Coloured pillsPete Marsh

Ensuring that the left hand of primary care knows what the right hand of secondary care has done creates so many common problem that in Wirral we have a name for them – ‘L&Rs’.

Drug histories is an L&R that merits some discussion. In A&E and on admission, drug history taking can vary in quality. Elective admissions can fail to consider the community scripts in place during the patient stay.

Similarly, discharge letters with take home medication fail to explain if the current community scripts are still valid, if they changed and why they changed. What is needed is to record ‘why’ when performing electronic prescribing. What is required is electronic transfer of community prescribing data into secondary care on admission.

A common lexicon

Clearly a common lexicon is needed and the Dictionary of Medicines and Devices (dm+d) database must have a role here. However, primary care electronic prescribing is order only and not administration, so care is needed in using this data in any automation. The single integrated record is the answer, but it is a little way off at the moment.

The user interface and alerting will also differ from primary to secondary care in functionality and the wider generalist knowledge of the GP versus the specialist knowledge of the hospital consultant and the trainee doctors’ grades.

Asynchronous rules engines should be plugged into all the messaging within the electronic record, again watching out for the patient in a busy, dangerous environment. Watching kidney function and checking it is being monitored when a patient is on a kidney toxic drug over time is the sort of toolkit needed.

The NHS should start building up libraries of issues, risks and solution sets in terms of rules in plain English. Arden syntax was a start in this area, but complex rules meant it was not very intuitive. The work effort in building this knowledge will be significant and needs to be shared.

A checklist

Here are some useful tests and questions to check on the maturity of a supplier of electronic prescribing and drug administration:

  • How do you handle the clock change? If they do not know what you are talking about — run away. Setting system clocks back an hour can have interesting and dangerous effects on schedules such as drug administration or order placement. The possibility of an event happening twice is not a good idea.
  • The Frusimide 60mg test. Doctors order clinical amounts (in secondary care) and 60mg of Frusimide doesn’t exist so a solution to give 3*20mg or 1*40 and 1*20 is required. Systems that flex the clinical process at the front end and interpret the “real world” effects at the back are essential.
  • How do you handle downtime? If they talk about clustering, RAID technology, DR processes — run away. Business processes that kick in when a system is not available must be ready and waiting to go and not rely on technology. Even the best technology fails.
  • Legal implications of inpatient v outpatient prescribing. The inpatient setting is an instruction from a doctor to a nurse to give a drug and is not a prescription. Controlled drugs do need a human signature. Outpatient scripts are an FP10 type process. The supplier should be aware of this.

The process is lengthy and knowledge continues to build about how to improve and make safe the process. The NHS needs to learn lessons from the past and move forward at the point of activation of the new national projects, we must not take a step backwards in order to go forward, the users will never accept it, and they are what it is all about.