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Electronic prescribing and medicines reconciliation

PHARMACY PRACTICE
By using electronic prescribing, a hospital pharmacy in Cornwall has successfully implemented a scheme for recording the medicines reconciliation process, ultimately developing a prioritisation tool for the clinical pharmacy team
Iain Davidson MRPharmS
Chief Pharmacist,
Royal Cornwall Hospitals Trust, Truro, UK
Email: Iain.Davidson@rcht.cornwall.nhs.uk
Medicines reconciliation (MR) is now a well recognised key intervention of any hospital pharmacy service for reasons set out in the joint National Institute for Health and Care Excellence and National Patient Safety Agency safety alert,(1) with the evidence showing unintentional variances of 30-70% between the medications patients were taking before admission and their prescriptions on admission, and is detailed as one of the core standards in the Royal Pharmaceutical Society Professional Standards for hospital pharmacy.(2)
 
More locally, the South West Quality & Patient Safety Improvement Initiative has MR as one of its core workstreams to improve patient safety. This important initiative encourages service improvement via small tests of change and, as with all service improvement, one of the building blocks is a consistent and robust measurement tool to evidence improvement.
The pharmacy department at the Royal Cornwall Hospital NHS Trust (RCHT) uses the JAC pharmacy stock control system. The Trust also purchased the JAC Electronic Prescribing and Administration (EPMA) module in 2009. This article details how RCHT has evolved the use of the JAC system, initially as a measurement tool for recording MR and as a repository for the MRs, to an MR prioritisation tool, and ultimately to a general ward task 'pharmacist friend' prioritisation tool.
Making the MR process electronic
Pre-implementation of inpatient electronic prescribing
The Trust took a stepwise approach to the implementation of EPMA, starting with electronic discharge prescriptions (eTTA), followed by inpatient prescribing and administration (EPMA) and lastly electronic outpatient prescribing (eOP). 
JAC does not yet have a bespoke MR module; however, the 12 months it took for the implementation of eTTA essentially gave the team a period of time in which we could 'hijack' the inpatient prescribing module (POE) for the purposes of MR.
The pharmacists and technicians recorded the patient's medication history directly onto the JAC prescribing module and, using crystal reports, exported these data into a MR template that could be printed off, annotated and then filed in the patient notes. This had the added advantage that the medicines were already prescribed on the system when the doctor came to discharge the patient, and therefore they had a simple box to tick to move it over to the eTTA rather than having to electronically prescribe it from scratch, leaving them only the new medicines to be prescribed. This speeded up the discharge process and improved the acceptability of the eTTA project to prescribers. It also meant that, if patients were re-admitted, their old records could be reactivated, saving further time at the MR and discharge stages.
To annotate the drug history that had been completed on JAC, we 'prescribed' MR as a drug on the EPMA system. This meant, again using crystal report, we could report exact figures on MR that detailed:
1. The name of the patient
2. The name of the member of the pharmacy team that had completed the MR
3. The time and date of the MR
4. The time since admission the MR was completed (24, 48 and >48hours)
5. The name of the ward from which the patient was discharged 
6. The percentage MR completion rates for each ward
7. The total number of MRs completed for each member of the pharmacy team and for the department as a whole.
This robust report allowed us to clearly evidence whether changes in practice and staffing levels are affecting MR rates.
Post-EPMA deployment
In December 2012, the Trust began the roll-out of inpatient electronic prescribing and administration, meaning that we could no longer use JAC as a repository for medication histories and that we needed to adapt our process. 
As wards move over to EPMA, the drugs are prescribed electronically at the point of admission by the prescriber, and therefore the benefit at discharge of the pharmacy team entering the medicines history onto the prescribing system becomes redundant. The team also had to change how it recorded when a MR was completed, because prescribing MR like a drug would mean it would show up on the patient’s drug chart and would be confusing for clinicians and nursing staff.
The clinical pharmacy team now utilises the notes function within JAC for the purposes of recording whether a MR has been carried out. We have augmented the original process further to provide a more comprehensive picture of the state of play with MR. The process of MR at RCHT is essentially a three-step process: 
1. The 'New' stage: taking the drug history, often carried out by a pharmacy technician
2. The ‘Review’ stage: the drug history is reviewed by a pharmacist to resolve any discrepancies (not always required)
3. The Complete stage: the drug history is reconciled and the MR is signed off as complete. This step may be competed by a pharmacy technician or pharmacist.
Using a MR note on the JAC system, staff mark the note either new, review or complete, changing the title as they progress from one stage to the other. We are then able to pull the MR report, but we can now capture not only those that are complete but also those that are in progress.
The benefit of this method is that it reveals the workload of all those involved in the process, not just those that do the final 'complete' step, so the hard work that the pharmacy technicians carry out in supporting the ward pharmacist is also visible. This method also helps flag any gaps between the number of MRs started and the number of complete MRs, which can highlight a gap in pharmacist resource in that area.
For example, a technician on the admissions unit might undertake the initial drug history taking (new) and then leave it for the pharmacist to complete. The old method would only flag the pharmacist’s step. The new method now records both the technicians’ and the pharmacists’ input to that process. The figures might also show that the technician had completed 100 drug histories on the ward but only 75 of these have been reconciled and completed by a pharmacist, highlighting that additional pharmacist resource might be required in this area.
MR prioritisation tool
Using the same data, we are able to provide our clinical pharmacy team with a live MR status report, showing exactly which patients have had MR on each ward, the stage of the process and which patients are yet to be reconciled. This prioritisation tool helps the team to use their limited time on the wards more effectively, increasing MR rates and ultimately improving patient safety. 
Uses
For the Trust
The monthly MR figures feed directly through to the Divisional performance framework, which is scrutinised each month by the Executives. It is one of the key performance indicators that are used when deciding whether or not the Division remains an autonomous business unit or whether it requires closer oversight by the Executives.
The report also shows the Trust the MR rates in each specialty, and clearly identifies the gaps in service, for the Trust to then take a risk-based approach on investment in those areas. 
For the department
Within the department, the data are used to feed back to the team and acknowledge and celebrate the good work that is going on. The report flags gaps in resources and skill mix on specific wards, allowing the management team to reallocate pharmacy resource month on month and also helping highlight staff that may need additional training and support.
The monthly MR data, coupled with the published evidence estimating that each MR saves the healthcare community a total of £5, allows the pharmacy management team to articulate the value of the clinical pharmacy reconciliation service and construct robust business cases for service improvement.(3) 
For the patient
The pharmacy clinical team is ultimately aiming to have consistent input to all inpatients - a pledge of service to deliver medicines optimisation. This service includes:
  • MR on admission
  • Medication counselling
  • Clinical screening and interventions as necessary
  • Timely provision of medicines at discharge
  • Referral onto the community pharmacist for further support services, such as the new medicines service and targeted medication usage reviews.
By using the notes function method of recording and reporting, we feel we have identified a simple way of annotating when these key steps have been undertaken, and ultimately the team will be able to evidence to patient level how we are performing against our pledge and where the gaps in service lie.
Conclusions
Using electronic prescribing, we have successfully developed a process for recording the MR process, ultimately developing a MR prioritisation tool for the clinical pharmacy team. We estimate that the introduction of the prioritisation tool has resulted in a 10% improvement in completion rates.
Using other functions of electronic prescribing, we have now developed a more detailed 'pharmacist friend' prioritisation tool, which highlights other core tasks that the clinical pharmacy team need to complete. The tool shows the ward clinical pharmacy team at a glance those patients who require MR, those who have medications requiring a clinical screen and supply, those patients with discharge prescriptions written and awaiting processing, and flags any patient prescribed a high-risk medication.
The tool also flags any missed doses for a patient and the number of these that are critical medicines. This tool allows the team to take a more risk-based approach to their ward work and use their time on the ward more effectively, potentially not seeing some patients when there has been no change from the previous day. The tool also shows the pharmacy management team how comprehensively a ward is being covered by the clinical pharmacy team and, as with the MR tool, will highlight areas where additional resource or training and support is required and provide us with robust, accurate, continuous data on clinical pharmacy activities to help with service development.
Key points
  • A robust, continuous measurement tool is key to service improvement.
  • Where possible, these tools should be part of business as usual and not be a burden to complete or collate.
  • Assuming your key performance indicators match your clinical service objectives, such tools  can be used as both a measurement and prioritisation tool.
  • Electronic prescribing and administration should be seen as a key enabler to such an approach.
  • Ultimately, tools such as 'the pharmacist friend' developed at the Royal Cornwall Hospitals Trust will allow for a risk-based approach to patient care, ensuring limited pharmacy resource is directed to the most appropriate patients.
References
  1. National Institute for Health and Care Excellence/National Patient Safety Agency. Technical patient safety solutions for medicines reconciliation on admission of adults to hospital. NICE & NPSA Safety Alert. NICE/NPSA/2007/PSG001. December 2007.
  2. Professional Standards for Hospital Pharmacy Services. Optimising patient outcomes from medicines. For pharmacy services in acute, mental health, private and community service providers;July 2012.
  3. Campbell F et al. A systematic review of the effectiveness and cost effectiveness of interventions aimed at preventing medication error (medicines reconciliation) at hospital admission. www.nice.org.uk/ nicemedia/pdf/ patientsafetymedssystematicreview.pdf  (accessed 20 May 2013). 

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