Picture the scene. A doctor is attending a Fitness to Practise hearing at the General Medical Council. She stands accused of making a prescribing error which has lost a patient his life. The doctor is now fighting for her career.
Meanwhile, managers at the trust which employs her are facing their own problems. The latest inspection report from the new government’s health service watchdog has led to serious questions about why the trust has not implemented a system which is known to cut the risk of prescribing errors significantly. The managers’ careers are also in jeopardy.
This scenario is not as far-fetched as it might currently seem. A report published recently by the GMC, the regulator body for doctors, (http://www.gmc-uk.org/about/research/research_commissioned_4.asp#) on prescribing in hospitals raises serious questions about how accurately it is done. Although it was based on the most junior doctors (foundation years), the study of prescribing errors found they were all too common among doctors at every stage in the career path. Shockingly, the study found that almost nine per cent of medication orders contained errors, more than half of which were deemed “potentially significant”.
The GMC report finds a number of reasons for the level of mistakes – and makes some headline recommendations, including the need to introduce consistency in prescribing forms from hospital to hospital.
But the report also states clearly that “electronic prescriptions were 12 per cent less likely to be associated with a prescribing error than handwritten prescriptions” (page 31).
If, as this report and others suggest, ditching the handwritten prescription can improve patient safety and save lives can managers, doctors – and regulators –afford to ignore it?
Stephen Goundrey-Smith, a pharmacist by background and author of Principles of Electronic Prescribing, believes the GMC report is significant.
“This is a sign that regulators are getting interested in the whole area,” he says. “Once there is a professional requirement to use appropriate systems, it will be difficult for trusts to ignore.”
According to the NHS’s Connecting for Health, the earliest adopters of electronic prescribing have had systems in place for over a decade (source: http://www.connectingforhealth.nhs.uk/systemsandservices/eprescribing/challenges/Final_report.pdf).
Yet even the most ardent champions of e-prescribing would have to confess that it is still far from widespread throughout Britain’s NHS hospitals.
There are several reasons for this, says Mr Goundrey-Smith, What he calls the “political angle” is important. “We’ve spent many years thinking that there was going to be a national system; we now know that it’s not going to happen in quite that way, but people’s reluctance was understandable.”
The need for a real change management programme throughout the organisation – and getting buy-in from everyone, not just those who were keen to use the new technology – was seen as a barrier by some.
There has also been some natural caution. “People wanted to be sure that the systems work,” he says.
Connecting for Health has moved from a position of developing a standard for a national system to becoming a resource for those trusts who wanted to move forward and implement their own systems, he says. This help has ranged from support and advice, but the change of government has meant that the future of Connecting for Health is far from certain.
So what will trusts do? They will look at their local needs and at other factors, says Mr Goundrey-Smith. “If people do decide to do their own thing, then we may well find more people going ahead [with electronic prescribing] in the next few years, but that will partly depend on how the finances are.”
Standards are key
Asked whether he can envisage a doctor being called before the GMC because he or she has not used electronic prescribing, Mr Goundrey-Smith thinks it’s a possibility. “I think that day is coming, but I’m not sure when – we could see it in the next 10 years.”
He thinks that other regulators will be looking at e-prescribing too. For example, if e-prescribing systems which include other functions, such as clinical decision-making support, were to be regarded as medical devices, then the MHRA (Medicines and Healthcare products Regulatory Agency) may be interested.
“I think the GMC work suggests that it is a potential regulatory issue,” he says. “But I think before it’s mandatory for health professionals to use them, that e-prescribing systems should conform to standards.
“I’d like to see professional bodies engaging with suppliers to come up with agreed standards, and I’d like to see suppliers working with professional bodies to find out what clinicians want. I think this is a huge unexplored area and would benefit from further work.”
Although there are relatively few trusts which have implemented trust or hospital-wide electronic prescribing, that doesn’t mean they are e-prescribing free zones. On the contrary, says Mr Goundrey-Smith, you might find that some have introduced it across one or more units or specialities. Or they might have an electronic discharge system in place, to streamline prescribing communication between the hospital and primary care.
This “pragmatic” introduction of e-prescribing will, he believes, continue to grow over the next few years – particularly as those who have been accustomed to using it move to other units where it is not in use and “spread the word”.
“What you might find is that people might complain about e-prescribing when they have it, but they are bereft when they don’t!” he laughs.
The doctors, nurses and pharmacists who have worked at one of the early adopter sites, such as Winchester and Eastleigh Healthcare Trust, which uses the JAC e-prescribing system, are therefore among the most effective advocates. “The bottom line is that once you’ve got it, nobody wants to go back,” he says.
“There’s a degree of pressure from young pharmacists and doctors in favour of electronic prescribing and that could well be a significant factor.”
Electronic prescribing – taking note of the evidence
Increasing professional buy-in is certainly a challenge. One way forward – and this is happening to an extent – is by making sure that those who are using the systems are well-equipped to do so. That involves setting and insisting on educational standards, both at an undergraduate and postgraduate level. Of a necessity, this involves getting professional bodies, such as the Royal Pharmaceutical Society, on board.
Mr Goundrey-Smith believes that the GMC might actually be ahead of the RPS on this one, as evidenced by its paper on prescribing errors.
But it is not only the professional regulators who are likely to be taking notice. Prescribing errors have been a particular focus of other bodies, such as the National Patient Safety Agency or other quality bodies. If trusts find that they are lambasted for failing to introduce the systems which, the evidence suggests, improve the safety of prescribing, cutting errors and potentially saving lives, they might be impelled to act.
To return to the imaginary scenes in the under-fire trust, described above. “Why?” says the chief executive, contemplating the loss of even the new, slimmed down NHS pension when he is ignominiously sacked. “Why didn’t we implement electronic prescribing when we saw the evidence in its favour stacking up?” The medical director and chief pharmacist, anticipating their own letters from their respective regulatory bodies, can only nod and agree.
Stephen Goundrey-Smith is a pharmaceutical informatics consultant and author of Principles of Electronic Prescribing