More to do on e-med management in aged care

The full benefits of electronic medication management systems in aged care are currently not available in Australia largely due to the lack of integration with electronic prescribing, writes Dr Rohan Elliott.

Electronic medication management systems are increasingly used in residential aged care facilities with the objectives of improving the quality and safety of residents’ care and enhancing workflow and efficiency. But is there evidence that currently available electronic medication management systems achieve these desired outcomes? And what are their limitations?

The central component of electronic medication management systems is the electronic medication administration record (eMAR). An eMAR is an electronic record of medication orders and administration of medication doses. In hospitals, the medication orders that populate the eMAR are usually entered by doctors using an integrated e-prescribing module. In aged care facilities, the orders are usually entered by pharmacists or pharmacy technicians, transcribed from doctors’ paper-based medication orders.

Perceived benefits from the use of eMARs include improved legibility of medication administration orders, the ability to track dose omissions and enforce recording by staff of reasons for dose omission, improved timing of administration, reduced risk of medication administration errors and improved efficiency.

Unfortunately, there has been little research focusing on the benefits and risks of eMARs, especially in aged care. A 2013 review of published literature conducted for the Australian Commission on Safety and Quality in Health Care identified only one study examining the impact of eMARs in aged care, and 10 studies in hospitals.

Most studies were poorly designed and executed, and only one study (conducted in a hospital) demonstrated a statistically significant reduction in medication administration errors (dose omissions). There was evidence that documentation of the reasons for dose omissions was improved. Two studies reported conflicting results in relation to changes in the efficiency of medication administration after implementation of an eMAR. The authors concluded that there is a lack of evidence that eMARs reduce medication errors or improve efficiency in aged care facilities.

A major limitation of eMARs used in Australian aged care facilities is lack of integration with electronic prescribing (e-prescribing), leading to a need for the aged care facilities contracted pharmacy service to create and maintain the eMAR based on prescribers’ paper or telephone orders. Recent research conducted by the Centre for Medicine Use and Safety at Monash University, published in the journal Australian Health Review, found that lack of integration of the eMAR with e-prescribing contributed to medication errors and workflow inefficiencies for nurses and pharmacists.

Errors resulted from discrepancies between paper medication orders and the pharmacy-maintained eMAR and delays in updating the eMAR when a medication was commenced, modified or discontinued. Inefficiencies resulted from nurses having to fax orders to the pharmacy whenever there was a medication change (even if medication supply was not required, as that was the only way for the eMAR to be updated), checking pharmacy-entered orders on the eMAR and sorting out discrepancies. Pharmacists spent considerable time maintaining the eMAR.

A survey of staff at 274 residential aged care facilities conducted by the Australian Commission on Safety and Quality in Healthcare in 2012 identified inefficiencies and safety risks with eMARs that are created from paper medication orders. Issues identified included multiple, potentially conflicting versions of medication charts, limited or no access to eMAR updates after-hours and weekends and lack of consolidated medicine prescribing and administration history. Recent research conducted by the Centre for Health Systems and Safety Research at the University of New South Wales has similarly reported issues around safety and workflow inefficiencies with eMARs in Australian residential aged care facilities.

It is likely that the benefits of electronic medication management in residential aged care will only be fully realised when systems are available that integrate all aspects of medication management, including prescribing, charting, ordering, dispensing and recording of medicine administration. There is evidence that e-prescribing systems, especially with in-built decision support, can enhance the safety and quality of prescribing, for example by ensuring complete and legible prescription orders and reducing some types of prescribing errors and adverse reactions.

A commercially developed beta version of an integrated e-prescribing-eMAR system was recently piloted at a Melbourne aged care facility and evaluated by the Centre for Medicine Use and Safety at Monash University, in a study published in the journal Applied Clinical Informatics. The system enabled prescribers’ electronic orders to directly populate the eMAR and to be automatically transmitted to the aged care facility’s pharmacy, thus eliminating the need for manual communication of medication orders and transcription of orders to create the eMAR.

Doctors could enter orders into the system from anywhere, using either a desktop computer or a mobile device to access the e-prescribing module. When doctors used the e-prescribing module to order medicines, nurses and pharmacists reported significant benefits in terms of both efficiency and safety. However, doctors did not consistently use the module (only 26 per cent of new medication orders were made via the e-prescribing module), so the hybrid paper-electronic system continued to be used for most orders.

The main reasons that prescribers continued to use paper medication orders were:

• To meet legislative and accreditation standards, the aged care facility needed a hard copy medication order with the prescriber’s handwritten signature, so if the doctor used the e-prescribing module to order a medicine a hard copy had to be printed and signed. Therefore, when doctors were at the aged care facility they found it faster to hand-write orders than to use the e-prescribing module.
• The e-prescribing module was not integrated with the doctors’ existing clinic software, so as well as using the e-prescribing module they had to enter the data into their own software at the clinic in order to generate a Pharmaceutical Benefits Scheme (PBS) prescription and update their prescribing record.
• Medication orders were often initiated by doctors other than the resident’s general practitioner (e.g. locums, specialists, palliative care services, hospitals), and these prescribers did not have access to the e-prescribing module.

These barriers to the use of e-prescribing need to be addressed in order to make integrated electronic medication management systems acceptable and effective. Prescribers should be able to enter a medication order just once and have that order populate the eMAR, generate a PBS prescription and update their clinic records. The order should be automatically transmitted to the aged care facility’s pharmacy and ideally auto-populate the pharmacist’s dispensing and packing systems (after review and verification by the pharmacist) in order to avoid the need for data transcription. There should be no need for a paper order.

There also needs to be well designed, well executed, independent research to evaluate the implementation of new electronic medication management systems, to determine whether intended benefits are realised and unintended consequences are avoided – for example, unfavourable effects on workflow or introduction of new types of errors.

In the meantime, it is important that aged care providers and their pharmacy service providers are aware of the limitations and risks associated with currently available medication management systems, and implement risk mitigation strategies to avoid harm that may result from medication errors.

Dr Rohan Elliott is senior aged care pharmacist at Austin Health and clinical senior lecturer at the Centre for Medicine Use and Safety at Monash University.

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