to November 2011 Above is a graphic representation of patient registration onto the system from November 2009 till November It should be remembered that these patients do not include ART patients. [NB: In September 2010 the server crashed and staff temporarily had to revert to the manual system. A backup server system has since been installed to prevent any loss of data and allow uninterrupted entry of data.] 48

49 number of patients Enhancing efficiency in pharmacy and patient management Registered private patients on Rx Solutions at IHO y = x Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Figure 23: Trend of registration of private patients The registration of private patients onto the system started in January 2011, when the system was extended to the private ward. Before this only a handful of private patients were captured onto the system at the main reception. Staff in the private ward was trained on use of the RxSolution system. This was important for the private ward, mainly for the purposes of being able to account for pharmaceuticals and related items used for the patients. This would help in expediting processing of claims from the different medical aid schemes, an issue that was resulting in losses of revenue to the hospital. Private patients who visit the hospital can now be easily categorised to the medical aid scheme they belong to. Below is a list of the medical aid schemes. It should be noted that there are also some private patients without medical aid, and these are captured as cash patients. Private patient cash Private NHP Private Renaissance Private PSEMAS Private MVA Private Napotel Private BankMed Private Day one health Private Namdeb 49

50 Number of patients Enhancing efficiency in pharmacy and patient management Private patients in IHO Medical aid Scheme Month Cash NHP Renaissance PSEMAS MVA Napotel BankMed Day one health Namdeb Other Private Totals Jan Feb Mar Apr May Jun Jul Aug Sep Oct Nov Totals Table 11: Dispersion of private patients in IHO among the different medical aid schemes and payment options It was previously not possible to obtain the information shown in Table 10 above with a manual system of filing. With RxSolution software, the hospital management can now obtain the information easily for quick decision-making Distribution of medical aid scemes in private patients at IHO Jan-11 Feb-11 Mar-11 Apr-11 May-11 Jun-11 Jul-11 Aug-11 Sep-11 Oct-11 Nov-11 Cash NHP Renaissance PSEMAS MVA Napotel BankMed Day one health Namdeb Other Private Figure 24: Distribution of private patients in IHO among the different medical aid schemes 50

51 Distribution of IHO private patients among medical aid schemes 19% Cash 3% 0% 37% NHP Renaissance 0% 1% 1% PSEMAS MVA Napotel BankMed Day one health Namdeb 35% 1% 3% Other Private Figure 25: Distribution of private patients in IHO among the medical aid schemes Data on these patients shows that about 37% of all private patients that visited the IHO between January and November 2011 were not on any medical aid but were cash patients. This strengthens and also emphasises the need for a robust system for monitoring payments and accounting for the cash fees paid. 51