Special report: e-prescribing
The roll-out of e-prescribing across the NHS in England is glacial; and the sudden removal of tech fund money has all but halted its advance. Will things change as trusts progress their digital maturity and more government cash is released, asks Daloni Carlisle.
The clinical case for e-prescribing and the return on investment is pretty much proven. It reduces drug errors, improves patient safety, increases efficiency and productivity.
It’s also expensive, time consuming, and difficult to implement. Perhaps it is no wonder, then, that progress on rolling out e-prescribing is at best slow – and at worst glacial.
A third of the way there, and stalling
The latest data from Digital Health Intelligence’s Clinical Digital Maturity Index shows that, by 2015, 38% of England’s 154 acute trusts had implemented inpatient e-prescribing.
However, only 25% (39 trusts) had the more advanced functions of an e-prescribing integrated with a clinical decision support system. Among mental health trusts, 17 (30%) had e-prescribing and 11 (20%) had e-prescribing and CDSS combined.
Put all that together, and only one third of trusts have e-prescribing with decision support in place. And looked at over time, the rate of roll out is slowing – not speeding up.
The responses to the questionnaire that NHS England sent out to form the basis of its Digital Maturity Index are hardly more encouraging; as Paul Rice, head of technology strategy at NHS England, acknowledged in April.
“The high level summary on digital maturity is good, but with opportunities to improve,” he said. “The picture is quite good on access to care records, but the picture is less good on access to e-prescribing.”
Impact of the tech funds
Given that e-prescribing is cited as key not just to delivering a paperless NHS but also to transforming outcomes (Personalised Health and Care 2020) and improving efficiency and productivity (Carter report) this is surely an unhappy state of affairs.
The finger of blame for how it has come about is often pointed at NHS England for the sudden withdrawal of a large chunk of the second technology fund in 2015.
The first – or Safer Hospitals, Safer Wards – technology fund was initially been billed as an e-prescribing fund. But short timescales and variable assessment processes meant that it ended up funding a lot of electronic patient record and related systems.
Some e-prescribing projects that were already a long way down the procurement - or even the deployment - track got through.
But when the second – or Integrated Digital Care – technology fund was announced, it looked for some months as if less well developed projects were going to be organised into second and third funding waves.
When almost all of the fund disappeared - clawed back by the Treasury, to avoid a ‘winter crisis’ ahead of the general election – trusts that had been relying on the money were left high and dry.
Duane Lawrence, managing director of secondary care at EMIS Health, says: “There is still a desire on the part of most trusts to move forward with e-prescribing – but the money that was allocated to it nationally has dried up.”
“Central support evaporated. The ambition is there but not the means,” agrees Professor Michael Thick, chief medical officer of IMS Maxims, which offers e-prescribing as a module in its open source EPR.
Some suppliers are optimistic that trusts are just biding their time and waiting for another tranche of money to be released.
After all, health secretary Jeremy Hunt has said that £4.2 billion will be spent on healthcare IT over the course of this Parliament, with £1.8 billion of that earmarked for his ‘paperless’ agenda – which would logically include e-prescribing.
Before trusts see this cash, however, they must contribute to the local digital roadmaps being drawn up by their health communities; and the broader sustainability and transformation footprints that must be finalised by this summer.
Ann Slee, NHS England’s e-prescribing lead, still wants to see progress. In a statement to Digital Health, she said: “The Safer Hospitals, Safer Wards fund has seen a step change in the roll-out and availability of e-prescribing across the NHS in England.
“This has been evidenced by both the national digital maturity self-assessment recently published and the CDMI.
“It is clear that the trusts adopting the technology have put significant effort into rollout and are already starting to see the initial benefits.
“Providers are now starting work to optimise their systems. We know that optimisation, the beginning of the journey to mature systems, will provide the longer term quality and efficiency benefits that will underpin transformation.
“[It will also] support the improved safety, care of patients and efficiency within organisations and across health and care systems.”
Activity under the surface
Linda Elverson, business development director at Civica, says it is important to understand that it is not just the central funding that has slowed the adoption of e-prescribing. It is also the wider context of an organisation’s digital maturity.
“Yes, some providers are simply finding it difficult to find the funds,” she says. “But others have not advanced to the point where they understand where electronic prescribing fits into the broader scope of their transformation plans.”
So for Civica, the name of the game right now is “supporting trusts where they are on their journey.” Elverson says: “We are working with providers to help them understand what they are trying to achieve and to do it. EPMA will be one significant element of that transformation.”
“Plans,” she says, “are simmering. Business cases are getting prepared. We are expecting adoption of e-prescribing to increase.”
Professor Thick says this transformation piece is crucial – as is integration with the EPR. “If you want to get the advertised benefits - that have been proven in the literature - you have to have a deep integration,” he argues.
“You also have to carry out the clinical process transformation before implementation – otherwise all you do is automate bad processes.”
Doing it bit by bit
EMIS Health, meanwhile, is taking a pragmatic approach with its customers. In some places, its consulting team, which includes pharmacists, is working with trusts on the clinical transformation around medicines management that experience has shown is required ahead of implementing an electronic system.
In other places, it is exploring other models that include e-prescribing software as a service; and working with trusts to start small and expand ward by ward over a longer period.
“If there is nothing they can do financially, then we can just work internally, for example by adding e-prescribing capability to our A&E systems so we can begin the integration of A&E prescribing with community pharmacy and primary care,” Lawrence says.
Slee says NHS England continues to support trusts that are implementing e-prescribing. Her statement to Digital Health says: “The implementation of e-prescribing is complex and is an area in which subject matter expertise and specific tools are required, both of which NHS England will continue to support.
“The recent production of a specific maturity tool for e-prescribing has been well received and used to support sites; it will continue to be developed moving forward identifying where sites have expertise to share and where market development should be prioritised.”
Advancing by inches
But will new funding be allocated to EPMA this year? Slee makes no promises. Her statement simply says: “e-prescribing continues to be a key priority as evidenced by its inclusion with the recent Carter report.
“It is expected that e-prescribing and medicines optimisation will be a key part of the local digital road maps and sustainability and transformation plans moving forward. Any future funding is likely to be based on the priorities identified within these.”
That hardly makes it sound as if there is going to be a huge pick-up in pace. The roll-out of e-prescribing in 2016 looks set to be slow enough to gather some moss.