Presentation slides from CLAHRC WM Programme Steering Committee on 21st September 2015 - Theme 1: SPACER project, Carole Cummins

1. Evaluation of the introduction of
Electronic Prescribing and
Medicines Administration (EPMA)
at Birmingham Children’s Hospital
Carole Cummins
Maternity and Child Health Theme

2. Children are not small adults
• Cognition
• Development
• Physiology
• Pharmacokinetics
• Pharmacoodynamics
• Prescribing

3. ePrescribing at Birmingham
Children’s Hospital
• UK paediatric hospitals are late adopters of ePrescribing systems
• Paediatric prescribing is more complex but with a weaker evidence
base than prescribing for adults
• Key barrier to adoption is lack of a computerised knowledge base to
inform decision support
• In order to introduce ePrescribing BCH invested in:
– Development of a drug database and procedures to review and
check drug information (now with support from NHS England)
– Adoption of the UHB NHS FT PICs platform
– Committed to the required estates changes and acquisition of
peripherals
• CEO identified ePrescribing as an area for evaluation and matched
funding in the WM CLARHC Maternity and Child Health Theme

4. BCH Business Case
Benefits Realisation
plan
We needed to
consider how an
evaluation can be
aligned against
realisation plan but
the plan requires
development.
An NHS England
Framework provides
an similar but more
extensive catalogue.
Issues: conceptual
overlap, atheoretical
Benefits Area
Anticipated Benefits
Patient
Safer = far fewer drug errors.
Charts less likely to get lost.
Easier access to previous prescriptions = saves time, effort
and fewer mistakes.
Nurse
Legible record = save time & reduce errors.
Decision support = fewer errors.
Doctor
Warnings = stop major errors.
Decision support built into system = faster & fewer errors.
Remote access = better work flows.
Pharmacist
Access to records in use = better work flows e.g. TTOs ,
clinical screening etc
Traceability of all drug prescription and administration.
Formulary control.
Full audit trail = better clinical governance, financial control
and better macro decisions about drug policy.
Operational
Easier data compliance with national standards.
Better workload planning.
Identification of prescribers and prescriber performance
indicators.
Financial
Capturing High cost drug data/PBR support reclaims.
Support continuing care claims.

5. Provisional CLAHRC view of benefits
realisation and proposed evaluation
components
• BCH data sources
– Include Board safety
report, audit data,
incident reports (Merck
classification of harm)
• University of Birmingham
– Impact on the hospital
ward: ethnographic
study
• Aston University
– Efficiency and value
Benefits
Area
Domain Evidence
Patient
Quality
and safety
Incident reports
Drug chart review
Prescription audit
Medication audit
Medication error
Qualitative research
Surveys
Nurse
Doctor
Pharmacist
Efficiency
and value
Proposed Data Envelopment Analysis
Pharmacy process
Operational
Financial

6. Proposed evaluation
• Evaluation plan covers the first stage of implementation:
• Pre-, during and post- implementation
– Will use currently available or potentially collectable measures
• Board safety report covers incident reports,
medication/prescribing audits, errors, root cause analyses
• Measurement of some metrics changes pre- and post-
intervention
• Post implementation development will allow quality improvement
innovations that are not currently possible
– Relates to benefits realisation plan
– These are likely to involve prescribing, medicines administration
and drug costs at the individual patient level –
– later CLAHRC projects? Additional funding?

7. Complexity…
• ePrescribing is a complex intervention implemented into complex
hospital systems
• Example: To Take Out (TTO) medications
– Efficient supply of TTO prescriptions is a marker of pharmacy
efficiency
– TTOs have been identified as a critical path in the discharge
pathway
– A discharge planning intervention is part of wider innovation to
improve the flow of patients through the hospital and the
efficiency of bed use
– Improved bed use will impact on the routing of patients into the
hospital via the ED, GPs and referrals
– Improved routing of patients will impact on other health providers
for children

8. A suitable theoretical model for this evaluation?
Triangle model for evaluating the effect of health information
technology on healthcare quality and safety, JS Ancker 2012
Adaptation of Donabedian model
Structure
Process
Outcomes

9. Some questions/ points for discussion:
• How/ should we link the components of the planned evaluation?
• How do we allow for complexity?
• Can we fit the evaluation into a single theoretical model?
• Is the triangle model a good fit?
• Can and should we publish an overarching protocol?
• Safety: as serious harm is rare and hard to measure, we will largely
be looking at changes in processes to mitigate risk – discuss.