Implementing a Network E-prescribing Solution Chair: Jeff Koundakjian Former Lead Pharmacist North Wales Cancer Centre

Implementing a Network E-prescribing Solution

Chair: Jeff KoundakjianFormer Lead Pharmacist

North Wales Cancer Centre

Electronic Prescribing – a Network Approach

BOPA symposium October 2008

David Barber – BOPA 2008

These slides are intended to provide additional material to illustrate the points made in the presentation and should not be used out of context

Introduction

• The network• Background• Business case and procurement• Implementation• Benefits and drawbacks• The future

LSCCN ePrescribing Project

The Network



Lancashire & South Cumbria Cancer Network

• 1.5m population• 4 Trusts• 6 chemo units• 20,000 chemo

attendances• Cancer centre at LTH• Haematology at BVH• “Decentralised”


Background

• June 2006 – DH and CAT announced capital funding for interim EP system for oncology

• National solution to be implemented when available (about 4 years)

• Business cases from Trust or network to be completed by September 2006

• Preferred supplier to be named by March 2007


Electronic Prescribing Solution



Interim Solution


Features of an Interim Solution

• No interfaces– Time consuming– Politically sensitive– Complex– Expensive– Unreliable

• Simple– Less validation– More freedom– Minimise “culture shock”


Initial Working Group

• Network pharmacist• Lead service improvement facilitator• Network manager• Head of D&T• Lead clinician


Business Case - Benefits

• Why do we need it?– Safer prescribing– Network wide reporting– Scheduling


Safer Prescribing

• About 5-10 serious prescribing errors per month at Cancer Centre

• About 1 case maladministration per year• Errors:

– Dose alterations not continued– Miscalculations– Transcription errors– Wrong dose– Illegible prescriptions


Network Wide Reporting

• LSCCN is a decentralised network – treatments available at all sites

• LSCCN consistently performs badly on audit of NICE drug use performed by CAT

• Planning new developments• Capacity and demand• D&T• Audit


Scheduling

• 5 sites using paper scheduling• Cancer centre using MS Outlook• Maximise capacity


Business Case – Costs

• Identify costs– Capital

• Software• Hardware• Setup

– Revenue• Maintenance• Support• Capital charges


Costs – Capital• Software

– Initial purchase– User licenses

• Hardware– Server– PCs– Other e.g. printers, network points

• Setup– IT– Training– Configuration e.g. regimens, documentation– Validation


Costs - revenue• Maintenance

– Server– Other equipment– System admin

• New regimens• New users

• Support– IT– Supplier

• Capital charges– Depreciation– Interest


Business Case

• Who do we need?– Oncologists– Finance– Pharmacy– Nursing– IT


Oncologists

• Access to patients’ prescriptions from anywhere in network

• Prescribe using PC not chart

• Up to date prescription info

• Calculations• Quicker(?)


Pharmacy

• Reduce prescription errors

• Reduce paper chasing


Nursing

• Accurate prescribing• Reduce paper chasing• Nursing

documentation(?)


IT

• Income stream• Interim solution• Where is CfH?


Finance

• All the above


Working group

• Expanded to include– Haematologist– More pharmacists (oncology and chief)– IT staff from Morecambe Bay


Technical Architecture


Outcome of LSCCN Bid – October 2006

• Successful (ish)

– LSCCN awarded ~£500k for purchase of ePrescribing software

– MBHT agreed to host– MBHT procurement to assist in tender


Tendering Process


Advert in OJEU(Dec 06)

20 expressions of interest(Jan 07)

Operational requirements(Aug-Dec 2006)

Site visits by applicants(Feb 07)

5 responses

Site visits to Norwich and UCLH(March 07)

Preferred supplier selected(26th March 2007)

2 bids

Supplier presentations(March 07)


• US based company• Manufacturers of XRT equipment• Expanding European base

Implementation May- August 2007

• Establish implementation plan• Hardware installation (MBHI)• Database initiation (Canada)• Software installation• Establish local steering groups• Mapping exercise


Regimen Building

• WebEx training• Internet portal• Regimen building

– 2 pharmacists– 4 months– ~300 regimens


Training


Training

• Super-user training– 4 sites– 3 days at each site– Nurses, pharmacists, IT, reception/admin

staff

• Cascade training


Administration• Information governance• Contingency plans• Error reporting• Change management• System admin• Communication plans• Legal issues• SOPs• Validation

– Regimens– Processes– Reports


Roll-out (October-December 2007)

• Staggered go-live• New patients from go-live date• Minimum dataset

– Name– NHS no.– DOB– Tumour type & stage– Allergy status

• Scheduling• Nurse administration


Results (what we did right)

• Roll out completed on time and within budget (got VAT part-refunded)

• 1st fully networked cancer network in the UK (we think)

• All solid tumour chemotherapy prescriptions (and most IV haematology) electronic since February


Benefits Realisation – Safety

Fewer calculation errorsNo transcription errorsLegible prescriptions× Wrong regimen

– Need regimen for every eventuality e.g. IV/oral, cisplatin/carbo, infusor/pump, trial arms

× Creatinine- Entered manually


Benefits Realisation – Scheduling

• Now possible• Variable uptake• Further training


Benefits Realisation - Reporting

• Basic reporting possible• Network wide – good• Local unit – poor

– Where does patient belong?• Report building

– Complex– Expensive– Time consuming– Varian report builder now available


Results (where could we have done better)

• Training– What do we need to know?– How do we set up an unknown system?– Further training organised

• Data entry– Underestimated time to enter patients

• Validation errors– Capecitabine minimum dose 1300mg– Caelyx regimen set to 3 weekly


Results (where could we have done better)

• Prescribers “jumping the gun”– Paper prescriptions do not translate easily to

electronic ones– Differences in rounding etc– Paper and electronic prescription in circulation

• IT– Should have got fully engaged at all sites from

outset


Teething Troubles

• Access rights– “Why won’t it let me do my job?”

• Number/position of PCs• Printing issues• General software faults (mostly minor)

– Crashes– Network issues– Creatinine clearance calculator


Other Benefits (the bits we like)• No paper chasing• Access from anywhere in network• 1 log-in• Network consistency• Manage change

– Antiemetics– Dose banding– Hydration

• Reporting• Very flexible system• Stable program


Drawbacks (the bits we don’t like)

• Printed prescriptions• Steep learning curve esp. Prescribing• No electronic clinical check• Lots of paper

– 1 x A4 per cycle/day

• Very passive system – difficult to keep track• No paper to scribble on!


Non-interfaced system

• Duplicate patients– Rare– Manageable

• Creatinine clearance for carboplatin– Be vigilant!


The Future

• Improve reporting & data quality• C-PORT• Notes• Oral chemo• Communication• System upgrades• CFH


Thanks for Listening

Any questions

?LSCCN ePrescribing Project

Documents

Implementing a Network E-prescribing Solution Chair: Jeff Koundakjian Former Lead Pharmacist North Wales Cancer Centre