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Clinical IT in Aged Care Product Trial - Trial of a Medication Management System - Report

Report of the product trial of an Medication Management System

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Residents in aged care homes tend to take a large number of medications, many with complex medication schedules. As a result they have an increased risk of experiencing adverse drug events (ADEs) and disruption to their medication supply, particularly with the disparate locations of the prescribing GP, the dispensing pharmacist and the aged care home.

Electronic prescribing, dispensing and administering of medications has the potential to eliminate most transcribing errors and improve communication between GPs, pharmacists and staff in aged care homes resulting in improved management of medications for aged care residents.

Situation

Current medication systems in aged care tend to be either strictly paper based or they use IT systems that have primarily been developed for the GP market. These IT systems are traditionally 'standalone', cannot easily be interfaced with other patient care systems and cannot be accessed remotely. Without the ability to share information electronically, both systems contribute to breakdowns in communication between GPs, pharmacists and nursing staff that lead to impediments in the quality of care for residents in aged care homes.

At the time this trial commenced, no system enabled all relevant aged care staff, GPs and pharmacists to access a single, accurate medication profile for medication management purposes. Goodwin Aged Care in Canberra, ACT, undertook to address this problem with the assistance of Hatrix Pty Ltd and participation from the Australian Pharmacy Group. Hatrix adapted and installed MedChart, a previously hospital centric product, as a single medication management and decision support IT system for use by aged care staff, GPs and pharmacists. MedChart allowed authorised individuals to use the same electronic clinical record for prescribing, pharmacy review and administration of medications.

The Clinical IT in Aged Care project provided $322,415 to Goodwin Aged Care Services for the trial. Additional funds (cash and in kind) for the project were provided by consortium members.

Aim of the Trial

The trial aimed to evaluate how a single computerised medication management record could improve the quality of care provided to residents in aged care homes and deliver benefits and efficiencies to the home, pharmacists and GPs.

The trial focused primarily on changes to the process of prescribing, reviewing, dispensing and administering medication when moving from a paper-based system to an electronic management system.

Additional areas of focus were identification of barriers to the uptake of such a system and exploring the adaptability of MedChart to the aged care environment.

The Trial Setting

Two of Goodwin Monash's residential aged care 'cottages' in Canberra were included in the trial as test and control groups. The control group was engaged to allow for comparisons to be made where baseline data was not available. A total of 13 residents had their medication records entered into MedChart for the period of the trial. Three GPs participated, along with one pharmacist and 12 nursing home staff.

Consortium Members

Hatrix Pty Ltd developed and installed MedChart software and provided technical support to GPs, pharmacy and nursing staff.

Nursing staff and resident participation was drawn from the Azalea and Bluebell Cottages of Goodwin Aged Care Services based in Monash, Canberra.

The participating pharmacy was the Australian Pharmacy Group's Manuka Plaza Pharmacy based in Manuka, Canberra

The Solution

MedChart was installed as a single Internet browser-based medication management and decision support IT system. Authorised aged care staff, GPs and pharmacists had online access to the same electronic clinical record for prescribing, pharmacy review and administration of medications.

GPs electronically prescribed medication and had access to a clinical decision support tool that checked drug to drug interactions (including multiple drug to drug interactions), and drug to allergy interactions. GPs either used MedChart from their surgery or whilst visiting the aged care home. GPs could check on the progress of their prescription and review comments from the pharmacy or aged care home.

The pharmacy electronically reviewed the medication ordered by the GP. The pharmacy then approved, provided comments or rejected an order if necessary. Following approval, medications were dispensed into 'Webster Packs' and couriered to the aged care home. The pharmacy was able to interact with GPs and nursing staff on patient specific issues as well as set reminders for themselves or GPs regarding these issues.

Nursing staff in the aged care home used MedChart to record administration of the medications, taking notice of any notes made by the pharmacy and/ or GP. They were able to electronically document administration details for each resident. Residents were more easily identified with a digital photo stored as part of the medication record.

Approximately 20,000 separate medications were managed via MedChart during the trial which ran from April to September 2005.

Involvement of clinical staff, the pharmacy and GPs

Participating medical, pharmacy and aged care staff were trained in the use of MedChart. Hatrix staff were available 24 hours a day 7 days a week to provide telephone support to staff during the trial.

Securing participation from GPs proved to be challenging. Some GPs who initially expressed interest in the project withdrew. Broadband installation was offered to GPs as an incentive to participate.

Involvement of Residents

Not all residents were included in the trial which resulted in staff having to run dual processes – one for residents involved in the trial and the other for residents remaining on the paper-based system. The small number of participants meant that the availability of baseline data used in the evaluation was limited. There were also delays in establishing broadband connectivity across the trial. These factors limited the outcomes of the trial.

A third party was used to seek consent from residents to their participation in the trial. Residents were given an explanation of the purposes and requirements of the research both in writing and verbally. They retained an information package and written consent was provided by either the resident or their legal guardian.

The trial was introduced gradually starting with one resident. More residents were added as system users became more confident. It is worth noting that residents were accepting of the use of MedChart as they saw the use of technology to be adding to the care they were being provided.

Outcomes

Overall, Medchart was perceived to provide better record keeping for the medication administration record and allow better internal monitoring of nursing home staff activities. It was also reported to result in safer, faster, and more appropriate medication orders including medication reviews as well as more timely dispensing and supply of medications. It also improved communication between the home, GPs and pharmacists and removed the ambiguities encountered in written instructions.

In addition, all stakeholders noted the potential for time savings and that this would increase with the number of residents involved. With MedChart providing a single source of information for each resident, there was greater integrity in relation to medication changes, less chance for confusion or errors in relation to medication management and therefore less chance of Adverse Drug Events (ADEs).

Nursing staff reported that efficiency and accuracy of medication management would improve if MedChart alone could be used to record the administration of medications as it would be less time consuming than manually signing medication charts. Nursing home staff noted that Medication Profiles could be printed from MedChart to be used for Specialist appointments.

GPs reported that they were able to make more timely changes by adding or altering medication at the aged care facility on a record that could then be accessed from their surgery. It was discovered in the implementation stages of the trial that the medications recorded in the GP's surgery did not always match the information that was recorded in the home and therefore the pharmacy which meant that some medication records were inaccurate.

It was further reported that residents involved in the trial were less likely to suffer from an ADE caused by an error in prescribing, dispensing by the pharmacist or administration by nursing staff. However, while the number of recorded ADEs actually increased during the period of the trial, there was a reduction in the number of events that directly affected residents' wellbeing (a phenomena which is now commonly noted in literature). The increased reporting of ADEs was attributed to the ease of highlighting issues such as incorrect webster packing or incorrect dosage information (eg. medication ceased) at the time of medication administration.

Barriers

The trial identified a number of issues and barriers which impacted the results, efficiency and acceptance of MedChart by stakeholders. Key issues included:

• GP Engagement – Although IT provides tools for GPs to work more efficiently, GPs were reluctant to adopt a software application that may not continue past the trial and which was in addition to or was not able to electronically link with their existing software.
• IT Literacy Levels – Staff in the participating aged care home had little previous exposure to computers in their workplace with all computers pre-trial only available to executive and “front desk” clerical staff. This meant that assistance was required with basic problem solving issues such as refilling printer paper.
• Lack of Evidence to Support Adoption – Aged care providers are more likely to invest in technology once there is evidence to support a return on their investment. At the time the trial commenced, there was very little evidence available to suggest that there were benefits and efficiencies to be gained from the implementation of IT.
• Integration with Other Systems – The seamless exchange of information between systems is necessary for maximum efficiencies to be gained through use of IT in any area of clinical or administrative care. Automatic generation of a resident medication profile is generally not possible without an electronic link to other systems used by GPs, pharmacies or aged care homes unless the same system is used by all parties. Integrating MedChart with other systems such as Medical Director was not possible at the time and cooperation from other software suppliers is necessary to be able to develop appropriate interfaces.
• Legislation – The current legislative requirement for a pharmacy to have a hand signed prescription before they are able to make PBS claims restricts the effectiveness of electronic management systems.
• Process Duplication – Duplication of effort is an inherent limitation for a trial with a finite period. There was a need to run dual processes which made efficiencies difficult to achieve during the period of the trial.

Lessons Learned

There were many issues encountered during the course of the trial that impacted on the results, efficiency and acceptance of MedChart by trial participants. These included:

• Data Collection – to effectively measure ADEs, and benefits/improvements, it is essential for comprehensive pre-trial data to be available and scrutinised prior to commencement of the trial.
• Trial Size – For a system such as MedChart to be of significant benefit to aged care homes, it must be adopted by or be able to electronically link with all GPs servicing the aged care home. Because the trial was for a finite amount of time, there was a requirement for all participants to maintain dual records. This created extra work. It was noted that potential for time savings and efficiencies would increase with the number of residents managed with MedChart.
• GP Adoption – GPs were reluctant to adopt a software application that may not continue beyond the trial and which was in addition to their existing software.
• IT Awareness – staff at the aged care home had little exposure to computers in their workplace with all computers pre-trial only available to executive and front desk clerical staff. Training GPs and pharmacy staff was difficult due to their inaccessibility. It was essential to provide a flexible training program that met the needs of all stakeholders, particularly to suit the availability of GPs and pharmacy staff.
• Technology - A major challenge turned out to be the installation of broadband connections in participating GP surgeries. A considerable amount of time was spent resolving issues around the connections which were installed at the commencement of the trial. If broadband were set up in advance, this could have been avoided.
• Cost Estimates - Long term costs for implementation are dependent on a number of factors such as the size of the organisation, the IT literacy level of staff and existing IT infrastructure (both hardware and software), therefore it was difficult to estimate the cost for other organisations to take-up this technology.

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.