Oncology electronic prescribing integrated with an electronic patient record
The Clatterbridge Cancer Centre NHS Foundation Trust is one of the UK’s leading cancer centres providing highly specialist cancer care to a population of 2.3m people across Cheshire, Merseyside and the surrounding areas including the Isle of Man. It is one of the largest cancer centres in the UK, employing approximately 1,200 staff and treating more than 27,000 patients every year.
Clatterbridge is a tertiary cancer centre which means that the patients who are seen have already been diagnosed and referred by other hospitals. The Centre provides non-surgical cancer care, for example, chemotherapy and radiotherapy for solid tumours and blood cancers.
In July 2017, the Royal Liverpool Haemato-oncology service transferred to the management of Clatterbridge with the acknowledged issue that the service was non-compliant with the national standard for electronic prescribing of all adult non-clinical trial systemic anti-cancer treatment (SACT), also called chemotherapy.
To enable haemato-oncology electronic prescribing and patient management, the Clatterbridge pharmacy informatics team needed to build custom haemato-oncology diagnoses, drugs and chemotherapy treatment regimens into the Clatterbridge electronic patient record (EPR) and electronic prescribing and medicines administration (EPMA) system. Without this additional specific content it would be impossible to move away from the paper-based system.
Expanding the EPR system at Clatterbridge to provide a safe and effective electronic drug administration process for haemato-oncology.
Solution and impact
A project team was formed to oversee the safe implementation of electronic prescribing for the haemato-oncology service. The team included members of the Clatterbridge informatics team which had previously implemented the Clatterbridge EPR system and developed e-prescribing functionality for solid tumours. Membership included programme and project managers, data specialists, EPR and informatics pharmacy developers, as well as members of the pharmacy team. In addition to this, Liverpool University Hospitals NHS Foundation Trust clinicians, nurses, pharmacists and directorate managers were included in the team.
Due to the complexities involved, it was decided that electronic prescribing for lymphoma, myeloma and then leukaemia and myeloproliferative neoplasms would be built and implemented in a phased approach. This was dictated by clinical buy-in, the physical location, and timing of clinics to allow pharmacist backfill to integrate extra checks during the implementation. It was decided that lymphoma and myeloma both had significantly more intravenous (IV) drugs and the obvious safety improvements of electronic prescribing would be of more benefit to the largely reactive oral medication of leukaemia and myeloproliferative neoplasms.
The NHS mandates electronic prescribing of SACT, but only the prescribing aspect is mandated. The recording of administration was not mandated at this time. To get the maximum safety benefit, it was decided to expand the scope to include nurse administration and supportive therapies to give enhanced visibility to clinical staff. It was decided that the benefits to safety of enhanced visibility of administration of previous cycles and improving the audit trails was worth the additional workload. However, focussing resources here did negatively impact the timescales of later phases of the project.
Interoperability, data and standards
The recent NHS medicines optimisation CQUIN (commissioning for quality and innovation), which requires SNOMED codes to be reported with SACT minimum datasets, has been possible to achieve by attaching the reference codes at a drug level. This enables standardisation across the NHS landscape for all Trusts that administer chemotherapy.
Dictionary of medicines and devices (dm+d) numbers are attached to stock drug data from the Trust’s formulary service vendor and this unique identifier is used to pull down accurate drug information. This includes monographs and British National Formulary (BNF) warning labels for patients for each medicine used at the Trust. By using this approach, content is automatically identifiable when updating the drug catalogue and there is assurance that drug data is current and accurate. This development enables to add enhanced, product-specific decision support, enabling increased reporting accuracy on the use of specific products to the NHS.
By inserting standard attributes, such as SNOMED, dm+d, national regimen names and Office of Population Censuses and Surveys (OPCS) codes into medicines and treatment regimens, the Trust were able to automate more of their data collection for mandatory reporting in minimum data set (MDS) and SACT in line with changing requirements. OPCS coding for their most commonly-performed interventions and treatments has also streamlined the coding function at the Trust.
An e-prescribing for haemato-oncology pathway that is integrated with Clatterbridge’s Meditech EPR system allows the reviewing of previous medical history, including treatment plans, dosage, date and time, and the prescriber.
Standard dose attenuation strategies have been built to align to best practice across the network. By only allowing prescribers to prescribe doses which have been allowed in the protocol, it is expected that this will lead to better and more accurate dosing and tolerance of chemotherapy.
Benefits for patients
- Improved patient safety and overall quality of care
- Better patient outcomes through the avoidance of errors and improved efficiency
- Proficient e-prescribing processes at all Clatteridge locations, improving safety, reducing delays
Benefits for staff
- Reduced risk of medication errors
- Improved access to drug reference information, warnings and alerts
- Access to patients’ medical history at the point of care
- Improved efficiencies for pharmacy and drug administration
An EPR system which provides an effective electronic chemotherapy prescribing and administration process.
Key learning points
Due to the level of development required to build outpatient regimens, a decision was taken to deliver inpatient prescribing at a later date. However, outpatient prescribing did account for 80% to 90% of the volume and would provide the most clinical benefit.
At the outset this was a clinically-led project and those particular clinicians were keen to adopt an EPMA system. Consequently it was easy to get buy-in. However, at later stages it was more challenging to engage effectively with clinical staff (for a number of reasons), so clearly defined milestones, driven at executive-level, would be beneficial to maintain the momentum of the programme.
Discussions around whether to train staff in readiness for future phases, or to focus on specific content and provide refresh training at a later date, took place. It was decided to reduce the scope of training to match the specific functionality at go live and revisit the team at a later date when additional functionality was implemented.
Sarah Barr, chief information officer, The Clatterbridge Cancer Centre NHS Foundation Trust
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