Electronic Prescribing at
Monash Health –
A new era
Adam Stormont – Senior Pharmacist New
Technology and Systems Developme...
Monash Health
• Victoria’s largest public health service
• 2156 Beds
• Annual Expenditure $1.3 billion (10% Vic. Hospital ...
Area serviced by Monash Health
Over 1 Million residents

2031 km²

Monash Medical Centre Clayton
Monash Medical Centre Moo...
Why E-Prescribe?
•
•
•
•
•

Efficiency
Legibility
Patient safety
PBS issues
Embracing the move to e-health
Why is Electronic Prescribing so
important?
Medication error rates
• Aust - Fry 1985, Coombes 2001 – Prescribing error rat...
Why is Electronic Prescribing (EP)
so important?
The impact of EP on medication errors
• EP by clinicians has had the larg...
Why is Electronic Prescribing (EP)
so important?
• US (landmark study) – IP (Bates 1999 and Bates 1998) - all
medication e...
Pre-implementation Study - Overview
Dates study undertaken

22/10/2012 – 26/10/2012 (5 days)

Inclusion criteria

All hand...
Pre-implementation Study - Data Analysis
Error type:
Prescription writing or documentation errors

Number
(%)
N=924

Minim...
Pharmacist Interventions: January 2013
Wrong medicine
Prescribed despite ceased/withheld
Altered medication
Unnecessary me...
Starting Out
• Business case prepared
• Submitted to Information Technology
Investment Committee (ITIC)
• 4 options
1. Do ...
Overall Plan
Phase 1 Outpatient Clinics
Emergency Department
Phase 2 Discharge Prescriptions
Oncology
Phase 3 Electronic M...
Pharmhos Software
• Australian Company – Head Office in Port
Melbourne
• Software Developers & provide Support
• Focus on ...
Merlin® – Pharmhos Software
Single Application covering all aspects pharmacy
business
• All modules fully integrated with ...
Merlin® – Pharmhos Software
• Proven capability for Downstream information –
Financials, Patient Debtors, Discharge Summar...
Merlin® – Pharmhos Software
• Merlin IT Architecture – How does it work ?
• Centralized Server at a single location
• Acce...
Merlin® – Pharmhos Software
• All business logic programs execute on the Central
Server – no loss of data
• Shared common ...
Merlin MAP E-Prescribing
• Direct link to dispensing module
(No new interface needed)
identical medication list
common ord...
Building the Relationship
• Partnership required with Information
Technology
• CIO – huge supporter
• Investment in new in...
Selling to Medical Staff
• Vision was to engage medical staff early. Make
it their system!!!
• Key senior medical staff re...
Small Wins and Carrots
• Keeping it Simple
• Logons and Passwords
• Patient/Medication Search
• Been accessible to users
•...
Aims (ESEP)
•
•
•
•

Easier
(E)
Safer
(S)
Efficiency
(E)
PBS Revenue (P)
Aims (ESEP)
• Easier
- PBS rules
- past prescriptions
• Safer
- less transcribing
- common drug list
- prescription guidan...
Aims (ESEP)
• Efficiency
simplify process
-

eliminate some steps

-

less time correcting problems

• PBS Revenue
guidanc...
Project Steering Committee
•
•
•
•
•
•
•
•

Director of Pharmacy (Chair)
CIO
COO (or delegate)
Senior Medical Staff
Nursin...
Governance Structure
ITIC

IT Support

SMS Special
Interest Group

Steering Committee

Focus Groups

Project Team

Technic...
A New Beginning – E-Day!!
• Pilot of software went live June 22nd in
outpatient clinic – Infectious Diseases
• 7-10 prescr...
E-Prescribing
• Logging in made simple
by using same
credentials as hospital
email.
• Logons mapped to
active directory
• ...
E-Prescribing
• Software easy to
navigate and intuitive
• Cheat sheets available
within software
• Only concise and
necess...
•

•
•

•

E-Prescribing
Medication lookup
simple and
straightforward
Ability to search by
generic and trade name
Generic ...
E-Prescribing
• Prescribing is aided by
the use of simple drop
down options
• Common doses,
routes, frequencies etc.
• Mak...
E-interface – 1st step towards
paperless prescriptions
• MerlinMAP links to existing Merlin dispense
• Merlin dispense alr...
st
1

E-interface –
step towards
paperless prescriptions
• Typing essentially eliminated.
• Streamline and authority infor...
E-Interface – Prescription
Exchange
Adverse Drug Reactions and Drug
Hypersensitivities.
• Prescriber’s required
to confirm ADR status
prior to prescribing.
• ...
Adverse Drug Reactions and Drug
Hypersensitivities.
• Medication database
mapped to AMT
• Compatible for
PCEHR
• Mandatory...
Emergency Department – Go-Live
• Training conducted for around 70 users
• Pharmacy Support Staff onsite 7am-7pm in first
w...
Emergency Department – Go-Live
• Successful Go-Live
• Smooth Transition
• Well supported by ED Management
• No Major Issue...
Uptake of the System - Overview
Month

Clinic Go-Lives

Prescriptions
Processed

Items
Processed

June 2012

Infectious Di...
Efficiency Gains
Pharmacy Processing
(hours/month)

Medical /Pharmacy Staff
Interaction (hours/month)

Reduction in patien...
New Errors associated with eP
• Medication catalogue – selection error
• Wrong printers/wrong paper
• Prescription for wro...
Other Issues to consider
• Super Users
• Backfill $$$$ (?Supernumerary)
• High Availability/Disaster Recovery
• Mirror Ser...
Other Issues to consider
• Interaction with Medical Record
• Not overreacting to minor setbacks. Rome
wasn’t built in a da...
Looking to the Future
• Medication reconciliation on admission
• Medication management plans
• Antimicrobial stewardship
•...
Thankyou

Questions?
Adam Stormont, Monash Health, VIC: Taking On The Challenge: The Development, Design And Implementation Of An Electronic Pr...
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Adam Stormont, Monash Health, VIC: Taking On The Challenge: The Development, Design And Implementation Of An Electronic Prescribing Software

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Adam Stormont, Senior Pharmacist - New Technology and Systems Development, Monash Health, VIC delivered this presentation at the 2013 Electronic Medication Management conference. It is Australia’s only conference to look solely at electronic prescribing and electronic medication management systems. For more information on the annual event, please visit the conference website: http://www.healthcareconferences.com.au/emedmanagement

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Adam Stormont, Monash Health, VIC: Taking On The Challenge: The Development, Design And Implementation Of An Electronic Prescribing Software

  1. 1. Electronic Prescribing at Monash Health – A new era Adam Stormont – Senior Pharmacist New Technology and Systems Development Ian Larmour – Director of Pharmacy
  2. 2. Monash Health • Victoria’s largest public health service • 2156 Beds • Annual Expenditure $1.3 billion (10% Vic. Hospital Exp.) • Employ approx. 13,000 staff • Service over 1 million people in immediate catchment • WIES points 2011-12 - 139,259
  3. 3. Area serviced by Monash Health Over 1 Million residents 2031 km² Monash Medical Centre Clayton Monash Medical Centre Moorabbin Dandenong Hospital Kingston Centre Casey Hospital Jessie MacPherson Private Hospital
  4. 4. Why E-Prescribe? • • • • • Efficiency Legibility Patient safety PBS issues Embracing the move to e-health
  5. 5. Why is Electronic Prescribing so important? Medication error rates • Aust - Fry 1985, Coombes 2001 – Prescribing error rate of 2.4% to 25% • Majority of errors were incorrect dose, route, frequency or incomplete information • Aust - Thornton 1990, DeClifford 1993 - Dispensing error rate of 0.08 to 0.8% • Majority of errors were incorrect drug, strength, form, quantity or label directions
  6. 6. Why is Electronic Prescribing (EP) so important? The impact of EP on medication errors • EP by clinicians has had the largest impact of any automated intervention in reducing medication errors. • How? - Orders are structured and legible, information is available during the prescribing process, and these systems can provide CDS.
  7. 7. Why is Electronic Prescribing (EP) so important? • US (landmark study) – IP (Bates 1999 and Bates 1998) - all medication errors reduced by 83% and serious errors reduced by 55%. • UK – IP (Dean Franklin 2007) - prescribing error rate reduced by 47%. • (Devine 2010) US – OP – prescribing error rate reduced by 10%. • Studies of impact of EP with pharmacy system interface are limited – impact on dispensing error rates to be determined.
  8. 8. Pre-implementation Study - Overview Dates study undertaken 22/10/2012 – 26/10/2012 (5 days) Inclusion criteria All handwritten outpatient clinic and ED prescriptions dispensed by MMC Clayton Pharmacy Department Number of prescriptions reviewed 301 Number of prescription items 501 Prescriptions with at least one prescribing error 287 (95.3%) Number of prescribing errors Clinical or decision making errors Prescription writing or documentation errors 924 302 (32.7%) 622 (67.3%) Number of prescribing errors/prescription item 1.84 Summary of prescribing practices pre-implementation of eP
  9. 9. Pre-implementation Study - Data Analysis Error type: Prescription writing or documentation errors Number (%) N=924 Minimised by eP? Error prone terminology, abbreviations and symbols 381 (41.2%) Yes Allergy status incorrect or omitted 168 (18.2%) Yes – omissions Route incorrect/omitted 126 (13.6%) Yes – omissions, some incorrect Dose incorrect/omitted 76 (8.2%) Yes – omissions, some incorrect Strength incorrect/omitted 43 (4.7%) Yes – omissions, some incorrect PBS documentation omitted/incorrect 32 (3.5%) Yes Quantity or duration incorrect/omitted 31 (3.4%) Yes – omissions, some incorrect Frequency incorrect/omitted 12 (1.3%) Yes – omissions, some incorrect Dosage form incorrect/omitted 11 (1.2%) Yes Patient weight omitted when required 11 (1.2%) Yes - paediatrics Top 10 most common prescribing errors and potential for error risk to be minimised by eP
  10. 10. Pharmacist Interventions: January 2013 Wrong medicine Prescribed despite ceased/withheld Altered medication Unnecessary medicine Otherwise inappropriate Wrong frequency Incomplete prescription Wrong dose/strength/form/vol/conc Not prescribed 0 50 100 150 200 250 300
  11. 11. Starting Out • Business case prepared • Submitted to Information Technology Investment Committee (ITIC) • 4 options 1. Do nothing 2. Implement HealthSmart clinical system 3. Investigation of other electronic prescribing systems 4. Implement MerlinMAP e-prescribe • Decision to proceed with option 4.
  12. 12. Overall Plan Phase 1 Outpatient Clinics Emergency Department Phase 2 Discharge Prescriptions Oncology Phase 3 Electronic Medication Chart &4
  13. 13. Pharmhos Software • Australian Company – Head Office in Port Melbourne • Software Developers & provide Support • Focus on Medication Management Systems only • Medicare Australia Certified • Longstanding working relationship with Monash Health
  14. 14. Merlin® – Pharmhos Software Single Application covering all aspects pharmacy business • All modules fully integrated with each other • Proven Multi-Campus capability • Proven Multiple PBS Approval Number claiming from a common database • Proven integration capability for Upstream information (PMI/ATD)
  15. 15. Merlin® – Pharmhos Software • Proven capability for Downstream information – Financials, Patient Debtors, Discharge Summary • Proven IT Infrastructure that supports large enterprise installations from a centralized server • Administration of the system can be managed centrally
  16. 16. Merlin® – Pharmhos Software • Merlin IT Architecture – How does it work ? • Centralized Server at a single location • Access via secure connection over WAN, VPN, and other methods over the internet • Thin Client connection from a PC, Mac or Linux Workstation to the centralized server • Thin Client Text and Web Browser User Interfaces
  17. 17. Merlin® – Pharmhos Software • All business logic programs execute on the Central Server – no loss of data • Shared common data across the enterprise – centrally maintained • All updates applied only to the centralized server – Drug/PBS data etc. & Software upgrades
  18. 18. Merlin MAP E-Prescribing • Direct link to dispensing module (No new interface needed) identical medication list common order sentences PBS mature two way access to dispense records access to past prescriptions to create new prescriptions • Input to development • Cost
  19. 19. Building the Relationship • Partnership required with Information Technology • CIO – huge supporter • Investment in new infrastructure – virtual server • Printers – lengthy discussions • Interactions with mobile devices – iPads • Wireless capability required • Relationship with vendor • Change management
  20. 20. Selling to Medical Staff • Vision was to engage medical staff early. Make it their system!!! • Key senior medical staff recruited to steering committee • Important to sell the message – our system was different to other existing systems. • Took the system to them! • Presented to over 20 medical units. Asked for volunteers to be stakeholders/system testers.
  21. 21. Small Wins and Carrots • Keeping it Simple • Logons and Passwords • Patient/Medication Search • Been accessible to users • Making yourself known to medical staff • Home Grown System
  22. 22. Aims (ESEP) • • • • Easier (E) Safer (S) Efficiency (E) PBS Revenue (P)
  23. 23. Aims (ESEP) • Easier - PBS rules - past prescriptions • Safer - less transcribing - common drug list - prescription guidance
  24. 24. Aims (ESEP) • Efficiency simplify process - eliminate some steps - less time correcting problems • PBS Revenue guidance on rules and quantities - Medicare/concession details - less rejected prescriptions
  25. 25. Project Steering Committee • • • • • • • • Director of Pharmacy (Chair) CIO COO (or delegate) Senior Medical Staff Nursing Representatives IT Staff Project Staff Health Information Services
  26. 26. Governance Structure ITIC IT Support SMS Special Interest Group Steering Committee Focus Groups Project Team Technical Systems Project & Business
  27. 27. A New Beginning – E-Day!! • Pilot of software went live June 22nd in outpatient clinic – Infectious Diseases • 7-10 prescribers at one time • Well supported by pharmacy staff and vendor • Escalation and rollback plan in place • Prescriber’s must complete E-learning module before allowed access to system. • Project pharmacist and other pharmacists available to troubleshoot
  28. 28. E-Prescribing • Logging in made simple by using same credentials as hospital email. • Logons mapped to active directory • E-learning launches automatically after first logon.
  29. 29. E-Prescribing • Software easy to navigate and intuitive • Cheat sheets available within software • Only concise and necessary information is displayed on screen.
  30. 30. • • • • E-Prescribing Medication lookup simple and straightforward Ability to search by generic and trade name Generic name always returned in medication search Improved compliance with generic prescribing
  31. 31. E-Prescribing • Prescribing is aided by the use of simple drop down options • Common doses, routes, frequencies etc. • Make it as intuitive and easy as possible • Prescriber is assisted but still required to take responsibility for the prescription – can’t say system let me do it!!!
  32. 32. E-interface – 1st step towards paperless prescriptions • MerlinMAP links to existing Merlin dispense • Merlin dispense already has tested and trusted PMI/ATD interface • Prescriptions accessible from interface screen • Pulls all appropriate information from the script into the dispensing screen
  33. 33. st 1 E-interface – step towards paperless prescriptions • Typing essentially eliminated. • Streamline and authority information automatically populates. • Australian first • Just need Medicare to catch up
  34. 34. E-Interface – Prescription Exchange
  35. 35. Adverse Drug Reactions and Drug Hypersensitivities. • Prescriber’s required to confirm ADR status prior to prescribing. • Read only mode – a user can view patient’s profile without confirming ADR status.
  36. 36. Adverse Drug Reactions and Drug Hypersensitivities. • Medication database mapped to AMT • Compatible for PCEHR • Mandatory to record remark/reaction – can put “Unknown” • Still developing functionality
  37. 37. Emergency Department – Go-Live • Training conducted for around 70 users • Pharmacy Support Staff onsite 7am-7pm in first week • Vendor support also onsite • Centralised Printer model approach used MFDs – ensure setup correctly
  38. 38. Emergency Department – Go-Live • Successful Go-Live • Smooth Transition • Well supported by ED Management • No Major Issues
  39. 39. Uptake of the System - Overview Month Clinic Go-Lives Prescriptions Processed Items Processed June 2012 Infectious Diseases 31 51 July 2012 23 48 August 2012 43 80 September 2012 Renal 93 204 October 2012 Diabetes 163 313 November 2012 Rheumatology 168 332 167 312 December 2012
  40. 40. Efficiency Gains Pharmacy Processing (hours/month) Medical /Pharmacy Staff Interaction (hours/month) Reduction in patient waiting time (hours/month) 1.7 2.6 13.4 1.6 1.9 9.9 2.7 3.6 18.6 6.8 7.8 40.3 10.4 13.6 70.6 11.1 14 72.8 10.4 13.9 72.3
  41. 41. New Errors associated with eP • Medication catalogue – selection error • Wrong printers/wrong paper • Prescription for wrong patient/given to wrong patient. • Additional instructions contradicting order sentence. • Clinical appropriateness of order. • Lesson – Still need pharmacists!!!!!!
  42. 42. Other Issues to consider • Super Users • Backfill $$$$ (?Supernumerary) • High Availability/Disaster Recovery • Mirror Servers etc. • Keeping the Positive Message Going • Reporting
  43. 43. Other Issues to consider • Interaction with Medical Record • Not overreacting to minor setbacks. Rome wasn’t built in a day • Terminology and Communications • Technical knowledge • How much do I really need to understand?
  44. 44. Looking to the Future • Medication reconciliation on admission • Medication management plans • Antimicrobial stewardship • Pharmacist prescribing • Only the beginning! • A journey not a project…..
  45. 45. Thankyou Questions?

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