Evaluation of community pharmacy electronic patient medication record systems’ functionality focusing on safety features and alerts

Studies on electronic patient medication record (ePMR) systems that are used in community pharmacy in England have focused primarily on the ability of these systems to highlight potentially hazardous co-prescriptions and prevent clinical hazards and harm to patients. As such, there is a scarcity of literature on the use of ePMR systems, other safety functionality of the systems and user responses to alerts. This thesis aims to fill this gap by examining the functionality of ePMR systems used in community pharmacy in England, focusing on safety features and alerts. This research was conducted in England between July 2010 and July 2013. Evidence for the effectiveness of safety features and alerts in ePMR systems during the dispensing process was evaluated through a systematic review of the literature. Stakeholder perspectives of ePMR systems’ functionality were then obtained through qualitative interviews. The performance of ePMR systems licensed for the electronic prescription service (release 2) in the community pharmacy setting were then assessed using a simulated observational testing approach. Ethnographically informed observations in community pharmacies were subsequently used to study how community pharmacy professionals use ePMR systems and manage alerts in practice. The systematic review included five studies - three randomised controlled trials and two before-after studies, with drug-drug interaction (1), drug-laboratory (2), drug-pregnancy (1) and drug-age (1) alerts. The review revealed that ePMR systems in conjunction with embedded safety features are effective in picking up clinical hazards at the point of dispensing. However, there are problems of false alerts and inconsistencies in alert management. Empirical findings indicate that there are significant issues with the way ePMR systems and alerts are designed and used. Thirty participants took part in the qualitative interviews - community pharmacy professionals (13), health care policy makers (5), legal practitioners specialising in pharmacy (3), ePMR systems’ software vendors (4) and ePMR systems’ software knowledgebase creators (5). Participants attributed alert ineffectiveness in community pharmacy practice to factors such as lack of harmonisation of alert severity levels in systems, poor alert design, over-presentation of alerts and absence of management advice in alerts. Five unique ePMR systems were evaluated in eight participating pharmacies with a sixth ePMR system assessed in a demonstration setting. The systems’ performance was variable and sub-optimal. The ethnographically informed observations took place in the eight pharmacies where system assessment was conducted. The observations revealed that the current design of ePMR systems and presentation of alerts are limiting the quality of support provided to pharmacists and their support staff. This research is part of a growing body of work on the functionality of ePMR systems, their safety features and alerts indicating that ePMR systems require improvements if they are to effectively support patient safety and consistently deliver better patient outcomes. The findings highlight the need to incorporate patient context into alerting to increase alert relevance. In addition, system vendors need to make use of the evidence in the literature to design effective ePMR systems, alerts and user interfaces. An authoritative body should set the minimum specifications for ePMR systems and alerts, and identify the critical alerts that pharmacy professionals should evaluate at the point of dispensing. Additionally, training of pharmacy professionals in health information and communication technology is required to improve patient safety. This should cover areas such as informatics, human factors, safety culture, clinical decision-making, alert management, risk management and communication. Many of the findings are likely to be relevant to similar medication record systems in ambulatory pharmacies around the world; however, further work is required to understand fully the extent of the issues identified in this research

Evaluation of community pharmacy electronic patient medication record systems’ functionality focusing on safety features and alerts

Studies on electronic patient medication record (ePMR) systems that are used in community pharmacy in England have focused primarily on the ability of these systems to highlight potentially hazardous co-prescriptions and prevent clinical hazards and harm to patients. As such, there is a scarcity of literature on the use of ePMR systems, other safety functionality of the systems and user responses to alerts. This thesis aims to fill this gap by examining the functionality of ePMR systems used in community pharmacy in England, focusing on safety features and alerts. This research was conducted in England between July 2010 and July 2013. Evidence for the effectiveness of safety features and alerts in ePMR systems during the dispensing process was evaluated through a systematic review of the literature. Stakeholder perspectives of ePMR systems’ functionality were then obtained through qualitative interviews. The performance of ePMR systems licensed for the electronic prescription service (release 2) in the community pharmacy setting were then assessed using a simulated observational testing approach. Ethnographically informed observations in community pharmacies were subsequently used to study how community pharmacy professionals use ePMR systems and manage alerts in practice. The systematic review included five studies - three randomised controlled trials and two before-after studies, with drug-drug interaction (1), drug-laboratory (2), drug-pregnancy (1) and drug-age (1) alerts. The review revealed that ePMR systems in conjunction with embedded safety features are effective in picking up clinical hazards at the point of dispensing. However, there are problems of false alerts and inconsistencies in alert management. Empirical findings indicate that there are significant issues with the way ePMR systems and alerts are designed and used. Thirty participants took part in the qualitative interviews - community pharmacy professionals (13), health care policy makers (5), legal practitioners specialising in pharmacy (3), ePMR systems’ software vendors (4) and ePMR systems’ software knowledgebase creators (5). Participants attributed alert ineffectiveness in community pharmacy practice to factors such as lack of harmonisation of alert severity levels in systems, poor alert design, over-presentation of alerts and absence of management advice in alerts. Five unique ePMR systems were evaluated in eight participating pharmacies with a sixth ePMR system assessed in a demonstration setting. The systems’ performance was variable and sub-optimal. The ethnographically informed observations took place in the eight pharmacies where system assessment was conducted. The observations revealed that the current design of ePMR systems and presentation of alerts are limiting the quality of support provided to pharmacists and their support staff. This research is part of a growing body of work on the functionality of ePMR systems, their safety features and alerts indicating that ePMR systems require improvements if they are to effectively support patient safety and consistently deliver better patient outcomes. The findings highlight the need to incorporate patient context into alerting to increase alert relevance. In addition, system vendors need to make use of the evidence in the literature to design effective ePMR systems, alerts and user interfaces. An authoritative body should set the minimum specifications for ePMR systems and alerts, and identify the critical alerts that pharmacy professionals should evaluate at the point of dispensing. Additionally, training of pharmacy professionals in health information and communication technology is required to improve patient safety. This should cover areas such as informatics, human factors, safety culture, clinical decision-making, alert management, risk management and communication. Many of the findings are likely to be relevant to similar medication record systems in ambulatory pharmacies around the world; however, further work is required to understand fully the extent of the issues identified in this research

Assessing the safety features of electronic patient medication record systems used in community pharmacies in England

Aims: To evaluate the ability of electronic patient medication record (ePMR) systems used in community pharmacies in England to detect and alert users about clinical hazards, errors and other safety problems. Methods: Between September 2012 and November 2012, direct on-site observational data about the performance of ePMR systems were collected from nine sites. Twenty-eight scenarios were developed by consensus agreement between a general practitioner and two community pharmacists. Each scenario was entered into the ePMR system, and the results obtained from the assessment of six unique systems in nine sites, in terms of the presence or absence of an alert, were recorded onto a prespecified form. Results: None of the systems produced the correct responses for all of the 28 scenarios tested. Only two systems provided an alert to penicillin sensitivity. No dose or frequency check was observed when processing a prescription for methotrexate. One system did not warn about nonsuitability of aspirin prescribed to a child of 14 years of age. In another system, it was not possible to record a patient's pregnancy status. None of the six systems provided any warning for diclofenac overdose, high initiation dose of morphine sulfate or significant dose increase. Only one of the systems did not produce any spurious alerts. Conclusions: The performance of the ePMR systems tested was variable and suboptimal. The findings suggest the need for minimum specifications and standards for ePMR systems to ensure consistency of performance

The evidence for the effectiveness of safety alerts in electronic patient medication record systems at the point of pharmacy order entry: a systematic review

Background: Electronic Patient Medication Record (ePMR) systems have important safety features embedded to alert users about potential clinical hazards and errors. To date, there is no synthesis of evidence about the effectiveness of these safety features and alerts at the point of pharmacy order entry. This review aims to systematically explore the literature and synthesise published evidence about the effectiveness of safety features and alerts in ePMR systems at the point of pharmacy order entry, in primary and secondary care. Methods: We searched MEDLINE, EMBASE, Inspec, International Pharmaceutical Abstracts, PsycINFO, CINHAL (earliest entry to March 2012) and reference lists of articles. Two reviewers examined the titles and abstracts, and used a hierarchical template to identify comparative design studies evaluating the effectiveness of safety features and alerts at the point of pharmacy order entry. The two reviewers independently assessed the quality of the included studies using Cochrane Collaboration’s risk of bias tool. Results: Three randomised trials and two before-after studies met our criteria. Four studies involved integrated care facilities and one was hospital-based. The studies were all from the United States (US). The five studies demonstrated statistically significant reduction in medication errors in patients with renal insufficiency, pregnant women dispensed US Food Drug and Administration (FDA) risk category D (evidence of fetal risk but therapeutic benefits can outweigh the risk) or X (evidence suggests that risk to the fetus outweighs therapeutic benefits) medication, first dispensing of inappropriate medications in patients aged 65 and above, co-dispensing of interacting drugs, and adverse drug events related to hyperkalaemia. Conclusions: This systematic review shows that the safety features of ePMR systems are effective in alerting users about potential clinical hazards and errors during pharmacy order entry. There are however, problems such as false alerts and inconsistencies in alert management. More studies are needed from other countries and pharmacy practice settings to assess the effectiveness of electronic safety features and alerts in preventing error and reducing harm to patients