Published: 21/03/2002, Volume II2, No. 5797 Page 16 17
The Audit Commission released another damning report just before Christmas, this one on medicine management in the NHS. Deaths from adverse drug reactions have risen from around 200 in 1990 to almost 1,100 in 2000, according to A Spoonful of Sugar. And medication errors cause another 150 deaths a year.
Yet many hospital medicine-management systems remain 'rooted in the 1970s' and crucial progress on IT systems is 'painfully slow'.
The report acknowledges that the reasons for the poor state of hospital pharmacy are complex. It investigates shortcomings in doctors' training, staff shortages and management issues.
But it reserves some of its most damning criticisms for IT. The report criticises trusts for not implementing electronic health records and electronic prescribing, claiming that only 10 per cent of trusts will meet the 2005 deadline for their introduction.
Each hospital will need around£2m to set up a system, with£500,000 in annual running costs, it admits. But the money should be recouped by 'eliminating a large proportion of the£500m' wasted on treating patients harmed by medication errors and adverse reactions each year.
One US study quoted found computerisation could cut adverse reactions from transcription errors by 78 per cent, by cutting out doctors' handwriting. 'Errors are mainly caused because the prescriber does not have immediate access to accurate information, either about the medicine or the patient, ' the report says. 'Handwritten prescriptions also contribute to errors as they may be illegible, incomplete and subject to transcription errors.'
However, as problems with Prodigy, the GP prescribing system, show (see box overleaf ), simply providing IT is not enough. The IT has to be good, up-to-date and user-friendly. For example, one of the most important ways of tackling adverse drug reactions is to provide warnings - but less is more, according to Chris Curtis, head of pharmaceutical services at Queen's Hospital in Burton upon Trent.
Queen's systems are paperless: all orders for drugs, tests, x-rays and so on must go through the Meditech-based computer systems.
Mr Curtis said they learnt from colleagues at other hospitals. 'We heard of one that put up warnings for everything under the sun, and the staff were starting to ignore it, ' he says. So his system only warns on the two most urgent levels of four.
'It was to make sure the warnings didn't lose their impact. It is like crying wolf - if the system warns on everything, staff would just turn off, ' he says.
Dr Dwomoa Adu, a consultant at University Hospital Birmingham, implemented a three-level system: the highest level of warning blocks an action, the intermediate level requires a user to re-enter their password, acting as an electronic 'are-you-sure?'; and the lowest level simply displays the warning.
There are benefits in getting such systems properly used. They can stop doctors prescribing drugs that clash with others taken by that patient, or which have side-effects which need to be considered, or to which the patient is allergic.
'It is very difficult for the doctor to remember all the permutations associated with a complicated prescription, ' says Dr Adu.
And the systems can also be used to implement hospital policies. 'We only use one proton-pump inhibitor, for example, ' says Mr Curtis at Queen's, of four or five available. Doctors who order another find the system defaults to the preferred supply.
Dr Adu's system uses warnings to promote better use of antibiotics: it issues a warning when a patient has been on intravenous antibiotics for three days, or oral antibiotics for five days.
Though both systems are compulsory, both hospitals have paid attention to what users want. In Birmingham, nurses requested a messaging system.
A query from a nurse remains as an outstanding item until it is answered by a doctor. For nonurgent questions, this is better for a doctor than being paged to take a phone call, while the nurse is certain of getting an answer.
Mr Curtis says nurses like Burton upon Trent's system because it gives them an unambiguous record to work from, while doctors enjoy the access to further information on drugs and procedures easily accessible through the system.
Both hospitals think such systems help teach junior doctors, as well as steering them away from mistakes, and provide excellent material for auditing and research.
If data collection is improved, more sophisticated techniques for picking up problems can be implemented.
Hanon Solutions is implementing a neuralnetwork based system at Lothian University Hospitals trust, to provide advanced warning of adverse effects. Such technology looks for patterns in data, finding possible links which humans might not notice, using advanced mathematics. It can often predict outcomes better than human practitioners - but it does need accurate data.
'One of the problems with the NHS is data quality, ' says chief executive of Hanon Solutions Neville Cannon.He says that one way of ensuring staff use computerised systems carefully - so improving the quality of data - is to have the information shared with other professions, such as social services. 'That gives a driver to make sure what you put in is not garbage - it will be seen by your peers, ' he says.
Mr Cannon says excess security can be a problem in ensuring correct use.He cites as an example a case from another company, where nurses tended to start numerous records for the same patient, because editing existing records meant going through a complicated security procedure.
He adds that voice and gesture recognition may help boost take-up of systems in future.However, both the Burton and Birmingham hospitals reckon they can teach new staff to use their systems in two or three hours.
The Department of Health says it is watching the results of three hospital trials in this area with enthusiasm. 'Good progress has been made since the approval of three pilots, ' says a spokesperson.
'The pilots will be independently evaluated. l lQueen's Hospital's work in this area is highlighted in A Spoonful of Sugar on the Audit Commission's website at www. audit-commission. gov. uk
University Hospital Birmingham's work in this area was highlighted in the British Medical Journal 2000, 320:750-53, available online at http: //bmj. com/cgi/content/full/320/7237/750
Prodigy: a tale of missed opportunity?
The NHS has a software system for GPs that is designed to help prevent drug errors, but figures for its use are disappointingly low.Here, the problem is not so much installation.Most GPs have Prodigy - It is just that they are not using it.
The Sowerby Centre for Health Informatics, part of Newcastle University and Prodigy's designer, said last June that its system was being used by one-third of the 70 per cent of GPs that had it installed - about 23 per cent.
The centre eventually clarified this as 'enablement', not usage.The real figures, based on a survey of 10 per cent of all GPs, found that just 11.4 per cent used Prodigy in 2001, though this was up from 9 per cent in 2000.
'I would been very keen on getting Prodigy to work.As soon as it was available, I got one of the first copies, ' says Dr William Hammerton, a GP in Bridgnorth in Shropshire.'We had it on all the computers in our practice, and all the partners eventually switched it off. I just do not find one can use it in a consultation.'
Dr Hammerton says Prodigy is a useful tool - away from consultations.The problem with using it with patients is that a diagnosis has to be entered right at the start, he says, adding: 'That is not the natural way you do things.'
Furthermore, some of the information seemed outdated, and the user interface was less than intuitive.
'It may be just my fault that I didn't use the system properly, but it will take more time to do this, ' he says.'What needs to happen is to get it to be much more user-friendly, easier to use and up-todate.'
This is not the view of Prodigy's designers.'Two key factors have been identified that may affect Prodigy uptake and use, these being computer skill levels and levels of computerisation within the practice, ' said SCHIN, in a statement responding to these criticisms.
The centre is trying to boost take-up through organising training sessions, with more than 170 seminars held, mainly through primary care groups and trusts.
On the issue of user interface, the centre said: 'Each system supplier implements their own unique user interface for Prodigy, in line with the host clinical system, so usability issues relating to one system are not necessarily generic to all versions of Prodigy.'
Not our fault, in other words.SCHIN also point out that the data used was updated quarterly, and it was the software vendor's responsibility to pass this on - ditto last comment.
'There was some perception that Prodigy slowed down the consultation, ' the statement added, 'though video findings and usability testing suggested that this was not the case.'
However, the statement admitted: 'Users sometimes felt overloaded with information, which was not adequately structured or sign-posted, and these findings have informed subsequent approaches to authoring and structuring the guidance.'
Dr Paul Cundy, chair of the British Medical Association's GPs committee information management and technology subcommittee, is not satisfied with this.He feels training is a side issue, and challenges the claim that using the system doesn't add to consultation time.'Prodigy has clearly had a chequered history.They need to listen to the concerns being expressed, 'he says.