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Clinical IT in Aged Care Product Trial - Trial of an Electronic Prescribing System - Report

Report on the product trial of an electronic prescribing system

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PDF printable version of the Trial of an Electronic Prescribing System (PDF 339 KB)

Residents of aged care homes have a high prevalence of chronic illness and complex care needs which can result in large amounts of medical information being generated. In an environment where the GP managing a resident's care is not always available on site, remote access to up to date information holds increasing significance for the effective management and administration of medications.

The Illawarra Division of General Practice (IDGP) modified and installed an existing GP clinical package, in aged care homes and GP practices to assess the impact of remote access by GPs to medication information stored at the aged care home.

Situation

Electronic medication charts can be easily produced, are clear to read, can be easily modified, and are less prone to misunderstanding or misinterpretation. By comparison, handwritten medication charts are prone to illegibility, are time consuming to create, are unable to make use of online decision support tools and are inaccessible off site.

Typically, a GP visits an aged care home where staff may provide them with reminders about medication needs. The GP sees their patients and writes up medication charts and prescriptions by hand either at the home or back at the surgery. The resident's medical record remains at the aged care home, and is sometimes copied or summarised for the GP surgery. Often the only copy is held at the aged care home. The prescriptions are taken to the pharmacist who interprets the prescription, questions the GP if it is unclear, dispenses and delivers the medication to the aged care home. Nursing staff in the aged care home administer medications according to a handwritten medication chart. Illegible instructions or medications are discussed with other staff, often resulting in calls to the GP and delays medication administration.

In addition, the greater the number of medications consumed, the greater the probability of drug to drug interactions. In this situation the use of prescribing software to identify likely drug to drug interactions and drug/disease interactions is extremely important.

By introducing electronic medication charts and creating the capacity to produce electronic prescriptions from the aged care home, it is thought that medication management for residents in aged care homes can be significantly improved and allow for rapid review, adjustment or continuation of medications by the GPs, reducing the time taken with paperwork and the possibility of medication errors.

The Clinical IT in Aged Care project provided $205,330 to IDGP for a trial of an Electronic Prescribing System. Additional funds (cash and in kind) were provided by consortium members.

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Consortium members

The trial was led by the Illawarra Division of General Practice, NSW.

Intrahealth Limited were engaged as the developers/vendors of the GP clinical package used in the trial "Profile."

The Centre for Equity and Primary Health Research in the Illawarra and Shoalhaven (CEPHRIS) was engaged to conduct the evaluation.

Participating homes were engaged through the Illawarra Retirement Trust and included St Andrew's RACF "Olunda" in Wollongong and Unanderra Care Services, NSW.

Aim of the Trial

The trial focused on improving the management of residents' medication through electronic prescribing and generation of medication charts. It examined the impact of IT on resident health outcomes, clinical workflow and on communication between homes and local GP practices. Observations from pharmacies supplying the homes were also recorded.

Specifically, the trial sought to learn:

• Issues faced during the introduction of the technology in aged care homes, GP surgeries and in linking the two sites via broadband.
• How behaviours of participating stakeholders (eg. clinical staff, GPs) changed with the introduction of the system.
• Improvements to the standard process of medication management through use of the system.
• Unexpected and unintended outcomes from the introduction of the system for residents, staff, GPs and community pharmacists.
• The impact of the system on the GP and the care provided for aged care residents.
• How learnings from this trial be applied more widely in the Illawarra and further afield.

The Trial Setting

The Illawarra Division of General Practice (IDGP) managed the project in collaboration with five local GPs. These GPs came from three practices and visited four aged care homes. The aged care services involved in the trial were; the Illawarra Retirement Trust (IRT) through its The Trial Settingfacilities at Towradgi Park and Diment Towers; St Andrews (Olunda); and Unanderra Care Services (Uniting Care). The homes involved varied in size and in low and high care types. The number of residents involved in the trial at each facility constantly fluctuated.
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The Solution

Profile is a complete practice and clinical management software for Windows which can be customised to suit particular needs for GPs, aged care homes and other healthcare providers. It has been adopted by a number of GPs in the Illawarra as a clinical management system which is able to interface with a full range of other clinical information systems used locally. Profile conforms to the HL7 messaging standard, allowing it to communicate and exchange data with other conforming information systems.

For the purpose of the trial, IDGP worked with Intrahealth Limited to develop medication chart templates and remote communications infrastructure that were suitable for GPs to access information either on-site at the aged care home, in their surgery or from home. The infrastructure adhered to strict security standards and the electronic medication chart was required to meet NSW State legislative requirements.

The Profile system provided a complete record of prescribing, medication charts, medication reviews and changes for the period of the trial, allowing review of the quality of medication management for residents. It also included MIMS as a decision support component to assist GPs in making informed decisions about prescription and management of medications.

The project was broken into two phases:

Phase 1 – Installation and use of the clinical prescribing information management system, Profile, in the participating aged care homes. This allowed for onsite production of electronic medication charts and prescriptions. Staff in aged care homes entered residents' demographic details and the GPs added their medication records.

Phase 2 – Expanded on the use of Profile within the aged care homes by linking with computers in GP surgeries via broadband (ADSL), thus allowing the GPs to remotely access and update or review residents' medication charts and profiles. A secure communication technology called Stunnel was utilised. This allowed the data to be communicated in a secure and encrypted manner. Technical difficulties resulted in only two GPs having remote access during the last few months of the trial. In particular, lengthy delays were experienced with Telstra's broadband installation in the GP surgeries.

Phase 1 ran from November 2004 to July 2005. Phase 2 commenced in March 2005 and concluded in July 2005.

Involvement of Aged Care Home Staff and GPs

Staff in aged care homes were provided with one hour of training prior to the start of the project. Training occurred during work hours and not all staff were able to attend. Those responsible for initial data entry attended, however most of the clinical staff who would be end users did not attend. Some staff felt that this amount of training was sufficient, whilst others asked for more training at the end of the trial period given the system was being retained.

All staff were provided with both hard and electronic copies a training manual.

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Outcomes

The main outcome reported from the trial was the increased legibility of the medication charts. This was seen to reduce delays during medication rounds and was likely to lead to a reduction in medication errors. Participating GPs noted significant time savings when generating medication charts, although initially they felt they were spending more time entering new residents onto the computer than they would have with the paper based system.

The system improved access and sharing of the residents' medication profiles.

Those GPs with remote access were able to see each resident's current medication chart which meant that they did not have to rely on their memory or a duplicate set of notes when conversing with other care providers.

The system was widely accepted and no major organisational change was identified as necessary for its success. In many cases it was noted that involvement in the trial had strengthened relationships between key stakeholders.

Set up costs and future annual fees are dependent upon numerous variables including the number of workstations required, number of GPs using the system and current software that each GP uses. The only ongoing costs the aged care homes would incur are the licence fees for Profile and MIMS. These costs are minimal as demonstrated by the fact that three aged care providers opted to continue with the system after the trial had ceased.

At the conclusion of the trial, GPs were looking to utilise the system more fully by using it to keep resident notes as well as medication profiles. This would then negate the need for a written file. In addition, to improve medication management and system efficiency, the Illawarra Retirement Trust has completed the transfer of all patients onto a single centralised Profile database for all of their aged care homes in the Illawarra region, post trial.

Benefits

An unforseen benefit was that residents' medications were reviewed as they were entered onto the system.

One GP reported that he could produce 5-6 charts in less than twenty minutes when it used to take over forty five minutes.

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Lessons Learned

Providing training to all of the participating staff in each aged care home proved to be challenging as staff were not always available during business hours. IDGP reached the conclusion that training for staff in aged care homes needed to be held after hours.

It was interesting to note that prior to commencement of Phase 2 and at the conclusion of the trial, all GPs reported that they had been provided with sufficient training. None reported experiencing issues that could have been overcome through training. By comparison, over half of the staff in aged care homes reported experiencing issues due to the GPs not having had enough training.

For full benefits to be realised, the system needs to be implemented across the whole of an aged care home, involving all residents and GPs. Due to the trial nature of this project, and the need to maintain duplicate systems - one for the trial participants and the other for those still using handwritten medication charts - there was a limit to the outcomes achieved.

The location of computers was reported as being vital to the success of such a system as convenience was a major element of GP participation. Generally, if computer access for GPs was in a different location to where they would usually draw up medication charts, the system may not be fully utilised. It was suggested that the availability of this system throughout aged care homes may encourage more GPs to work in aged care.

This product trial summary was prepared as part of the Australian Government Department of Health and Ageing's Clinical IT in Aged Care Project. The product trials aimed to assess improvements to the care provided to residents in aged care homes as a result of the implementation of technology. The use of the IT product in this trial should not be taken as an endorsement of the product.
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