EPMA: WHAT

WORKS? Peter J Murphy

Consultant In Paediatric Anaesthesia

Clinical Lead EPMA UHBristol

CONTENT OF PRESENTATION

Secondary Care Prescribing

Why EPMA (current views)?

Medication errors

Prescribing Process (how and where EPMA works)

Evidence Base for EPMA

Why EPMA (the vision)?

WHY EPMA? (A). SAFETY

WHY EPMA (B).COST

Medication errors cost

the NHS up to £2.5bn a

year

“Primum non nocere”

Safety/Quality Agenda/commissioning (Never Events..including new expanded list)

Patient expectations/medico-legal

Staff expectations (Staff supportive of EPMA)

Potential shortfall in Nursing Numbers (especially senior nurses)

Less experienced junior doctors (WTD)

Secondary Care is becoming much more complex

Financial/resource issues (National and Local)

Population/demographic changes (aging population)

MEDICATION ERRORS

MEDICATION ERRORS IN CLINICAL

PRACTICE

High Incidence of low risk prescription errors (Chart not signed/ prescription illegible/ time of administration not ticked/ drug not available)….”low hanging fruit” which most ePrescribing Systems largely eliminate

Moderate Risk Issues (Missed drugs, significant drug interactions, incorrect doses in renal/hepatic failure etc,)

Low incidence of High Risk errors (administration errors/incorrect prescription and drug still given/wrong route administration/wrong patient/wrong drug/”picking” errors)

High risk

Critical Care

Maternity

Operating

Theatres

Accident and

Emergency

Care of the

Elderly

Mental Health

Paediatrics Oncology

Renal/Hepatology/Transplantation Neonates

High Risk Areas for Medication Errors

EPMA SYSTEM HAS TO BE SEEN TO WORK IN

TERMS OF TOTAL MEDICINES MANAGEMENT

PROCESS IN ORDER TO BE EFFECTIVE

Implementing EPMA should include;

EPMA Systems (esp in high risk areas)

Interface for TTO’s supporting patient discharge

Knowledge Support

Clinical Decision Support

Advanced Decision Support

Intra-operability with Other Clinical Systems (esp order comms/Pathology)

Support for Drug Administration

Networks and Hardware

WHERE EPMA SYSTEMS ACT TO IMPROVE SAFETY

VIA THE MEDICINES PROCESS

Current Process

Basic Knowledge

Support

Basic Decision

Support

Advanced Decision

Support/Interfaces

Easy-but little impact on clinical

safety

Difficult- but huge potential for

improving clinical

safety/outcome

Immediate

Improvements with

Basic System

Prescriber

Local Prescribing

Guidelines “on line”

Allows Formulary

Control and Cost Savings

Ensures

Legible/Complete/

Sensible

Prescription plus

Electronic

Signature and

Audit Trail

Prescription

Pharmacist

Intermediate decision

support

i.e. Drug Interactions

First Data Bank

software and updates

Knowledge

support (i.e.

BNF for

Children)

Availability of

locally produced

“Order Sentences

and Order Sets”

Basic Decision

Support

(Allergy Check)

Checks

Intra-operability with other Clinical Systems (Order

Comms) eg Renal Failure/ Meds needing Blood Levels

Calculations, weight

based prescribing and

dosage limits

Support for complex IV’s,

Medical Gases etc.

Integrating

Prescribing With

Care Bundles

Paper Chart

Intra-Operability

with other EPMA

systems (ICU,

Oncology)

Prescription

Checks

Pharmacist

Nurse Drug

Pharmacy

Supplies

Alerts Pharmacy

(Stock Control)

Knowledge Support/Local

Guidelines for preparing

drugs

Picking

Support

(PYXIS) and

Staff

Identification

Barcodes to ensure

correct drug has

been picked

Standardisation for

EPMA allows

standard infusions to

be produced in

pharmacy

EPMA System

highlights

missed/delayed doses

all drugs administered

have to be signed for

Drug Nurse/Doctor

2nd

Checker

Drug

administered to

Patient

“On Line” knowledge

Support for

administering

drugs/preparing

infusions/calculations

Bar-coded wrist

bands ensure

correct patient

Intelligent Infusion Devices

recognise bar-coded

infusions and calculate rate

of infusion/ confirm route of

admin etc.

PRESCRIBING INDICATORS STUDY EDELPHI

(COLLABORATION UHB AND UNIVERSITY OF

EDINBURGH/HARVARD)

Digoxin prescribed at a dose of >125 micrograms daily for a patient with heart failure who is in sinus rhythm (Increased risk of digoxin toxicity)

Thiazide diuretic prescribed for a patient with a history of gout (Increased risk of exacerbating symptoms in pre-existing gout)

Thiazide diuretics prescribed for a patient with eGFR <30mL/min/1.73m2 (Increased risk of side effects)

Amiodarone prescribed for a patient with abnormal thyroid function tests (TFTs) (Increased risk of thyroid disorders)

Beta-adrenoceptor blocking drug prescribed for a patient with serum potassium >5mmol/L (Increased risk of hyperkalaemia)

Non-selective beta-adrenoceptor blocking drug prescribed for a patient with asthma (Increased risk of bronchospasm and acute deterioration)

Aliskiren prescribed concomitantly with ACE inhibitors or angiotensin-II receptor antagonists (Increased risk of serious adverse cardiovascular and renal outcomes)

Aliskiren prescribed for a patient with an eGFR< 30ml/min/1.73m2 (Risk of hyperkalaemia)

Super advanced

decision support

IN SUMMARY

Most UK EPMA systems are very very basic. They significantly reduce medication errors (low hanging fruit) but do not exclude serious errors particularly around drug administration. They are not suitable for many high risk areas (paediatrics). Most systems will not interface with Order Comms/Pathology or indeed other EPMA systems. Therefore these systems are unlikely to show significant improvements in clinical outcomes.

They do give the Trust better control of the Hospital Formulary, and better drug audit capabilities and allow for improvements in drug error investigations.

Deployment of EPMA systems is expensive, and it is hard to see where and when cost savings envisaged by the tech fund are going to arise

SHOW ME THE EVIDENCE THAT

EPMA IMPROVES OUTCOMES

UH BIRMINGHAM DATA

DELAYED/MISSING MEDICATION DOSES IDENTIFIED VIA E-PRESCRIBING

AND HIGHLIGHTED VIA INTERFACE WITH CLINICAL DASHBOARDS

J R Soc Med Sh Rep 2012 .

WHY AM I STILL ENTHUSIASTIC?

EPMA represents the best (only) long term hope of reducing

medication errors in hospitals (aging population/junior staff etc).

We need to get basic EPMA systems in and working before gradually

building advanced EPMA Systems (advanced decision support, links to

other clinical systems and devices) which will significantly reduce errors

and improve clinical outcomes

PERSONALISED HEALTH

Pharmacogenetic research holds out the prospect of personalised

medical care in the future….in terms of medication this can only be

achieved with EPMA

PERSONALIZED (PRECISION) MEDICINE

Pharmacogenetics/Pharmacogenomics

the study of inherited genetic differences in drug metabolic pathways which

can affect individual responses to drugs, both in terms of therapeutic effect

as well as adverse effects

Pharmacogenetics and Asthma

Pharmacogenetics and Pain Therapy

Presonalising Treatment Strategies on Oncology Haematology

Personalised Immonosuppression

Pharmacogenetics of Cardiovascular and Diabetic Drugs

Personalised therapy for Metabolic Disorders

Genomics & Pharmacogenomics

September 21-23, 2015 San Antonio, USA

RECENT US NIH GRANTS

St Judes Children’s Research Hospital (July8th 2015) $12Milion

Precision Medicine for the treatment of Leukaemia

eMERGE program (1st Sept 2015) $48million

Linking the EHR to an individuals genome to enable personalised care

Vanderbilt University Phenome Scanning of EHR (1st Sept 2015) $12.8 Million

"Our goal is to understand the fundamental mechanisms putting patients at risk for severe adverse drug reactions and, more broadly, to predict how individual patients will respond to drug therapy,”

AREAS DEVELOPING

PERSONALISED/PRECISION THERAPY

Rheumatology

Oncology

Pain Medicine

HIV Therapy

Metabolic Disease/Diabetes

Treatment of Cardiovascular Disease

CODEINE

Widely used in Paediatric Practice

Codeine is metabolised in the liver by the enzyme CYP2D6 to its active ingredient Morphine

The CYP2D6 isoenzyme is polymorphic, with individuals classified according to one of four levels of activity: poor metabolisers, intermediate metabolisers, extensive metabolisers and ultrarapid metabolisers (URM). Individuals (1.7% Population) with duplication or multiduplication of the CYP2D6 gene are URM’s.

URM’s are more common among some ethnic groups. 29% of North African and Ethiopian populations are URM’s.

Codeine now banned in most

Paediatric Hospitals

Caution in Breast Feeding Mothers

EPMA WILL ENABLE

a scientific approach for individuals affected by adverse drug reactions

individuals to be given the drugs which will work best for them

Individuals to avoid drugs which will have side effects

clinicians to use the best drugs for particular types of disease in

particular individuals