PROJECT DOCUMENTATION STRATEGIC OUTLINE CASE e-prescribing SYSTEM Release: Draft vs. 0.3 Date: 20 th May 2008 Author: Liz Boylan Noy Scott House RDEH(Wonford) Barrack Road Exeter EX2 5DW Tel: 01392 402365 E/mail: Liz.Boylan@rdeft.nhs.uk 20 th May 2008 v0.3 Page 1 of 11
Table of Contents STRATEGIC OUTLINE CASE...3 1. STRATEGIC CONTEXT...3 2. NATIONAL CONTEXT...4 3. LOCAL CONTEXT...4 4. ORGANISATIONAL CONTEXT...4 5. THE CASE FOR CHANGE...5 6. SCOPE AND SERVICE REQUIREMENT...6 7. OPTIONS...7 8. BUDGETARY COSTS FOR IMPLEMENTATION OF E-PRESCRIBING...8 9. BENEFITS...9 10. RISKS...11 11. IMPLEMENTATION TIMETABLE...11 12. RECOMMENDATIONS...11 20 th May 2008 v0.3 Page 2 of 11
STRATEGIC OUTLINE CASE 1. STRATEGIC CONTEXT 1.1 The RDEFT pharmacy department provides a comprehensive, safe and timely range of prioritised medicines management services that meet the needs of the patient, wards and the Trust. It is known that prescribing, drug administration and medicines management is the most common active intervention made with patients. It is associated with significant risk from adverse events, prescribing and drug administration errors. Electronic prescribing (e-prescribing) has been heralded as bringing major benefits to patients by reducing the incidence of medications errors and improving communication about medicines. 1 It will also support clinical activity by interacting with knowledge sources and providing decision support at the point of prescribing or administration. e-prescribing is the utilisation of electronic systems to facilitate and enhance the communication of a prescription of medicine order, aiding the choice, administration and supply of a medicine through knowledge and decision support and providing a robust audit trails for the entire medicines use process. The implementation of e-prescribing will support health care professionals at all stages of the medicines use process by introducing: o computerised entry and management of prescriptions; o audit trail of all prescription additions, deletions and changes o manage the prescribing of restricted drugs o decision support, aiding the choice of medicine and other therapies; o support for the administration of medicines; o knowledge support, giving users immediate access to up-to-date drug information (eg. The British National Formulary) and local information such as procedures and protocols; o electronic links between hospital wards/departments and pharmacies; o a robust audit trail for the entire medicines use process; o ultimately, links to other elements of patients individual care records; o the ability to work with pharmacy systems, such as stock control; o an element of customisation to take local processes and priorities into account (eg in local formularies and clinical protocols). 1.2 The objectives of this investment case are: to define the options for the procurement and implementation of an e-prescribing system across the RDEFT that will interface/integrate with the Pharmacy Stock Control system and will meet the Trust objectives for the treatment of patients requiring acute healthcare; to assess the costs and benefits associated with each option; and to identify a preferred option. 1.3 The estimated capital cost of the proposed investment will be approximately 489k over years 2008/09 and 2009/10. The annual revenue consequence of this investment will be 114k p.a. Approval for funding will be made in accordance with the RDEFT Standing Financial Instructions. 1 The Institute of Medicine(US). To Err is human: building a safer health system. National Academy Press 1999 20 th May 2008 v0.3 Page 3 of 11
2. NATIONAL CONTEXT 2.1 The proposed investment is aimed at contributing to improvements in the provision of health and healthcare services for the local population. However, it takes place in the context of developments in national health policy and associated strategies and plans. In some cases these have a direct bearing on local plans, directing or constraining the choices at local level; this is most clearly the case with national policy, strategy and plans for information and information technology. Examples include the national strategy set out in Information for Health and the various infrastructure projects and other IM&T initiatives 2.2 e-prescribing is one element within the national programme for information technology, delivered by NHS Connecting for Health. Electronic prescribing plays a major role in supporting a patient s treatment with medicines. It provides information about that treatment to whoever needs that information, whenever they need it, provided they have a legitimate right to access that information. 2.3 An e-prescribing system will provide online access, at the point of need, to relevant knowledge and to clinical decision support systems including: Access to prescriptions in multiple locations by multiple system users Automatic or semi-automatic stock control Legible prescription production Medication record availability Reminders and alerts, including those relating to formulary choice, to support prescribers at the point of prescribing Support for medicines administration Note-making facilities to support communication between all health care workers caring for a patient 3. LOCAL CONTEXT 3.1 The health and social care community covered by RDEFT has a resident population of 488,500. There are currently twelve community hospitals and seventy-six general practices managed by Devon PCT and three mental health hospitals and a multitude of satellite sites managed by Devon Partnership Trust. Westcountry Ambulance Services Trust provides emergency ambulance services, patient transport services and the NHS Direct service. All agencies share the responsibility for ensuring that information is used to support the delivery of better health and social care. 4. ORGANISATIONAL CONTEXT 4.1 The RDEFT Pharmacy Department, during 2007/08, provided a service for approximately 91,000 admitted patients with an average of 4/5 drugs prescribed per admission creating a total of 0.5m inpatient prescribing events. 4.2 Potential for inclusion of all outpatient prescribing, 92,917 new attendees and 178,401 followup attendees in 2006/07, for which we provide a prescription for 15% either as a trust script or FP10. 20 th May 2008 v0.3 Page 4 of 11
4.3 The Pharmacy Department is comprised of the sections set out in Table 1, indicating present workload and staffing levels. Table 1: Pharmacy Workload / Staffing Levels Section Workload (2007/08) Staffing WTE (2007/08) Dispensary 283,000 items 3 pharmacists, 4 technicians, 6 SATOs Stock Distribution Aseptic Services Medicines Information Procurement 244,000 items 1.5 technicians, 7.5 ATO s 24,000 items comprised of 17,500 cytotoxics, 6,500 other aseptic products 4 pharmacists, 10 technicians, 1 ATO 2,200 enquiries 1 pharmacist 14,200 orders, 26,000 invoices to value of 20,590,000 drug purchases 3.0 staff Clinical Trials 60 clinical trials 0.8 senior technician, 0.54 technician, 0.5 SATO Clinical Pharmacy Medicines Management Increasing number of wards (17 at 31 st March 2008) have a Patient s Own Drug scheme (PODs). 1 principal pharmacist, 7 senior pharmacists, + rotational basic grade pharmacists. 5 technicians. 5. THE CASE FOR CHANGE 5.1 In light of the strategic arguments at national, regional, local and organisational levels, the RDEFT Pharmacy Department recognises the need for change in the way IM&T is deployed in support of its staff and patients. To this end it has determined that it should seek to invest in improving its IM&T provision through the implementation of e-prescribing supported by a modern stock management system that will ensure the delivery of better clinical care. 5.2 The implementation of e-prescribing will require new roles in health/pharmacy informatics to support the continued development of systems based on feedback. There will be changes to practice and evidence generated that will enhance medicines management, risk reduction, patient safety and quality improvement in a variety of ways. Systems will facilitate the supply of medicines through links to stock control and automation. Time released from traditional activities will need to be redirected to clinical activities and used to promote optimised treatment for individual patients. 20 th May 2008 v0.3 Page 5 of 11
5.3 e-prescribing will impact on and require the support of everyone who prescribes, supplies or administers medicine. In addition to doctors and hospital pharmacists this will include nurses, midwives, and allied health professionals such as radiographers and physiotherapists. Many other NHS employees will also have an interest in the implementation of e-prescribing from senior management teams within trusts to the information technology teams which will provide local support to the systems. 5.4 The following sections describe in more detail: Scope of functionality and services required Main benefits and risks identified. 6. SCOPE AND SERVICE REQUIREMENT 6.1 Scope of functionality 6.1.1 There are currently over fifty wards / patient areas across the RDE where hospital prescriptions are written out by hand on drug charts. This strategic outline case provides for a project that will include the planning, procurement and implementation of an e-prescribing system in the following directorates: Child & Women s Health Medicine Surgery One Specialist Surgery Trauma & Orthopaedics Critical Care 6.1.2 The e-prescribing system must provide comprehensive facilities to support electronic prescribing, medicines administration and dispensing, or links to activities including dispensing worksheets, treatment/patient labels, dispensing and storage details. Access to the system by any user must be password protected. 6.1.3 Two-ways links/integration with the appropriate pharmacy system must be in place to facilitate the supply of medicines for all situations using standard NHS message standards. Information should be transferred automatically so the re-keying of data is not required (ie, patient demographics and medicines details with associated dose directions) 6.1.4 Use of generic drug names must be the primary mode of display within the system unless there are defined reasons to use a proprietary name (eg modified release, combination products or insulins) 6.1.5 The system must link decision support to administration together with any local information available to ensure that all warnings and notes are available at the time the medicine is to be given. 6.1.6 The system should default to outpatient mode if the prescriber is accessing a record for outpatients. 6.1.7 Requirements specific to clinical specialties, eg emergency, dermatology, elderly medicine, rheumatology and oncology, reflecting the reality that different clinical specialties will often require different things from e-prescribing. In some cases specialty-specific requirements may be pertinent to more than one clinical specialty and should therefore be viewed as being available for use in other clinical specialties if required. 20 th May 2008 v0.3 Page 6 of 11
6.1.8 Decision support will, for the most part, be similar in all specialties although there will be specific contextual rules that need to be developed for specific circumstances. 6.1.9 The system must be able to meet the following requirements: Medicines are sometimes administered by the prescriber, thus prescribing and administration may be required as one action Monitoring to inform actual medicines or doses to be administered. The recording of variable dosing/changes to other agents Routes of administration may be complex, with the use of multi-lumen lines, for example 6.1.10 The system must support the verification of prescriptions by pharmacists. The act of verification should be used as part of the control process for requiring a medicine supply to be made. Once verification has been completed the request, where a supply is required, should be forwarded to the relevant stock control system function. 6.1.11 The system must be able to record interventions or contributions made by pharmacy staff. These should be incorporated in the entry generated as part of the care record and fed into the local incident reporting system 6.1.12 The system should support the input of pharmacy notes 6.1.13 The system must provide local access controls to allow pharmacy staff to request drug levels for certain drugs from within the pharmacy specific work areas. 6.1.14 The system must allow pharmacists to view alerts that have been generated for drug interactions or other medicine-related issues as part of the verifications process so that they can see which ones have been overridden or accepted 6.1.15 The system must all the addition of patient-specific management notes that are highlighted eg outlining that there should be no benzodiazepines prescribed or supplied on discharge 6.1.16 The system should allow the addition of ongoing pharmaceutical care requirements to discharge information being sent to primary care. It must be possible to add these on an ongoing basis and to edit them at the point of discharge. 6.1.17 The system must be able to track changes to prescriptions over time including when new drugs were added, when and why they were stopped or changed. 7. OPTIONS 7.1 Solution Options 7.1.1 The RDEFT preferred solution must provide an e-prescribing system that will meet the strategic objectives and realise the benefits operational, managerial and financial benefits outlined in Section 9. Table 2 outlines the options considered: Table 2 e-prescribing Solution Options Option Solution Positives Negatives 1 Do Nothing Unable to access patients medicinal data as and when required 2 Procure e-prescribing system that will Additional costs and 20 th May 2008 v0.3 Page 7 of 11
interface with stock control system & implement for in-patients 3 Procure e-prescribing system that will interface with stock control system & implement across Trust 4 Procure integrated e-prescribing and stock control system & implement for inpatients 5 Procure integrated e-prescribing and stock control system & implement across Trust Integrated system providing seamless flow of data Integrated system providing seamless flow of data that will support a patient s treatment with medicines by whoever need it, wherever it is used potential issues associated with interfacing different systems Additional costs and potential issues associated with interfacing different systems Incomplete patient data 7.1.2 Option 5 is the preferred option. An integrated system would provide a seamless information system for the provision of pharmacy services across the Trust. A timely rollout would need to be achieved to ensure minimum disruption of service due to patient transfers, i.e. from an implemented ward to another awaiting implementation. A phased implementation of stock management followed by e-prescribing would be the chosen method of approach. The procurement and implementation of the stock control modules are covered by a separate Business Case. 7.2 Supplier Options 7.2.1 The Pharmacy Department has identified two major suppliers of pharmacy systems who can meet the specification required and are approved suppliers from the Connecting for Health evaluation for additional services. These are JAC Computer Services and Ascribe plc. Suppliers demonstrations have been arranged for May/June 2008. 8. BUDGETARY COSTS FOR IMPLEMENTATION OF E-PRESCRIBING 8.1 For the purposes of this SOC budgetary costs obtained from one of the LSP approved Pharmacy solution providers are detailed in Table 4. Table 4 Budgetary Costs for Implementation of e-prescribing System Supplier Costs Capital inc VAT Revenue inc VAT Software Trust Wide Licence up to 1,000 users 235,000 58,750 Cache 100 user licence 36,190 7,962 20 th May 2008 v0.3 Page 8 of 11
Installation 1,868 0 Training 9,342 0 Project Management (25 days) 23,353 0 Go Live Support (10 Days) 9,342 ADT PAS Enhancement 4,113 First Databank Europe Multilex Clinical Drug 0 24,440 File (40 wards) Subtotal 319,208 91,152 Optional Items Clinical Workstation Interface 11,750 2,938 Discharge Drugs Interface to EPR System 11,750 2,938 Subtotal 23,500 5,876 RDEFT Implementation Costs Windows 2003 Server (x2) 13,000 Programme Manager (B8 x 0.5 wte) 26,580 Implementation Manager (B7 wte) 39,760 Change Lead (B6 x 0.5 wte) 16,607 Trainers (B6 x 1.5 wte + 0.5 ongoing) 49,821 16,607 Subtotal 145,768 16,607 Total Expenditure 488,476 113,635 8.2. The above costs do not include any hardware on the wards. Implementation of e-prescribing will require a Wireless LAN and mobile recording devices such as laptop PCs, PC tablets and/or computers on wheels. 9. BENEFITS 9.1 e-prescribing has a number of documented benefits, including reducing risk by making legible prescriptions available to other members of the health care team and by providing decision support at the point of prescribing using alerts and reminders. Work in the UK has shown how the use of structured prescribing pathways can be customised for different 20 th May 2008 v0.3 Page 9 of 11
specialties, improving workflow and reducing the risk of error. 2 Further work has demonstrated how UK clinicians have benefited from the introduction of decision support alerts. 3 Electronic prescribing can also be used to facilitate both formulary compliance and cost reduction strategies. Potential benefits of e-prescribing in reducing medications errors and improving communication are widely recognised by hospital pharmacists. 9.2 The benefits of implementing e-prescribing have, for the purpose of this Strategic Outline Case, been categorised as Operational, Managerial or Financial. Those identified are set out in Table 5. Table 5 Benefits of Implementing e-prescribing Operational Benefits Prescription always available at point of need and at multiple sites, saving staff time Facilitate compliance with policies (eg antibiotics) and formulary at the point of prescribing (from 37% pre to 96% post in Doncaster and Bassetlaw) Accurate record of all drugs administered, assuming drug administration module included (from 65% pre to 96% post in Doncaster and Bassetlaw) Information on drug availability at the point of prescribing, assuming integrated with pharmacy stock management system Ability to target clinical pharmacist activity to patients with greatest need Managerial Benefits Reduce transcription errors prescriptions No legibility issues Notes can be attached clarifying decisions Allergy warnings always available and linked to drug selection Reduce adverse drug events (from 11% pre to 4.2% post in Doncaster and Bassetlaw) Reduce drug selection errors through drop down menu selection and ability to retrieve previous medication history for readmissions Reduce dose, frequency and duration errors through drop down menu selection Reduce risk of administration errors through bar code recognition at point of administration Reduced delays in treatment by reducing delays from prescribing to supply Reduce missed doses as prescription available at all times Ability to track and audit changes in drug treatment during admission Enforce national policies eg NPSA Safer Practice Alert for methotrexate Identifies drug interactions at the point of prescribing Potential to link with other decision support systems eg pathology that influence choice of drug, dose etc at the point of prescribing Ability to quickly identify high risk patients for closer monitoring eg specific high risk drugs (warfarin etc), patients on multiple drug therapy Ability to restrict the prescribing of high risk drugs to specific clinicians Accurate medication histories able to be transmitted to GPs including changes to therapy Financial Benefits Ability to accurately cost drug treatment of patients down to what has been administered rather than what has been supplied Ability to accurately track PBR excluded drugs for recharge purposes Reduced cost of dealing with adverse drug events (eg fewer tests, additional treatment and length of stay) Save staff time looking for and accessing drug charts by medical, nursing and pharmacy staff 2 Use of structure paediatric-prescribing screens to reduce the risk of medication errors in children. British Journal of Healthcare Computing Information Managerment 2003. 3 Implementation of rules based computerised bedside prescribing and administration: intervention study. BMJ 2000 20 th May 2008 v0.3 Page 10 of 11
Save staff time transporting drug charts around the site eg ward to pharmacy Potentially some drug expenditure savings through tighter control of prescribing eg duration of antibiotics 10. RISKS 10.1 The Project Manager will maintain a Risk and Issues Log throughout the life of the project. Those risks already identified have been included in Table 6. Table 6 Risks of Implementing e-prescribing Operational Risks Service delivery if system fails Training locum and bank staff at short notice and out of hours Does not cover all prescribing eg chemotherapy Incomplete use of system and therefore records if access is not optimised, requires access to appropriate IT hardware eg laptops, tablets, mobile PCs,etc Managerial Risks Need for manual back up system and procedures Staff deskilled in the use of hard copy Financial Risks Initial capital outlay including the provision of portable units Revenue costs for license Staff to support the system 10.2 The overall conclusion is that while there are a number of risks that represent a potential threat to the project s objectives and progress, these are not on a scale likely to result in major setbacks or failure. However, an active risk management strategy remains part of the overall approach to managing this project. 11. IMPLEMENTATION TIMETABLE 11.1 A full project plan will be developed with the chosen supplier. The preferred method of implementation would be to pilot the e-prescribing and Medicines Administration System on 2 wards for six months, review for three months and then roll out in the quickest possible timescale to ensure that problems arising from the transfer of patients between wards where e- Prescribing many not have yet been implemented is kept to a minimum. It is envisaged full implementation would be complete within twelve months. 12. RECOMMENDATIONS 12.1 The RDEFT is requested to approve investment in an e-prescribing system aimed to support its health care professionals at all stages of the medicines use process. Based on current knowledge, the procurement of an integrated e-prescribing and stock control system implemented across all services would provide the best possible solution to achieving those benefits detailed in this. 20 th May 2008 v0.3 Page 11 of 11