Introduction
Members of our Medicines Optimisation Network wanted to promote better adherence to protocols using order sets and to allow the easier review of guidelines and changes to be made centrally, as needed. They also sought visibility and accountability over compliance. The area is measured through audits of guideline adherence (including reports from system and case note reviews) and observations of practice.
Visibility of issues will be clearer through EPMA data, but ensure there is accountability and visibility across the organisation so trusts can see where things are going wrong as well as good practice
What peers in the network found
Define order sets before you begin
Be prepared to alter order sets as clinical guidelines and best practice changes, and don’t forget new drugs & NICE approvals. Create a team to keep order sets up to date and ensure they know their responsibilities. Review and deactivation are just as important!
Understand the problems the system will highlight, but not solve
ePMA will highlight poor processes or a disorganised ward but will not fix the process. You may go looking for benefits which cannot be achieved just by implementing an ePMA system.
Plan time for data analysis
There’s a risk that the data provided could be overwhelming, but it’s important that issues are not only identified, but also acted on. When there is more information available than ever before, managing expectations around what can be resolved and when, is imperative. Whilst it would be negligent not to act, having the resource and capacity to do so immediately may be unrealistic.
Create a clear governance structure
Different teams shouldn’t be working to different guidelines. Processes should be streamlined through a clear governance structure across the board.
Put things in one place
It sounds simple, but sometimes policies and guidelines get kept in separate places, particularly if they have been created by separate departments. Keep them together in one place, that everyone has easy access too.
Identify and find solutions to people’s workarounds
People will always find their own workarounds for new systems, spend time finding out what they are and then work on keeping those who do them on track. However, this option may restrict access to meds and prescribers will actively look for these.
Get clinical support in the design
Don’t just get supplier advice on how things should be done, widen the input on how you want to do it by involving clinicians at the design stage.
Take time to understand your staff.
This is particularly important for hard stops. You need to make sure that alerts/ decisions support happens at the most useful point in the prescribing and decision-making process. The best way to get this right is to involve your staff in the design process.
Make sure education is ongoing
Design it and evaluate it. Have clinical champions. Have value and reward systems. Bring education to workplace settings, not just in classrooms. Partner trainers and clinicians to come up with good scenarios that reflect real experiences.
Prioritise correctly
Use benefit maps as a way to prioritise which guideline to do first and which area is the most important.
Get support from your QI team (if your trust has one)
One trust asked their QI team to complete a diagnosis to work out which three things would have the most impact, and used this to support both their prioritisation, and identify the best measure to monitor them effectively.
Find themes in the issues logged to IT help desk
to find the areas where support is needed.
Tip:Making sure all issues are logged this same way will make this a lot easier to do.
What to look out for
- Although data was baselined, this was not always done correctly – be careful you’re comparing apples to apples.
- People input the wrong weight, so though calculation is correct, it is based on an adult weight of 1kg – ensure people know to enter the correct weight.
- Be conscious of legacy habits. People expect digital systems to work exactly how paper did. You need to help them understand the differences in this context.
- System constraints may make adherence difficult, for example around dose scheduling. Call this out from the beginning.
- Guidelines may be too inflexible to individual patient needs – don’t skimp on consultation time with your staff so that you really understand their needs.
- Ward whispers. Reflect collaboratively and regularly. Ensure that there is not one voice channelling the feedback and not just listening to ward whispers; need a structured process for feeding back in practice.
- Difficult to maintain guidelines. Who ensures they are up to date?
- Writing a prescription by hand is easier and quicker, and that’s a barrier but it may not be complete, and time will be required either later or by others to put it right – remember the gain may be further down the line.
What to read
Long reads
Clinical reminder alert fatigue in healthcare: a systematic literature review protocol using qualitative evidence
Ten Key Considerations for the Successful Implementation and Adoption of Large-Scale Health Information Technology
Investigating and Learning Lessons From Early Experiences of Implementing ePrescribing Systems Into NHS Hospitals: A Questionnaire Study
Sustained User Engagement in Health Information Technology: The Long Road From Implementation to System Optimization of Computerized Physician Order Entry and Clinical Decision Support Systems for Prescribing in Hospitals in England
Mixed methods study of medication-related decision support alerts experienced during electronic prescribing for inpatients at an English hospital
Who to talk to
Sarah Thompson – Head of Clinical Digital Optimisation Programmes, Stockport NHS Foundation Trust
Mark Livingstone – Head of Pharmacy, Pennine Acute Hospitals NHS Trust