Yogini Jani

Implementation and adoption of nationwide electronic health records in secondary care in England: final qualitative results from prospective national evaluation in "early adopter" hospitals

Objectives To evaluate the implementation and adoption of the NHS detailed care records service in “early adopter” hospitals in England. Design Theoretically informed, longitudinal qualitative evaluation based on case studies. Setting 12 “early adopter” NHS acute hospitals and specialist care settings studied over two and a half years. Data sources Data were collected through in depth interviews, observations, and relevant documents relating directly to case study sites and to wider national developments that were perceived to impact on the implementation strategy. Data were thematically analysed, initially within and then across cases. The dataset consisted of 431 semistructured interviews with key stakeholders, including hospital staff, developers, and governmental stakeholders; 590 hours of observations of strategic meetings and use of the software in context; 334 sets of notes from observations, researchers’ field notes, and notes from national conferences; 809 NHS documents; and 58 regional and national documents. Results Implementation has proceeded more slowly, with a narrower scope and substantially less clinical functionality than was originally planned. The national strategy had considerable local consequences (summarised under five key themes), and wider national developments impacted heavily on implementation and adoption. More specifically, delays related to unrealistic expectations about the capabilities of systems; the time needed to build, configure, and customise the software; the work needed to ensure that systems were supporting provision of care; and the needs of end users for training and support. Other factors hampering progress included the changing milieu of NHS policy and priorities; repeatedly renegotiated national contracts; different stages of development of diverse NHS care records service systems; and a complex communication process between different stakeholders, along with contractual arrangements that largely excluded NHS providers. There was early evidence that deploying systems resulted in important learning within and between organisations and the development of relevant competencies within NHS hospitals. Conclusions Implementation of the NHS Care Records Service in “early adopter” sites proved time consuming and challenging, with as yet limited discernible benefits for clinicians and no clear advantages for patients. Although our results might not be directly transferable to later adopting sites because the functionalities we evaluated were new and untried in the English context, they shed light on the processes involved in implementing major new systems. The move to increased local decision making that we advocated based on our interim analysis has been pursued and welcomed by the NHS, but it is important that policymakers do not lose sight of the overall goal of an integrated interoperable solution.

Implementation and adoption of nationwide electronic health records in secondary care in England: qualitative analysis of interim results from a prospective national evaluation

Objectives To describe and evaluate the implementation and adoption of detailed electronic health records in secondary care in England and thereby provide early feedback for the ongoing local and national rollout of the NHS Care Records Service. Design A mixed methods, longitudinal, multisite, socio-technical case study. Setting Five NHS acute hospital and mental health trusts that have been the focus of early implementation efforts and at which interim data collection and analysis are complete. Data sources and analysis Dataset for the evaluation consists of semi-structured interviews, documents and field notes, observations, and quantitative data. Qualitative data were analysed thematically with a socio-technical coding matrix, combined with additional themes that emerged from the data. Main results Hospital electronic health record applications are being developed and implemented far more slowly than was originally envisioned; the top-down, standardised approach has needed to evolve to admit more variation and greater local choice, which hospital trusts want in order to support local activity. Despite considerable delays and frustrations, support for electronic health records remains strong, including from NHS clinicians. Political and financial factors are now perceived to threaten nationwide implementation of electronic health records. Interviewees identified a range of consequences of long term, centrally negotiated contracts to deliver the NHS Care Records Service in secondary care, particularly as NHS trusts themselves are not party to these contracts. These include convoluted communication channels between different stakeholders, unrealistic deployment timelines, delays, and applications that could not quickly respond to changing national and local NHS priorities. Our data suggest support for a “middle-out” approach to implementing hospital electronic health records, combining government direction with increased local autonomy, and for restricting detailed electronic health record sharing to local health communities. Conclusions Experiences from the early implementation sites, which have received considerable attention, financial investment and support, indicate that delivering improved healthcare through nationwide electronic health records will be a long, complex, and iterative process requiring flexibility and local adaptability both with respect to the systems and the implementation strategy. The more tailored, responsive approach that is emerging is becoming better aligned with NHS organisations’ perceived needs and is, if pursued, likely to deliver clinically useful electronic health record systems.

Electronic Prescribing Reduced Prescribing Errors in a Pediatric Renal Outpatient Clinic

OBJECTIVE To assess the effect of an electronic prescribing (EP) system on the incidence and type of prescribing errors and the number of error-free visits. STUDY DESIGN This was a before-and-after study conducted in a nephrology outpatient clinic at an acute tertiary care pediatric hospital. RESULTS A total of 520 patients had 2242 items prescribed on 1141 prescriptions during the study period. The overall prescribing error rate was 77.4% (95% confidence interval [CI] = 75.3% to 79.4%) for handwritten items and 4.8% (95% CI = 3.4% to 6.7%) with EP. Before EP, 1153 (73.3%; 95% CI = 71.1% to 75.4%) items were missing essential information, and 194 (12.3%; 95% CI = 10.8% to 14%) were judged illegible. After EP, only 9 (1.4%; 95% CI = 0.7% to 2.6%) items were missing essential information, and illegibility errors were eliminated. The number of patient visits that were error-free increased from 21% to 90% (69% difference; 95% CI = 64% to 73.4%) after the implementation of EP. CONCLUSIONS There was a high incidence of errors using handwritten prescriptions in the outpatient setting, with an overall error rate of 77.4%. EP significantly reduced errors related to completeness of prescriptions and eliminated legibility related errors.

Paediatric dosing errors before and after electronic prescribing

Objective To compare the incidence and severity rating of dose prescribing errors before and after the implementation of a commercially available electronic prescribing system at a tertiary care childrens hospital. Methods Dose errors were identified using prescription review to detect errors. Severity rating was determined by five judges using a validated, reliable scoring tool. The mean score for each error was used as an index of severity. Results Dose prescribing errors occurred in 88 of the 3939 (2.2%) items prescribed for outpatients and inpatients, and on discharge prescriptions prior to the implementation of electronic prescribing (EP). After EP, there were 57 dose errors in 4784 (1.2%) items prescribed (1% absolute reduction (p<0.001 χ2 test; 95% CI of difference in proportions −1.6% to −0.5%)). A decrease in the severity rating of dose errors was also seen: dose errors with potentially minor outcomes 35/3939 (0.89%) pre vs 21/4784 (0.44%) post (95% CI of difference in proportions −0.8% to −0.11%, p=0.009 χ2 test); moderate outcome 46/3939 (1.17%) pre vs 33/4784 (0.69%) post (95% CI of difference in proportions −0.91% to −0.08, p=0.019, χ2 test); severe outcome: 7/3939 (0.18%) pre vs 3/4784 (0.06%) post (95% CI of difference in proportions −0.31% to +0.04, p=0.11, χ2 test). Conclusion Electronic prescribing appears to reduce rates of dosing errors in paediatrics, but larger studies are required to assess the effect on the severity of these errors and in different settings.

Characteristics of clinical decision support alert overrides in an electronic prescribing system at a tertiary care paediatric hospital

Context  Electronic prescribing (EP) systems are advocated as a solution to minimise medication errors. Benefits in patient safety are often as a result of some clinical decision support (CDS) within the system.

Drug-related problem in children with chronic kidney disease.

Drug therapies in the management of chronic kidney disease (CKD) are complex and specialised and have a high potential for drug-related problem (DRP). In adult CKD populations, the identification and resolution of DRP has been shown to have beneficial effects on disease management, adherence and knowledge of treatment, patient’s quality of life, hospitalisation rate and length of stay and cost to the healthcare system. The focus of this article is the review of published studies on DRP in children with CKD. There is a lack of information on the epidemiology of DRP in this patient group, and research in this area is therefore needed to better understand and manage DRP in children with CKD.

Republished error management: Paediatric dosing errors before and after electronic prescribing

Objective To compare the incidence and severity rating of dose prescribing errors before and after the implementation of a commercially available electronic prescribing system at a tertiary care childrens hospital. Methods Dose errors were identified using prescription review to detect errors. Severity rating was determined by five judges using a validated, reliable scoring tool. The mean score for each error was used as an index of severity. Results Dose prescribing errors occurred in 88 of the 3939 (2.2%) items prescribed for outpatients and inpatients, and on discharge prescriptions prior to the implementation of electronic prescribing (EP). After EP, there were 57 dose errors in 4784 (1.2%) items prescribed (1% absolute reduction (p<0.001 χ2 test; 95% CI of difference in proportions −1.6% to −0.5%)). A decrease in the severity rating of dose errors was also seen: dose errors with potentially minor outcomes 35/3939 (0.89%) pre vs 21/4784 (0.44%) post (95% CI of difference in proportions −0.8% to −0.11%, p=0.009 χ2 test); moderate outcome 46/3939 (1.17%) pre vs 33/4784 (0.69%) post (95% CI of difference in proportions −0.91% to −0.08, p=0.019, χ2 test); severe outcome: 7/3939 (0.18%) pre vs 3/4784 (0.06%) post (95% CI of difference in proportions −0.31% to +0.04, p=0.11, χ2 test). Conclusion Electronic prescribing appears to reduce rates of dosing errors in paediatrics, but larger studies are required to assess the effect on the severity of these errors and in different settings.

An evaluation of the epidemiology of medication discrepancies and clinical significance of medicines reconciliation in children admitted to hospital

Aims To determine the incidence of unintended medication discrepancies in paediatric patients at the time of hospital admission; evaluate the process of medicines reconciliation; assess the benefit of medicines reconciliation in preventing clinical harm. Method A 5 month prospective multisite study. Pharmacists at four English hospitals conducted admission medicines reconciliation in children using a standardised data collection form. A discrepancy was defined as a difference between the patients preadmission medication (PAM), compared with the initial admission medication orders written by the hospital doctor. The discrepancies were classified into intentional and unintentional discrepancies. The unintentional discrepancies were assessed for potential clinical harm by a team of healthcare professionals, which included doctors, pharmacists and nurses. Results Medicines reconciliation was conducted in 244 children admitted to hospital. 45% (109/244) of the children had at least one unintentional medication discrepancy between the PAM and admission medication order. The overall results indicated that 32% (78/244) of patients had at least one clinically significant unintentional medication discrepancy with potential to cause moderate 20% (50/244) or severe 11% (28/244) harm. No single source of information provided all the relevant details of a patients medication history. Parents/carers provided the most accurate details of a patients medication history in 81% of cases. Conclusions This study demonstrates that in the absence of medicines reconciliation, children admitted to hospitals across England are at risk of harm from unintended medication discrepancies at the transition of care from the community to hospital. No single source of information provided a reliable medication history.

Taking the guesswork out of supplying multicompartment compliance aids: do pharmacists require further guidance on medication stability?

The purpose of this article is to identify information that is currently available to pharmacists concerning the stability of medications repackaged into multicompartment compliance aids (MCAs). This article explores the potential risks associated with repackaging medications into MCAs for pharmacists who supply and patients who use them.

An evaluation of paediatric medicines reconciliation at hospital discharge into the community

A UK national survey of primary care physicians has indicated that the medication information on hospital discharge summary was incomplete or inaccurate most of the time. Internationally, studies have shown that hospital pharmacists interventions reduce these discrepancies in the adult population. There have been no published studies on the incidence and severity of the discrepancies of the medication prescribed for children specifically at discharge to date. The objectives of this study were to investigate the incidence, nature and potential clinical severity of medication discrepancies at the point of hospital discharge in a paediatric setting.