Written by Joann Nesbitt
Hospitals throughout New Zealand are currently rolling out a new system called MedChart. MedChart is an electronic system, which will eventually override the paper-based system. This submission will focus on MedChart as an electronic medication management system, instead of the current system (paper charts).
There are many benefits in using MedChart compared to paper charts, including:
There are two recommendations in this submission. They are:
There is literature supporting the move to electronic prescribing tools such as MedChart. For example, one study focuses on how electronic prescribing effects adverse drug events and medication errors while another study concentrates on the quality of prescribing in regards to using an electronic prescribing system. I am supportive of the move to MedChart in our New Zealand hospitals as there is evidence that shows tools such as MedChart are effective in improving health care.
The following submission concentrates on MedChart and the effects it has on patients and staff in a hospital setting. It focuses on how nursing care is affected and the outcome for patients because of this. Recommendations are generated based on the literature provided below.
MedChart is an ‘electronic medication management (eMM) program’ (McDonald, 2012a, p.1), which is currently being trialed in hospitals all over the world, including Dunedin Public Hospital, Southern District Health Board. It is a computer-based system that has information on a patient’s medical history, allergies and current medical status/reason for their current hospital admission. There are many types of electronic prescribing (EP) software including MedChart. This system has been trialed in Dunedin Public Hospital’s two busiest medical wards since 2010 and is now in the roll out process with the hope that every hospital will being using the same system in New Zealand by 2014. Once accomplished, there will be a new roll out period where MedChart will reach communities, including General Practitioners and rest homes, in order to have everyone in healthcare using the same system (McDonald, 2012b). MedChart is not just an electronic prescribing tool; it is also intranet-based software that allows for electronic administration of medication to patients by Registered Nurses. Current legislation means electronic signatures are not yet legal practice in New Zealand under the Medicines Act 1981, however new legislation which was put forward in February 2012, ‘will change the wording of the 1981 Act to enable electronic signatures’ (McDonald, 2012b, p.1). ‘The team running the eMM system in Dunedin has been working under a special dispensation allowing electronic signatures to be used’ (McDonald, 2012b, p.1).
Time restraints, multiple patients, illegible handwriting on paper charts and other documentation, along with busy and lengthy shiftwork, can all lead to human error (DeLucia, Ott, & Palmieri, 2009). In the case of Registered Nurses administering medications under these conditions, medication errors due to illegible handwriting and other factors can lead to adverse drug events in patients, which can increase their length of stay at hospital or, worse case scenario, be fatal to a patient. James Rice, who is the Managing Director of iSOFT in New Zealand as well as Australia, stated “medication errors harm thousands of patients every year and consume precious healthcare resources” (iSOFT, 2011, p.2). These errors lead to an increase in hospital stay and the use of resources being preoccupied on a current patient to fix the error instead of exercising the resources on a new patient (iSOFT, 2011).
MedChart can help solve these issues as it has many benefits for everyone in the healthcare industry whether you are a patient, Registered Nurse, or a Doctor in any setting. MedChart helps to improve patient safety by decreasing adverse drug events and medication errors, which leads to an improvement of quality of care (CSC, 2013). It also improves efficiency in staff, as it is a faster way for Registered Nurses to accurately administer medication, therefore nursing staff will be spend fewer time seeking charts or translating illegible handwriting (iSOFT, 2011). This will mean nursing staff will have more time to devote to patients and will be able to focus on providing exceptional care (iSOFT, 2011).
Numerous studies have been completed over the last ten years on electronic prescribing. One of which was the study conducted in 2007 by Donyai et al., (2007) focused on how electronic prescribing affected the quality of prescribing. Donyai et al., (2007), suggested that while a mistake can happen at any phase of the drug-use practice, prescribing errors are at the top of the list in America and it is likely that the situation is comparable in the United Kingdom. Electronic prescribing has shown reduction in prescribing errors in hospitals in USA but the UK has a different way of prescribing (Donyai et al., 2007). For this study Donyai et al., (2007) defined a prescribing error as “a prescribing decision or prescription-writing process that results in an unintentional, significant: (i) reduction in the probability of treatment being timely and effective or (ii) increase in the risk of harm, when compared with generally accepted practice” (p.232). The results showed that there was a decrease in the number of errors made post-EP compared to pre-EP (Donyai et al., 2007). This study concluded that the EP system reduced errors in prescribing which enhanced the quality of prescribing (Donyai et al., 2007).
A study by Hsiesh et al., (2004) researched the effects of a “Computerized Physician Order Entry System” (p.482) (CPOE), which was the same system as MedChart. Hsiesh et al., (2004), found that CPOE is a significant instrument that health care organisations can apply to increase the safety of patients. This is because there is increasing evidence, which shows that the Computerized Physician Order Entry System reduces the incidence of medication faults in the inpatient situation (Hsiesh et al., 2004). It was also discovered that numerous benefits of CPOE resulted from the combined decision support tools, which included alarms when there was a concern regarding suitable medication treatment, and immediate warning for “drug-drug interactions and drug allergies” (Hsiesh et al., 2004, p.482). These support tools worked by checking patients’ treatment and sensitivity lists against the ordered medicines. The decision support then produced warnings that informed the physician of a likely aversion to the ordered medication (Hsiesh et al., 2004).
Another study was based on how electronic prescribing influenced avoidable and harmful drug incidents and medication errors (van Doormaal et al.,, 2009). Like Hsiesh et al,. (2004), van Doormaal et al., (2009) also looked into Computerized Physician Order Entry Systems. However, this study included basic Clinical Decision Support Systems (CDSS) to unearth how CDSS, when combined with a Computerized Physician Order Entry System, affected the frequency of unnecessary adverse drug events and medication inaccuracies (van Doormaal et al., 2009).
van Doormaal et al., (2009) recorded that the system being implemented was basic. The alarms were fairly straightforward and were only produced in the event of ‘drug-drug interactions, overdosing, and allergies’(van Doormaal et al., 2009, p.818). The study also verified that there were more advanced Clinical Decision Support Systems that did exist and performed further complicated tasks (e.g., adjusting for renal damage) (van Doormaal et al., 2009), however these systems were “still in an experimental stage” (van Doormaal et al., 2009, p.818). The results of this study uncovered that the average length of hospital stay diminished considerably following the implementation of the CPOE/CDSS system (van Doormaal et al., 2009). Also after implementing Computerized Physician Order Entry System and the Clinical Decision Support System there was an instant reduction in level and tendency of all errors in medication (van Doormaal et al., 2009). Finally, this study found that the major influence electronic prescribing had was on the quantity of administrative and technical errors (van Doormaal et al., 2009), which immediately reduced by 30%.
There was an earlier study, which was similar to that of van Doormaal et al., (2009). This study focused on the influence of electronic prescribing on medication inaccuracies and unwanted medication reactions (Ammenwerth, Schnell-Inderst, Machan, & Siebert, 2008). Ammenwerth et al,. (2008) exposed that electronic prescribing could significantly lower the possibility for errors in medication administration, which would decrease the chance of ADEs. The results indicated that electronic prescribing appeared to be a beneficial intervention for diminishing the threat of medication mistakes and adverse drug events (Ammenwerth et al., 2008).
Barber, Cornford and Klecun (2007) evaluated the attitudes towards the implementation of an electronic prescribing system. It was recognized that the majority of nurses felt uncertain towards the system in the beginning and were afraid to let go of old routines (e.g. having the drug chart at the end of the bed). The nurses also articulated that some were uneducated when it came to computers and feared that they would spend more time on the computers than with their patients (Barber et al., 2007). However, Barber et al., (2007) discovered, six to eighteen months since the electronic prescribing system had gone live, the attitudes within the nursing staff had changed. A staff nurse confided in Barber et al., (2007) that on a night shift electronic prescribing unquestionably helped. The nurse said it was faster and that there was a lower risk of error, especially as you are normally quite fatigued (Barber et al., 2007).
MedChart is an “electronic medication management (eMM) program” (McDonald, 2012a, p.1) being trialed in Dunedin Public Hospital, Southern District Health Board. It has been at this hospital where there has been a decrease in medication errors plus a rise in staff productivity (iSOFT, 2011). The two wards that were trialing MedChart reduced “incorrect or missing information from 82% to zero” (iSOFT, 2011, p.1). A study using electronic prescribing programs, one of them being MedChart, in an Australian hospital found that “wards using MedChart experienced a 57.5 per cent reduction in prescribing errors, harmful errors were reduced by an impressive 44 per cent” (McDonald, 2012a, p.1). The overall conclusion of this study resulted in prescribing errors reducing by over half while unfinished and vague medication orders were entirely eradicated (iSOFT, 2011).
MedChart has been described as being easy to use. Staff can now attain patient information easily at the bedside or through the Intranet, in place of trying to revise and decipher paper charts, which are handwritten (iSOFT, 2011). Also errors caused by scrawled handwriting have now disappeared due to electronic prescribing (Ammenwerth et al., 2008). MedChart has an extensive Clinical Decision Support System which includes functions such as ‘drug to allergy and intolerance warnings; drug to drug interactions; therapeutic duplication; pregnancy warnings; wrong dose – high, low, cumulative warnings’ (CSC, 2013, p.2) and many more. It also has an ‘offline chart backup facility’ (CSC, 2013, p.2), which guarantees patient information will always be obtainable, even in the case of the system failure (CSC, 2013). The offline chart backup facility makes sure there is an up to date copy of a patient’s notes on a nominated computer in the scheme (CSC, 2013).
The plan is to have eMM “installed in every hospital in the country” (McDonald, 2012b, p.4) and to develop “guidelines that can be mirrored in every hospital” (McDonald, 2012b, p.4). The New Zealand Universal List of Medicines (NZULM) group revealed to McDonald (2012b) that they were aware ‘there are different ways of prescribing medication that vary according to which hospital and which company you are purchasing from”’(p.4) so the NZULM’s plan is to ‘have a single list off descriptions of medicines and a single type of barcode that describes a medication right across the country’ (McDonald, 2012b, p.4).
· Rewrite the Medicines Act 1981 to enable electronic signatures.
In order for New Zealand to have effective health care nationwide through the use of MedChart, my recommendation is that the law be passed and electronic signatures become sufficient in New Zealand.
MedChart will create an environment where healthcare professionals are all working under the same guidelines, which will lead to patients getting improved treatment and care across the nation. By doing this a patient can move around within New Zealand and will still have a full medical history at their new General Practice or hospital in their new setting. Healthcare professionals will also be able to move without having to learn new ways of prescribing or new protocols for hospitals, as all hospitals will be run under the same guidelines throughout New Zealand. With this system in place, there will be an improvement in patient safety, quality of care and staff efficiency. There will also be shorter hospital stays due to the reduction in medication errors and adverse drug events.
In conclusion, it would be a wise move for healthcare providers to adapt to MedChart as it is proven to decrease adverse drug events and medication errors markedly. It also improves protection of the patient and the quality of care they receive, which is a priority for Registered Nurses and other healthcare professionals when providing care to their patients.
Ammenwerth, E., Schnell-Inderst, P., Machan, C., & Siebert, U. (2008). The Effect of Electronic
Prescribing on Medication Errors and Adverse Drug Events: A Systematic Review. Journal of the American Medical Informatics Association, 15(5), 585-600.
Barber, N., Cornford, T., & Klecun, E. (2007). Qualitative evaluation of an electronic prescribing and
administration system. BMJ Quality and Safety Health Care, 16(4), 271-278.
CSC (2013). iSOFT Medication Management (MedChart). Retrieved Thursday 21st March 2013 from:
DeLucia, P. R., Ott, T. E., & Palmieri, P. A. (2009). Performance in Nursing. Reviews of Human Factors
and Ergonomics, 5(1), 1-40. Retrieved Friday 12th April 2013 from: http://rev.sagepub.com/content/5/1/1.abstract
Donyai, P., O’Grady, K., Jacklin, A., Barber, N., & Dean Franklin, B. (2007). The effects of electronic
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Hsiesh, T. C., Kuperman, G. J., Jaggi, T., Hojnowski-Diaz, P., Fiskio, J., Williams, D. H., Bates, D. W., &
Gandhi, T. K. (2004). Characteristics and Consequences of Drug Allergy Alert Overrides in a Computerized Physician Order Entry System. Journal of the American Medical Informatics Association, 11(6), 482-491.
iSOFT. (2011). Decrease in medication errors at Dunedin Hospital after iSOFT Medication Management
Implementation. Retrieved Wednesday 27th March 2013 from: http://www.isofthealth.com/en-NZ/Solutions/ANZ%20Hospitals%20and%20Clinics/~/media/Files/AU%20files/Dunedin%20Meds%20Mgmt.ashx
McDonald, K. (2012a). NZ Expands MedChart Roll Out. Retrieved Tuesday 19th March 2013 from:
McDonald, K. (2012b). New Zealand Goes For Gold in Medication Management. Retrieved Tuesday 19th
March 2013 from:http://www.pulseitmagazine.com.au/index.php?option=com_content&view=article&id=1165:new-zealand-goes-for-gold-in-medications-management&catid=49:new-zealand-ehealth&Itemid=274
van Doormaal, J. E., van den Bemt, P. M. L. A., Zaal, R. J., Egberts, A. C. G., Lenderink, B. W., Kosterink,
J. G. W., Haaijer-Ruskamp, F. M., & Mol, P. G. M. (2009). The Influence that Electronic Prescribing Has on Medication Errors and Preventable Adverse Drug Events: an Interrupted Time-series Study. Journal of the American Medical Informatics Association, 16(6), 816-825.