Implementing a medication management solution in a Trust or a hospital typically represents a challenge for everyone involved in the project but especially for the care teams that have to change and adapt their processes to the new solution. Although there are many articles and research papers that explain how electronic medication management systems reduce errors and improve patient safety the adoption of these systems in practice still turns out to be slow and difficult.
Creating an exact prescription even for the most basic medication orders requires physicians to define at least 5 elements: medication, form, route, dose and dosing interval, and when it comes to the most complex prescriptions such as IV mixtures and protocols the prescribing process can be really time consuming. Nurses are typically very keen on using the electronic medication administration record because it brings clarity and transparency to their work and welcome a clear and comprehensive list of medications they need to administer during their shift. Furthermore, a crucial part of the prescribing process is also a pharmacist‘ s review of the prescriptions. Although there are more and more clinical pharmacists in each hospital, they still are often dislocated and not always present at the ward.
When deciding on a medication management solution it is crucial that the product offers solutions at least for all the above mentioned challenges in order to remove the very basic barriers for adoption. This means that the product should support electronic prescribing of absolutely all the different scenarios of prescriptions so that there is no paper fall back scenario even for the most “exotic” prescription types. In addition the product needs to cover all aspects of the medication management - from creating a medication list on admission , actively facilitating medication reconciliation throughout the care episode, support inpatient and outpatient prescribing as well as discharge prescribing, offer a comprehensive medication administration record and include a dedicated pharmacist‘ s review module.
These are, however, only the basic prescribing features which - if you think about it - are already supported in the paper based medication management processes. In order to truly leverage all that modern computers and smart devices are offering and to really improve the adoption rate of an electronic medication management system, the following features should be on your list of requirements whenever you are deciding for a medication management product:
- Order sets and configuration: Predefined order sets improve patient safety and reduce medication errors by offering to prescribers predefined sets of prescriptions for different conditions, age groups and in some cases even personalised order sets for a particular patient. Furthermore it is important that when a prescriber is manually creating a new prescription, that the system only shows relevant details for each medication - such as preconfigured licensed or unlicensed routes, direct access to relevant SMPC, PIL or diluting instructions.
- Advanced decision support: It is not enough that the product integrates with a drug database to offer alerts on allergies, duplicate therapies, disease contraindications, dose range checks, pregnancy/lactation/age/gender contraindications and others, but it should also include advanced decision support mechanisms thus preventing alert fatigue and enabling users to configure custom alerts, warnings and additional instructions on how to monitor the patient, adjust the medication dose and administer the medication. Furthermore, the decision support should also guide the prescriber to properly round the medication dose and offer to the prescriber a live alert when reaching or exceeding the recommended BNF max dose (either for a single medication or as a cumulative dose). The decision support should also automatically recheck all potential allergy alerts every time the list of allergies changes.
- Antibiotic stewardship: a prospective review of all prescribed antibiotics after two or three days of treatment should form the cornerstone of antibiotic stewardship programs to ensure the right drug is being prescribed at the right time for the right diagnosis (IDSA). Therefore the medication management system must have features addressing the antibiotic stewardship such as: automatic 2nd day warning to switch from IV to oral, automatic calculation of the number of consecutive days an antibiotic is beeing administered, hard stop and soft stop of the prescription, custom warnings to review the prescription. Features preventing the “Never Events”: Never Events are serious incidents that are wholly preventable as guidances or safety recommendations providing strong systemic protective barriers are available at a national level and should have been implemented by all healthcare providers (https://www.england.nhs.uk/patientsafety/never-events/). These guidelines must be incorporated within the medication management product in order to prevent events such as selecting a wrong route of administration, overdose of insulin due to abbreviations of unit, overdose of methotrexate for non-cancer treatment and others.
- Task lists and collaboration features: At any moment it should be clear what the outstanding tasks are and who needs to take action. Automatic creation of task lists and collaboration among all care team members are aspects of the medication management process that are not supported in the paper based version. However, in the electronic world, it is relatively easy to create task lists for nurses, clinicians and pharmacists. Nurses need to see a list of due/overdue medications, a list of all the medications they need to administer during their shift with the ability to sort/group/filter the list based on the medication type and/or route. Clinical pharmacists need to see a list of all new and modified prescriptions which they need to review. They also need to prioritise their work, therefore it is crucial that the pharmacist’ s task list can also be filtered/sorted based on urgency (prescriptions including high risk medications and admission prescriptions on the top of the list). Finally, physicians need an easy way to oversee if the medication administration is done regularly and if they have any outstanding pharmacist’ s reviews to check and confirm.
- Integration (with labs, pharmacy, EHR/PAS): When prescribing certain medications such as insulin, warfarin and others, prescribers need to check certain measurements (blood glucose, INR) before deciding on the medication dose. In order to make the prescribing process as seamless as possible and to remove the need for the prescriber to navigate to another screen or even another application it is important that the prescribing system supports the integration with the lab/PAS/EHR system to easily extract these measurements and show them to the prescriber within the prescribing window. An integration with the pharmacy system is needed in order to close the medication loop and simplify the supply and dispense processes.
- Analytical module: Having all the medication related data stored in a structured way it is really important that all this data is available for reporting. The system should not only support different BI suites but should also offer a set of prebuilt actionable reports which help to track the use of the system and help different stakeholders to analyse what is being prescribed.
Finally, no matter how good, user friendly or comprehensive the medication management solution is, the users will not start using it unless it is incredibly fast and responsive. Anyone logging into the system needs to gain access to the required data almost instantaneously.