Technology and Electronic Prescribing in Barnsley
Interviewee: Dominic Bullas (Chief Clinical Information Officer and Gastroenterologist – Barnsley Hospital NHS Foundation Trust)
The Outpatients Department at Barnsley Hospital NHS Foundation Trust has seen rapid progression in technology since the beginning of the COVID-19 pandemic. Infrastructures were put in place to ensure ease for staff including:
- Dual screens in all outpatients
- Upgraded broadband connection to 500GB
- Upgrade of the VMWare Horizon VDI environment.
- Paper-free phlebotomy
- Rapid implementation of accuRx and Microsoft Teams
- Development of an electronic prescribing platform
- All of the above completed while engaging in the implementation of a brand new EPR, Careflow (formerly Medway) by System C which went live in April
With a patient portal already in place, it was decided to re-engineer the platform using HTML 5 architecture ensuring additional functionality such as instant search and improved UI, and allowing greater resilience, security and performance. Conceptually the new design focused on distilling the workflow of a typical outpatient consultation into discrete domains of clinical activity, such as reference to electronic documentation, e-Outcomes, digital dictation and electronic prescribing so that they could be accessed in a stepwise fashion by the end-users.
Much work has been invested in the e-Prescribing platform within the new Patient Portal particularly with regards to enhanced layers of security to satisfy the legislative requirements for electronic prescribing. The premise is one of a secure e-form which is submitted from a Prescriber to the BHNFT Outpatient Dispensary using a bidirectional interface. None of this information crosses over into the public domain. In legal terms, the BHNFT Outpatient Dispensary is a wholly-owned subsidiary of Barnsley Hospital Foundation Trust.
Extra security was added to the system in the form of a virtual smartcard technology provided by Isosec, the use of which has been heavily promoted during the pandemic.
When a clinician accesses the electronic prescribing platform, a correct password allows an authorisation process to take place in real time during which NHS Spine is consulted to confirm the clinical role of the prescriber. If authorisation is granted, the prescriber may then access the system.
The actual form is simple in design and concept. Rudimentary demographic data is pre-populated on the form. The prescriber has to acknowledge the indication for the prescription, and then completes the prescription itself, defining the drug, dose, frequency and duration of treatment. The form is submitted to the Dispensary which has a dashboard for monitoring incoming prescriptions. The pharmacists have two options: to accept or reject the prescription. If a rejection notice is clicked, the pharmacist has to give a valid reason for the rejection, such as incorrect drug dose, possible drug interactions and stock issues. The prescriber can review the rejected prescription, make the necessary changes and re-submit the form.
The electronic prescribing platform at Barnsley Hospital has undergone multiple design and test cycles as one would expect of any clinical platform proposed for live deployment.
The development of the electronic prescribing platform required a close relationship between both the development team, the Pharmacy department and clinical staff. There was good engagement with the Pharmacy department throughout this process, meeting three times a week in the virtualised environment afforded by Microsoft Teams.
During the development phase, the Pharmacy Department raised concerns that the Isosec solution did not meet the requirements for an advanced electronic signature. Without their consent, the project could not continue, and remains in a state of suspended animation, awaiting final authorisation to proceed. This was despite consultation with national authorities on electronic prescribing who recommended that the project could continue with local endorsement by the Trust’s Executive, and the formal confirmation that the Trust would accept full responsibility for the use and maintenance of the platform.
The use of Microsoft Teams has been transformational for both clinical and non-clinical audiences at the hospital. Many MDTs (Multi-Disciplinary Teams) have transitioned to the platform for their ongoing clinical activities (such as the Xray MDT, IBD MDT and various cancer MDTs). Microsoft Teams has the performance and functionality to become the default MDT environment across the region.
AccuRx has an easy, intuitive and accessible web-based interface, making it the perfect medium for conducting video consultations with patients. It was particularly helpful in the Maternity Department so that pregnant mothers were not compelled to come into the hospital during the initial COVID-19 lockdown period. Other platforms were considered (such as Attend Anywhere), but accuRx seemed to be the best fit for the staff and patients.
Linking up with the Digital ICS has been a positive experience, as has giving interviews, such as this case study since it is about sharing good practice, collaboration with regional experts, and nuanced discussion about complicated matters of digital security and legal interpretation. Being in a virtualised space means being so much more direct and available.
It is imperative to have a common, shared goal that is consistent with the strategic vision of the Trust in all things digital. On a regional level, the Digital ICS has a vital role in ensuring that there are consistencies of approach between Trusts across the digital landscape. For instance, why does the OpenNet framework in ICE not link up all of the pathology departments in the region? Why can’t a BHNFT clinician who treats a patient from Huddersfield have access to the local pathology results, a lack of functionality that raises all sorts of questions about clinical safety?
The rudimentary document viewer built into the Patient Portal (v2) will be replaced by the implementation of MediViewer, a state of the art EDMS. Other post-EPR deployments over the next 12 to 18 months will include an EPMA solution and a centralised electronic handover platform (Careflow Connect).
Key Learning Points
- The legalese that surrounds an advanced electronic signature is a minefield, and one that is open to interpretation. Furthermore, there are considerable variances in practice across the region that mean that places such as Rotherham allow a simple electronic prescribing transaction to take place between the host EPMA (Meditech) and Lloyds Pharmacy with none of the layers of security in place that the BHNFT platform uses. That arrangement meets a level of technical and clinical assurance that is acceptable to the Rotherham Pharmacy Department and the respective Trust.
- Clinical engagement is the key to the development, implementation and rollout of any clinical platform. Even with the best digital platform in the world, a project will flounder without such engagement. In this particular case, the continuing use of the current paper-based prescribing system, with its inherent inefficiencies and inaccuracies (as many as 30% of all hand-written prescriptions are returned to the prescriber due to various errors, omissions or required corrections), has meant a delay in the safety and expediency of delivering vital treatments to patients at precisely the time when it is needed most.