Electronic Medication Management – Why?

FEATURE - Industry Innovation Article - Alcidion

Medication error is attributed to be the cause of an estimated 2,247 deaths per year in New Zealand. Further, in the paper by Davis P, et al, "Adverse events in New Zealand public hospitals", it was reported that medication-related events prolonged hospital admissions by a mean of 7.8 days; that 43.9% of cases were preventable; and 12.3% resulted in permanent disability or death.

These are just a sample of metrics available and more importantly, just a minor indication of the potential negative and personal impact on patients arising from medication error.

In response to these outcomes and the parallel advances in digital solutions, the Health Quality and Safety Commission New Zealand launched a programme to improve the way medicines are managed. The Commission is partnering with the Ministry of Health to explore the transition from paper to electronic medication management in hospitals establishing an eMedicines programme as part of the National Medication Safety Programme.

There are proven benefits to be realised in the digitalisation of the medication management process as well as opportunities and proven approaches to adoption available today that will expedite the transformation.

Obviously, New Zealand is not an “island” in this context. There is significant evidence in literature that Adverse Drug Events (ADEs) and clinical errors in the prescribing process contribute to patient safety incidents and efficiency issues.

In the United Kingdom it is reported that ADEs fill the equivalent of 8,000 hospital beds at a cost of £640M every year. Australian studies report 2-5% of drug charts contain prescribing errors. In addition, 5-18% of medications are administered in error (wrong drug, wrong patient, wrong route, wrong dose and / or wrong time). The Australian Institute of Health and Welfare reported that in the 2017-2018 year, 597,078 separations included a record of an adverse drug event; a rate of 5.3 per 100 hospital separations.

These statistics highlight the significant potential for digital solutions to support medication management processes and provide relevant clinical decision support to minimise and hopefully avoid adverse events.

Paper based medication processes inherently increase the risk potential. Some common problems experienced include:

• Lack of access to a consolidated, comprehensive patient medication history
• Paper-based, free text processes do not support alignment with standard terminologies or a local formulary
• Application of clinical decision support is a manual process and cognitive burden for clinicians
• Paper based medication charts do not promote timely administration recording
• Potential for transcription errors is escalated by hand-written prescriptions

There are some acknowledged challenges to adopting an electronic medication management (eMM) system including:

• Transition from a seemingly convenient paper-based process to a digital solution
• Engagement of multiple stakeholder groups
• Interoperability across multiple internal and external systems
• Increased need for timely access to devices
• Maintenance of reference systems e.g. formulary, decision support

These challenges have been addressed in multiple implementations across the world and there are significant benefits that have been realised in Australia:

• The Royal Children's Hospital in Melbourne reported a 13.4% reduction in medication errors (prescribing and administration)
• Peninsula Health, Melbourne realised a 33% decrease in medication errors reaching the patient across 2013-2014 and a 62% decrease in numbers of medication omissions dealt with by pharmacists in a 12-month period 
• Peninsula Health also recorded a reduction in missed doses from 2009-2014 across sub-acute 2.0% to 0.1%, acute 3.9% to 0.6% and mental health 6.0% to 0.7%
• Two New South Wales eMM implementations reviewed independently by Professor Johanna Westbrook demonstrated a 38% reduction in prescribing errors
• Austin Health, Melbourne achieved reductions in the number of ward medication incidents of 50% in sub-acute and 18.8% in acute.  They also achieved a 100% reduction in errors related to illegibility, transcription, frequency and signing of orders post implementation

Following are some broader examples of the improvements that can be realised:

• Reduction in drug prescribing errors through order formats aligned with best practice and supported by relevant alerts
• Reduced duration for nursing medication rounds as current information will be available as and when needed
• Eradication of illegible prescriptions and transcription errors as information is shared from the source and there is no need to rewrite
• Ability to define consistent treatment sets and monitor compliance
• Automated adherence to allergy checking and consistent reference to a patient’s allergy details 
• Alignment with required local practice through published order sets and formulary control
• Use of protocols defined with pre-set "step up" or "step down" stages to streamline ordering of complex medication regimes
• Application of decision support for prescription and administration of complex IV mixtures and titration 
• Reference to built-in calculators resulting in more tailored prescribing e.g. paediatrics
• Issue of proactive alerts and review reminders for antimicrobial stewardship 
• Support for the five rights of medication management e.g. right patient; right drug; right dose; right route, right time

Beyond the significant patient safety benefits, the adoption of eMM also has the potential to deliver cost savings:

• Austin Health identified inpatient dispensed medication savings of AU$700,000 in 9 months over 2013-2014 (i.e. full year estimated saving of AU$921,000)
• A reduction in medication costs due to the introduction of agreed cost-effective formularies and order sets was realised by The Royal Children's Hospital at 2.1% and Princess Alexandra Hospital, Queensland at 14% 
• Oxford University Hospitals NHS Trust realised a saving of 1% on medication costs when electronic prescribing referenced a standard drug catalogue which equated to £690,000

Alcidion work with Better and the Better Meds solution to deliver these benefits. Better Meds is based on modern open-standards technologies and supports the full medication process. APIs are used to facilitate interoperability. It is proven in several Trusts in the English NHS and was part of the achievement of HIMSS Level 6 in the Children’s Hospital, Ljubljana. We are about to enter the operational phase of a pilot project in New Zealand and look forward to sharing the outcome.

Given there are at least ten District Health Boards that still manage this critical process on paper, perhaps “why not” is the more appropriate question. The benefits that can be realised through adoption of electronic medication management are some of the most significant in terms of the provision of digital tools to support healthcare delivery. While it may be a challenging transition, the evidence suggests that it is certainly worth the effort.

Author: Kaye Hocking, Director Marketing & Partnerships, Alcidion

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