Research in Social and Administrative Pharmacy j (2013) j–j

Original Research

Learning to work with electronic patient records and prescription charts: experiences and perceptions of hospital pharmacists Angela Burgin, M.Ed., Dip.Clin.Pharm., M.R.Pharm.S.a,b,*, Rebecca O’Rourke, Ph.D.c, Mary P. Tully, Ph.D.a,b a

Salford Royal NHS Foundation Trust, Salford, UK b University of Manchester, Manchester, UK c University of Leeds, Leeds, UK

Abstract Background: The use of electronic patient records (EPR) and electronic prescribing systems (such as electronic patient medication and administration records (EPMAR)) have many benefits. Changes and problems can result, however. Anecdotally, how pharmacists respond to system introduction varies greatly; there is very little information regarding pharmacists’ experience in the literature. Objectives: This study aimed to establish the changes that electronic systems afforded to hospital pharmacists’ working practices and to investigate how and why they had responded to EPR and EPMAR. Methods: Four semi-structured focus groups were conducted with pharmacists with different levels of seniority, with 4–6 participants in each. The focus groups were held 8 months after implementation of EPR and EPMAR were complete, and each focus group met once. Transcripts were analyzed manually using thematic analysis and data interpreted through the application of Actor Network Theory (ANT) and human activity systems as described in Engestrom’s Expansive Learning Theory (ELT). Results: The three main overarching themes identified involved reduced patient contact, professional representation in the clinical environment and documentation in the EPR. Pharmacists felt less visible to, and had poorer relationships with, patients as they no longer saw them when they checked prescriptions. Interprofessional relationships changed as pharmacists provided informal EPMAR training for doctors and spoke more often with nurses to relay important information. Changes in whether, what and how pharmacists recorded information also were seen, particularly between pharmacists of different generations and years of working at the hospital. Analysis of the changes afforded by electronic systems using ANT and ELT suggest that pharmacists develop individual working practices in response to changes that electronic systems provide. Conclusion: For implementation success of EPR and EPMAR systems, pharmacists need to be taught not just the practicalities of system use, but also how to ensure that patients remain the focus of care, in response to the professional changes that may well occur following computerization. Ó 2013 Elsevier Inc. All rights reserved.

* Corresponding author. Pharmacy Department, Salford Royal NHS Foundation Trust, Stott Lane, Salford M6 8HD, Tel.: þ44 (0)161 206 4209; fax: þ44 (0)161 206 4311. E-mail address: [email protected], [email protected] (A. Burgin). 1551-7411/$ - see front matter Ó 2013 Elsevier Inc. All rights reserved. http://dx.doi.org/10.1016/j.sapharm.2013.11.005

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Keywords: Electronic prescribing; Computerization; Pharmacist; Electronic patient record

Introduction Over the last 20 years, the UK Government has driven the implementation of electronic systems in health care with the aim of improving patient care.1,2 The established benefits of electronic patient records (EPR) are well documented, and include improved legibility, improved completion and identification of author, improved quality and completion of records, and increased accessibility.3,4 The benefits of electronic prescribing are a little more contested and difficult to assess due to the multiple changes offered by these systems. Although found to reduce the number of medication errors associated with paper prescription charts, they do not eliminate errors completely. Rather, they serve to change the type of error made.5–9 There are currently only a few hospitals in the UK that have both EPR and electronic prescribing and medicines administration record (EPMAR) systems in place. More hospitals are due to work toward implementing dual systems in the foreseeable future. The implementation of the electronic interface has been recognized as resulting in huge organizational change.10–12 Historically, research has explored the perceived benefits of information technology (IT) systems in health care using quantitative questionnaires.13,14 The reliability of this method of data collection maybe limited as questionnaires can be misinterpreted, rushed or the answers given may not be full truths.15 It is also difficult to see how this method of data collection can tease out the intricacies of the complex nature of IT in health care, which Berg and colleagues’ work on the sociotechnical aspects of these systems has highlighted.16–18 More recently, systematic reviews have identified some of the changes, and problems, that occur secondary to computerization and the social aspects of technology are being used to understand and interpret integration of these systems.4,19,20 Actor Network Theory (ANT)17,18,21,22 and Expansive Learning Theory (ELT),23 are educational theories which make it possible to consider the sociotechnical nature of patient medical notes and the electronic interface. ANT and ELT enable the exploration of what is happening within the interactions between humans and the electronic interface. The former explores the interaction between non-human and human entities, and the

resulting behaviors and links that occur, whilst the latter allows us to make sense of what is happening at the point of interaction. This can be further supported by workplace learning theory proposed by both Billet24 and Eraut.25 As human and non-human entities (actors) exist and interact, they produce a patterned ‘nodular’ network.26,27 As actors come together to form these nodules, they undergo the process of ‘translation’ which ultimately results in ordered re-organization, sometimes with unexpected outcomes.19,22,26 The process of translation can vary between actors and can be affected by, for example, politics, individual differences and experiences. To understand what is happening at the translation process (i.e., a network nodule), it is useful to employ Engestrom’s ELT, which considers human activity systems as part of activity theory (see Fig. 1).23 The activity system can be applied to the pharmaceutical care model where, for example, the patient can be considered the ‘object,’ the ‘subject’ is the pharmacist and the ‘instrument’ is the medical notes or prescription chart. The ‘outcome’ would represent the delivery of pharmaceutical care to the patient. “Contradictions,” or tensions, can be found within activity systems, particularly if a new element is introduced (such as a new instrument in the form of an electronic prescription chart) to an activity system. When a contradiction is present, transformation of an activity system can occur which may result in changes to outcome and ultimately changes in the activity. Applying the pharmaceutical care model and pharmacist practice to the human activity system described by Engestrom provides a means of interpreting the forces at play within this complex scenario.23 As the pharmaceutical care model seemed to fit to the activity system, it was felt that using a combination of this, and ANT would provide understanding of why pharmacists work practices had changed. Anecdotally, the way pharmacists respond to the introduction of electronic systems varies greatly but there is very little information regarding this in the literature. As hospitals move toward the introduction of the electronic interface, an understanding of the impact of these systems on working practices is essential for successful implementation. This study aimed to establish the changes that electronic systems afforded to pharmacist’s work

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Fig. 1. Structure of a human activity system.24(p55)

practices, and to understand how and why pharmacists in a large UK teaching hospital had responded to these changes. These insights could then inform training and support for pharmacists through such changes in the future. Methods Study design and participants As little was known about the perceptions and experiences of pharmacists using electronic systems, a qualitative approach was used for this study through semi-structured focus groups. Focus groups were chosen as opposed to other methods of data collection as this method allows the researcher to ask questions and direct the conversation, as well as enabling the development, exploration and clarification of ideas within a group of like-minded people.28–30 This was considered essential to help tease out the intricacies of how the computer systems were used in practice. The hospital where the study took place is a large acute NHS teaching hospital. The hospital has both medical and surgical specialities including cardiology, renal medicine, intensive care, urology, respiratory medicine, emergency medicine, elderly care and stroke services. The hospital is also a tertiary referral center for clinical specialities such as neurology, dermatology, intestinal failure and some cancer services. Patients are admitted to hospital either through Accident and Emergency (A&E), or are referred by their General Practitioner (GP) or other hospitals. At the time of data collection, EPR had been in use for 3 years, and EPMAR had been implemented hospital-wide for 8 months. All pharmacists (34 in total) who used the EPR and EPMAR systems on a regular basis were invited to take

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part in the focus groups. The participants were work colleagues of the study investigator. One person was excluded from the study as they were line managed by the study investigator. This was to remove any coercion and bias that may have arisen from the working relationship. Pharmacists were initially contacted by e-mail explaining the purpose of the study. This was followed up with a further e-mail requesting those who intended to participate to register. A total of 22 pharmacists responded to the e-mail contact, of which 20 took part in the study. Two pharmacists could not attend the focus groups as scheduled. Most pharmacists had worked in the hospital for at least a year and were able to compare their experiences of using the electronic systems to previous paper based systems. See Text box 1 for a description of working practice before and after electronic implementation. Each focus group had 4–6 participants. The demographics of each focus group are shown in Table 1. Each group contained pharmacists of similar levels of seniority, categorized by their Agenda for Change (AfC) band.31 The NHS uses this banding system for grading and payment of all NHS staff nationally, except doctors and dentists. Within the AfC groups 8a and 8b/c, there was a wide variety of experience as the age range of pharmacists within these groups was quite large. Grouping participants in their AfC bands removed any hierarchal bias from the focus group and allowed group members to connect with each other, share common experiences, and establish and draw upon cultures within each group.29,30 The study received ethical approval from the University of Leeds. Data collection Prior to data collection, overarching topics were identified from both the literature and informal discussion with users of the electronic systems.3,10,32 The topics listed below provided some structure for the focus group discussion schedule shown in Appendix 1:  changes in work practice/workflow  perceived skill set required to use the electronic interface  use of the electronic interface  communication networks. The focus groups were conducted during working hours over lunch. Each lasted approximately 90 min. At the start of each focus group, ground rules were agreed and set. The discussion schedule

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Text box 1 Summary of changes to pharmacists’ working practices before and after electronic implementation Task

Before implementation

After implementation

Medication request

- Paper prescription charts frequently received in pharmacy from wards for ad hoc requests. - Pharmacist needs to be physically in the same location as the prescription chart. - Prescriptions clinically checked for appropriateness. - Clinical check includes: Dose, frequency, interactions, allergies, adherence to formulary/guidelines. - Blood results available if needed. - EPR enabled remote review of patient notes. - Order transcribed to appropriate order form. - Item dispensed.

- Ad hoc requests to the pharmacy minimal since EPMAR except at weekends. - Weekday item requests directed to a member of pharmacy team regardless of geographic location. - All patient information instantly available for clinical check. - Electronic clinical check undertaken (can be done remotely). - Order sent electronically to pharmacy printer. - Item dispensed.

Prescription review

- Prescription charts located at patient bedside. - Prescription review undertaken at patient bedside. - Clinical check involves above but also a conversations with the patient and relevant staff if appropriate. - Prescription errors discussed with and amended by doctor. - Pharmacist annotates a clinical check on the prescription in green ink (initials and date). - Additional medicines information annotated in green ink.

- Prescription charts located on computers. - Prescription review rarely undertaken at patient bedside. - The electronic pharmacist clinical check not readily visible to other staff. - Additional medicines information not readily visible, therefore not entered. - Additional medicines information relayed verbally. - Prescription errors discussed with and amended by doctor (sometimes remotely).

Monitoring

Monitoring - Almost all information available within EPR/EPMAR.

- Observation charts available at patient bedside. - Blood results available on computer. - Other patient information in paper records stored in ward offices. Documentation in patient records

- Pharmacists rarely wrote in paper patient records. - Information often written on patient prescription charts.

was used during each focus group as a prompt if topics were not covered. The focus groups were digitally recorded and transcribed verbatim. Data analysis The focus groups were conducted at 1–2 weekly intervals. This allowed time for the study investigator to complete the verbatim transcription, read and then discuss the content with the co-authors. Thematic analysis was conducted

- Nearly all pharmacists noted an increase in note entry. - Limited information added to electronic prescriptions.

using the discussion schedule and pre-identified topics for coding and then categorization of the data. Parts of the transcript were copied and pasted into individual category documents. For example, one identified category was ‘skills required for electronic systems.’ This category included codes such as ‘perceived skills required,’ ‘development/learning of skill set’ and ‘further learning required.’ However, new themes emerged as the data were discussed and analyzed.

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Table 1 Focus group demographics AfC band Descriptor of pharmacist role21 groupa

Number of Range of participants age of participants (years)

Range of Range of dual Range of length qualification electronic system of service at duration use (months)b hospital (years) (years)

6

6

22–25

2–3

6–24

0.5–3

4

25–28

3–5

4–24

2–5

6

26–45

6–28

5–24

1.5–18

4

33–47

11–25

3–14

1–25

7

8a

8b/c

First 3 years of career. Provides pharmacy service, undertakes risk management and ensures compliance with medicines legislation. Rotates around clinical specialities. Completes post graduate clinical diploma. Provides specialist pharmacy service. Will have set departmental responsibility. Usually qualified 4þ years. Will lead and deliver specialist pharmacy service. Will have some directorate and budgeting responsibility. Highly specialized within clinical field. Overall directorate/budgeting responsibility. Managerial responsibilities.

a The AfC banding system is used for grading and payment of all NHS staff except doctors and dentists. National job profiles were designed for each grade, in each profession, to ensure equity of pay for staff in comparable positions across all organizations. b The EPR system has been used hospital wide since 2006 and EPMAR since 2010. The EPMAR programme was initially piloted and rolled out within the medical directorate from 2008.

There were clear themes from each AfC banded focus group, but also within generations (pharmacists of a similar age) across AfC groups, e.g., the skill set obtained to use the system and how this has developed was very different between pharmacists of different ages. The generational data were explored using a matrix. The discussion of data in between focus groups allowed for exploration of variations between each group. The discussion schedule was updated to explore/clarify the identified differences. Consistency of themes between focus groups was scrutinized and the content of identified themes reviewed in line with current literature to ensure bias was minimized. Quotations were selected and coded to illustrate themes, and were discussed and then agreed with co-author MT. Pharmacists are identified

according to their focus group AfC band, and their allocated participant number. For example, band 8b/c, pharmacist 1 relates to pharmacist number 1 in the AfC band 8b/c focus group. An ellipse (.) was used to indicate the removal of extraneous material in the quote. Results Analysis of the data identified three main overarching themes: reduced patient contact, documentation in EPR and professional representation in the clinical environment. Reduced patient contact The strongest theme that emerged during each focus group was the dissatisfaction of pharmacists

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with the reduced patient contact that occurred subsequent to the implementation of EPMAR. When paper prescription charts were in use, pharmacists visited the patient bedside daily. With prescription charts now on the computer system, which are not, except in critical care areas, readily available by the patient beds, this no longer occurred. This was a significant change to the way most pharmacists organized their daily tasks, and utilized different processes to those in use pre-implementation. Most pharmacists described now doing some of their clinical work in the department, or in ward offices, before visiting the patient area. Pharmacists felt that they only saw patients on admission to undertake a medicines reconciliation (MR), if a new medicine had been prescribed, and/or on discharge when completing the discharge prescription. If pharmacists “inherited” a patient from another ward who already had an MR done, a visit to that patient usually occurred only if necessary to address problems. All pharmacists felt that this lack of patient contact has resulted in overall poorer relationships with patients. “No, but some days you wouldn’t have actually, you’d’ve talked to them about the headlines in The Sun [newspaper] and not their medicines, but that still built up that relationship.” (Band 8b/c, pharmacist 2)

Pharmacists also felt that the lack of regular patient contact during an inpatient stay meant that they did not pick up on the subtleties of medication side effects and patient compliance from casual conversation. “Whereas before go round every day and pick up little things that they say as you go round, just in chatting, “Oh, what’s this rash” [laugh] and you find out they’ve just started a medicine and you know, you don’t, I don’t think you pick that up that kinda thing.” (Band 8b/c, pharmacist 4)

This reduction in patient contact was seen across all AfC bands to be damaging to the pharmacist’s profile and the pharmacist–patient relationship. “[participant feels]. that they (the patient) don’t know what I’m doing, and they don’t see the relevance of me.” (Band 7, pharmacist 2)

“We’re almost going back to behind the counter. Pharmacists in the background.” (Band 8b/c, pharmacist 4)

Some pharmacists described actively trying to increase patient contact by taking portable computers to the end of patient’s beds and reviewing the prescription charts there. Due to the lack of working hardware, and the increased time this took, most pharmacists did not feel that this was a feasible solution. Others described ‘popping their heads into the bay and chatting to patients generally’ as something they tried to do at least on a weekly basis. During this discussion, however, younger pharmacists said that they did not always have time to do this, and that they “felt stupid” doing it. Some of the ‘older’ pharmacists continued to use this method of increasing patient contact. Removal of the paper prescription chart from the end of the patient’s bed had resulted in removal of the physical and social link between the pharmacist and the patient. Combined with remote information access, discussions within the focus groups implied that pharmacists now had a choice whether to see the patient or not. Prior to electronic implementation, this choice did not exist. Now, some pharmacists were choosing to complete other tasks as a priority when faced with time pressures and the increased time required to complete electronic pharmacy related activities. Documentation in electronic patient records Prior to electronic implementation, all pharmacists reported they rarely wrote in the patients paper medical records. Historically, pharmacists would write notes on the paper prescription charts about, for example, changes in medication doses or omissions of medicines due to changes in clinical state on admission. This was either on the prescription itself, or in the ‘pharmacy communication’ box on the front of the paper chart. This was often done to provide rapid access to information for other pharmacists and health care professionals (HCPs) during the time of paper patient records. Additional required information may not have always been accessible if the pharmacist and the paper prescription chart were in the dispensary, or when a patient and their paper notes were in the radiological department, for example. All pharmacists, except the 8b/c pharmacists, felt that they entered clinical notes

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in the electronic patient records (EPR) much more than they would have done with paper notes. There was a consensus amongst all groups that what and how much pharmacists wrote in EPR varied greatly between individuals and also AfC bands. It was felt that entering a clinical note on EPR was much easier than with the paper-based system due to differences in viewing, the instant accessibility of patient notes and, for some, handwriting issues. Senior pharmacists described viewing notes entered by all HCPs chronologically. This behavior mimics practices using the paper based systems. However, a band 6 pharmacist explained how changing the viewing screen of EPR clinical note entries meant that they felt more comfortable about making note entries, as it would be sorted and viewed with other notes written by pharmacists. “. you can change the view. it’s also another thing with me. I actually break up my clinical notes into discipline so I’ve got all the Doctor’s notes together, I’ve got all the pharmacists’ notes together. So again, that’s like another physical, er not physical, psychological kind ov, erm, you’re removed from it another degree. You’re removed from erm paper notes another degree by being able to separate it out again. So that’s another reason probably why I’m a bit freer with my, my clinical notes.” (Band 6, pharmacist 6)

Handwriting was considered more laborintensive by younger members of the focus groups, and the inability to type well and quickly was considered a problem by the AfC 8b/c focus group and older members of the AfC 8a group. This was in the context of time pressures and the potential of typing errors. The more “definitive” nature of electronic notes and the shadow of litigation were also considered an encouragement by some pharmacists to enter notes electronically. “[Electronic notes] . feel a lot more definite now compared to paper. . Considering legalities, it’s a definite document. You can’t, you know, you can’t lose a bit of paper [from patient records] like, before you used to have the paper notes and bits would be flying everywhere, an‘ there’d be a bit shoved in other people’s notes that, you know it’s, but, it’s a lot more definite now.” (Band 8b/c, pharmacist 4)

Pharmacists described being extremely aware of making sure that ‘they cover their backs.’

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“The main driver is, if you don’t document it, it didn’t happen.” (Band 6, pharmacist 6) “And then in terms of defensible documentation, like you say, safety issues protect yourself, know that you’ve had a conversation, whether they’ve done it or not, especially if it’s a safety issue, then you want to know it’s there, because, yes, they might not look at it the next 3 days, but if it turns up in court your note is there, and it’s very clear.” (Band 8b/c, pharmacist 3)

Changes in culture, linked to different generations amongst pharmacists, were seen as a possible reason for increases in note entry. “I think with our electronic system, we’re all so like, savvy with it and we’re all so like, you know, we’re all fine about writing in the notes. And I think, not to discriminate, I think some of the older members of the team are, when it first came on, when it first came up weren’t writing in the notes as much because they thought ‘oh we really don’t do that.’ Because they’re used to the notes where they didn’t really write in the notes as much. And I think now, the younger pharmacists coming through. are more happy to write in the notes.” (Band 7, pharmacist 2)

Pharmacists described EPR as feeling more like a shared record and thus considered it ‘less intimidating’ when entering notes as all HCPs now write in EPR. In addition, all patient information, including the prescription chart, was now in a single location, and pharmacists felt it was more appropriate to put prescribing issues into EPR. “I find. that clinical notes are all encompassing, isn’t it? And it is very generic and you can put anything in there, any error or issue that you’ve got. Whereas I used to feel with the paper notes [Interruption – Band 8a, pharmacist 6, “it’s just for doctors”] you wouldn’t really, I would write in paper notes but I wouldn’t sort of say ‘this dose is wrong’ and ‘maybe we should look about doing this. . the paper charts used to be at the end of patients’ beds, and the notes would be in the note’s trolley in a different location it, it wasn’t always logical to write things that they’d missed, or wrong doses in the notes, when it wasn’t with the drug charts.” (Band 8a, pharmacist 3)

One of the main concerns of the 8b/c pharmacist group was not only the quantity of notes

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entered by junior pharmacists, but also the way in which items were documented. It was felt that the clinical note entry was at times being used in preference to verbal communication with other members of the health care team, and that the content and tone of the note entry was sometimes considered inappropriate. The 8b/c pharmacist group felt that they rarely needed to document information in patient notes as they would speak to the doctors concerned instead and resolve problems that way. There was often reference to the ‘twitter generation’ when the 8b/c group were discussing practices of junior members of staff. Pharmacist 1: “. just brief statements, and you write it down, almost like a, like a blog. You know, rather than, whereas in the past, like you say, you would have Pharmacist 3: written some kind of structured document. Pharmacist 1: It’s just a random selection of statements.” (Band 8b/c)

Preferences for written rather than verbal communication were discussed with reference to some instances where more junior pharmacists had entered clinical notes on EPR without speaking to doctors directly. After entering a note, it was reported that often no further attempts were made at following up the problems which were then left unresolved. This was considered to be due to ease of note entry and also possibly pharmacists’ lack of confidence at approaching members of the medical team. “Well, you know, it that that’s what I mean. It’s very easy for people to say, ‘I’ve washed myself of responsibility with this now, I’ve put it in the notes that this needs to be reviewed,’ whether it gets reviewed or not.” (Band 7, pharmacist 1) “Maybe it’s [clinical note entry] too easy! And it stops you from, because you can just write it, it stops you from physically talking. Whereas if you were scared to write it in the notes, you would have to go and say it to somebody’s face wouldn’t you?” (Band 6, pharmacist 2)

Professional representation in the clinical environment It is common practice for pharmacists throughout the UK to annotate clinical checks,

amendments, additional medicine information, etc, on paper prescription charts. Prior to electronic prescribing, the convention was to undertake this activity with a green pen. The paper prescription chart and the green pen were felt pivotal to the pharmacist’s day-to-day work and their professional representation. The green pen was always distinguishable from any other HCP’s entry onto the prescription chart, and nurses and doctors would always know that a pharmacist had given that prescription the ‘safety stamp.’ The green pen was something that had power in the ward environment. Pharmacists were able to make certain amendments on prescription charts and were able to communicate important information in a place that was recognized as being the pharmacists’ domain. This has now changed. Once implemented, the EPMAR began to raise questions as to how pharmacists were going to communicate their messages with doctors and nurses. “. I guess how it’s gonna work with communicating with doctors ‘cos of notes and, erm, how, you know, what do we put on there? What do we not put on there? . How’s it get, you know, you used to get going round with your green pen. and scrawling all over it and changing stuff. How’s that work, in practice, I guess, legally. Erm, and also professionally?” (Band 8b/c, pharmacist 4)

Pharmacists felt that they now documented a lot less on EPMAR, as opposed to the EPR, as the majority of the information they would have originally added to paper prescription charts (such as special administration instructions) was already built into the electronic prescription. Additionally, it was a quirk of the EPMAR that there was nothing visible to say that a pharmacist has clinically checked the prescription. Any additional information that was added by the pharmacist was also not easy to see unless the user hovered the cursor over the prescription. Because of this, the consensus from all focus groups was that now it was pointless documenting information in the EPMAR as a lot of this information was not read. “What the nurses say is ‘well whenever we saw anything in green we knew it had been written by the pharmacist so we’d pay some attention to it’. Now of course it’s just in black and white text. . So, I’m not sure, and I don’t know what people’s opinion is, maybe that nurses pay less attention to the stuff that pharmacists write.”

Burgin et al. / Research in Social and Administrative Pharmacy j (2013) 1–15 (Band 8b/c, pharmacist 1) “. I mean, I’d like to think that nurses also looked at it [notes on EPMAR], cause I do write some things on there for nurses, but they don’t. . [I know they don’t read it as] they don’t do what I ask them to do, in the bluntest terms.” (Band 6, pharmacist 6)

Furthermore, pharmacists have observed that due to lack of availability and ease of reading, doctors did not view the EPMAR as frequently on ward rounds as they did when using paper prescription charts. If a computer was available on the ward round, the junior doctor would use it to enter the clinical note from the ward round on the EPR rather than to look at the EPMAR. “I just think though generally doctors don’t look at the drugs as much as they used to on drug [paper] charts. I know [now] on the post-take ward rounds they hardly look at drug [electronic] charts.” (Band 8a, pharmacist 2)

As the discussions around the removal of the paper prescription chart, and the reduction in annotation on EPMAR continued, one pharmacist began to question their role, “Yeah, and like, if we like got a different culture to all the other hospitals who don’t have this [electronic prescribing], I don’t know. I don’t know what, like what are we supposed to be doing? [Laughs] We need to know really. We need to be told this is the definition of what a clinical pharmacist at this hospital does.” (Band 7, pharmacist 2)

Whilst pharmacists felt that EPMAR had unexpectedly resulted in the loss of their professional profile generally within the clinical environment, it was felt that overall their relationships and professional standing with doctors had increased significantly. However, this was attributed to doctors contacting all pharmacists more with queries around the intricacies of using the EPMAR. Pharmacists described adopting a new IT training role on the wards. “Another thing is, the doctors often have to ask you how to prescribe things. So even with that kind of increased interaction, they get to know you a bit more as well. So you’ve got more, you know, interaction with the doctors just by teaching them how to use the system.” (Band 7, pharmacist 1)

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The junior pharmacists felt that although their interaction with consultants had increased as a consequence of technical queries, they found these interactions did also often lead to conversations about prescribing. “I actually know the consultants better, on a medical ward, now from this, from that prompt of them asking me how to actually do something [on the EPMAR system]. It opens up the door for you to discuss other issues, you know, once you’ve got your foot in the door, you can also say: ‘Oh by the way I notice with that patient, or another patient, this little scenario here.’” (Band 6, pharmacist 6)

In addition to this, as all health care professionals work now has to be entered onto a computer, the accessibility of hardware has also resulted in increased interaction with medical staff. “I find that actually I speak to the doctors a bit more. because your sat in the doctor’s office on their computer while they’re on the computer next to you .. You spend most of your ward visit, apart from doing TTOs [a patient’s discharge prescription] and drug histories, sitting next to the doctors, and you’re constantly discussing what’s going on. So actually, that’s been a huge benefit and I never really thought that until now [laughs].” (Band 7, pharmacist 2)

Discussion The introduction of both EPR and EPMAR systems resulted in multiple changes to the way in which pharmacists practice. In general, all pharmacists regarded the electronic systems in a very positive light, but saw significant changes in patient contact, documentation practices and their professional profile within the clinical environment. It is documented elsewhere that IT in health care results in changes in human information processing,11 practices of recording10 and also changes in communication methods which leads to subsequent changes in behavior.12,18,33 Engestrom’s human activity system (Fig. 1), and ANT were both useful tools providing ways of understanding what was happening as pharmacists learned to work with these new tools in the clinical environment.21,23 Engestrom’s theory allows us to understand the forces at play within

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individual activity systems and illustrates how the introduction of EPR and EPMAR resulted in what Engestrom terms an “aggravated secondary contradiction,” where the new elements collide with ‘old’ elements of the activity system. “Such contradictions generate disturbances and conflicts, but also innovative attempts to change the activity.”14(p57)

As human beings, our prior knowledge and experiences are very different and when a single new element is introduced to individual activity systems, interpretation and incorporation of that element is also likely to be different resulting in differences in individual practice and also outcome. ANT allows interpretation of activity systems within the wider network of the clinical environment and the hospital. Examples of such innovations in work practice were attempted as some pharmacists tried to adapt their practice to maintain frequent patient contact. Due to the introduction of a new instrument (electronic prescription chart) the structure of the activity system in this context has undergone an expansive transformation which has resulted in significant changes to ways of working. Prior to electronic implementation, the pharmacist’s work was very prescription-focused. Without the paper prescription chart, it seems that some, particularly younger, pharmacists, are a little lost with how to approach patients. The lack of a physical prompt has resulted in what some described as difficulties in building the pharmacist–patient relationship. The older, more senior pharmacists felt that the lack of paper prescription chart had not affected their approach to patients, although they felt that since the introduction of EPMAR, they did not seem to see patients as much. The patient, rather than the IT, needs to remain the focus of care; and work practices, and therefore the training to underpin changes in IT needs to be adapted to support this emphasis. This could be in the form of guidance through a new patient care model, or through departmental policies which incorporate expected minimum standards on how and when to approach patients. Support for more junior members of staff through enhanced communication skills training, and shadowing of ‘older’ pharmacists to observe how to approach patients, may improve patient relationship building for pharmacists with limited previous experience to draw upon. The differences in ways in which pharmacists interact with the electronic systems has resulted in

significant differences in pharmacists’ documentation practices. The flexibility of the electronic system now means that people have the ability to choose the type of information that they view, and how they view it. The capability of a system to do this is supported by the work of Winman and Rystedt who explain that for system success within institutions, staff need to have the ability to “.transform information into professionally relevant knowledge” to allow them to undertake their daily tasks.34(p59) Whilst pharmacists seem able to use the system to retrieve the information that they need, this flexibility, availability and ease of use has had an additional effect on some. The reasons for not frequently documenting in paper patient records were discussed by all focus groups. These reasons for this were varied and mirror those described by Francis et al35 and Pullinger and Franklin.36 With the implementation of EPR, the younger, junior pharmacists described feeling more able and freer to enter electronic notes than with paper records, whilst the older pharmacists explained that the number of clinical note entries they made had not really changed with the electronic system, stating that they preferred to use verbal rather than written forms of communication. This was in part due to older pharmacists feeling less equipped with computer skills than the junior pharmacists. Now that the paper chart has gone, some pharmacists feel that the EPR is a more appropriate place to enter medication-related problems than the EPMAR and they subsequently document a lot of information, more frequently. Implementation of the electronic systems has resulted in the physical focus of the pharmacist’s work (i.e., the electronic replacement of the paper prescription chart) becoming less visible in the clinical environment. As a result, one junior pharmacist began to question their role and seemed unsure of what they should be doing now. Professional practice of pharmacists is usually developed during the pre-registration training year and the first few years of a pharmacist’s career. The implementation of electronic prescribing systems has changed workflow and pharmacist practice so dramatically that those who have limited or no prior experience of paper systems have struggled to develop the skills necessary to undertake patient-centered care. More support, training and guidance would help newer pharmacists to develop patient-centered approaches with this type of environment. Pharmacists have tried to adapt and have adopted behaviors to

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compensate for their reduced professional representation within the workplace. They have attempted to increase their ‘presence’ and get their message across, some by documenting more in the EPR. The new training role that pharmacists have adopted has resulted in a change in agency. Through a change in agency, the pharmacist becomes an essential actor in the network to help doctors with prescribing, they become enrolled into the network; which Fenwick et al describe as a “ process whereby they become engaged in new identities and behaviors.”26(p100)

Whilst this change in role can be seen as a positive, the increase in responsibility has meant that helping with prescribing tasks has become more time consuming for pharmacists. Prior to the introduction of the electronic interface, all pharmacists were given training on how to physically use both EPR and EPMAR. Billet and Eraut discuss learning through work and how the introduction of new work tasks results in an extension of what is already known to produce new learning.24,25 All pharmacists explained that they had learned to ‘use the system mainly through trial and error in practice as situations arose.’ This seems to be reflected in the characteristics that Eraut uses to define informal learning in the work place, where learning is: “Implicit, unintended, opportunistic and unstructured. [with the] . absence of a teacher.”25(p250)

Considering how pharmacists learned to use the system by working with it in the here and now, with reference to situations and knowledge from the past, the typology of informal learning discussed by Eraut and Billet goes some way to explain the differences between individual pharmacists, and also between junior and older, senior pharmacists, in their interpretation and use of the systems within the clinical setting.24,25 Drawing on previous knowledge and experiences has resulted in multiple changes in practice with various outcomes. It is a limitation of this study that at the time of data collection, there were many other changes occurring within the NHS and within the hospital, which may also have affected how pharmacists worked with a new system. During the rollout of electronic prescribing, there was a change in national government. Decisions made by the new government resulted in significant changes in NHS structure and a 5% budget cut across all areas. This contributed to a loss of pharmacy staff, and a

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change in priorities and workflow. As such, pharmacists had less time and additional pressures to contend with during this time of change. This study, however, afforded excellent application of both ANT and ELT, allowing for a fuller understanding of what changes occurred, and why, for pharmacists using electronic notes and prescription charts. This will be invaluable for hospitals undergoing similar transitions in the future, and should help inform additional training and support to aid a smoother introduction of such systems. A further limitation was that whilst recruitment of participants was high, all participants knew each other, and also knew the principal researcher who was conducting the focus groups. This knowledge proved advantageous during the focus groups as they were comfortable with each other. However, this may have stifled some of the criticisms of the electronic system and how it was used, if it involved another group participant. Additionally, as the principal researcher was more senior than participants in three of the four focus groups, this may also have affected the content of the discussion. The principal researcher was also a user of the electronic system. This could have biased the focus for analysis of the data as ideas on changes, and potential causes of differences in how the systems were being used, may have been formulated prior to data collection. To aid a smoother transition for implementation of electronic systems, guidance and support on how to use the electronic system and incorporate it into daily practice needs to be made much more explicit to pharmacists. Removal of the paper prescription chart has meant removal of the physical activity focus of a pharmacist’s work. This provided a physical link between the pharmacist and the patient. Development of a clear patient-focused practice model, which has defined functions for the pharmacist, would guide pharmacists going through the transition from paper to electronic systems. This would ensure that the focus of their work remained the patient and not the computer. Negotiation and communication skills training and support, particularly for more junior pharmacists, would help develop confidence in this group of staff to ensure that they were able to build rapport with patients and not avoid difficult discussions with doctors. Clearer guidance on clinical note-writing was identified by pharmacists as essential to aid them in their documentation practices. Guidance on both when to enter clinical notes, and also how to do this would aid and support pharmacists. Referring

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to Engestrom’s activity system in Fig. 1, offering more guidance to individual activity systems, i.e., the provision of rules to a changing activity system, would go some way to supporting pharmacists through such innovative times. Conclusion There are clear benefits to the implementation of IT in health care, but the changes that such systems bring should not be underestimated. The results of this study show explicitly the anticipated and unanticipated changes to hospital pharmacists’ professional working practices, relationships and communication networks following the introduction of the electronic interface. Pharmacists’ work practices have changed in a variety of ways, with the main changes affecting patient contact, documentation in clinical notes and professional representation in the clinical environment. All of these changes are extremely significant to individuals and the profession. Using ANT and activity theory, it was observed that for implementation to be successful, pharmacists need to be taught more than the practicalities of the system. Clearly defined practice models should be developed that incorporate the electronic systems, but ensure that patients remain the focus of care. Training and support on verbal communication and negotiation would help develop junior pharmacists to improve confidence and relationship building with patients and doctors, and structured guidance on clinical documentation would ensure that the privilege of pharmacist clinical note entry was used appropriately. If not guided and supported, this study suggests that pharmacists may undergo a transition and amend their practices in ways that they individually see fit. This has the potential to undermine professionalism and standardization of services, to disrupt relationships both between pharmacists and the patients in their care, and the interprofessional working relationships they have with other HCPs, especially nursing and medical staff. Recognition of changes in work practices should go some way to ensuring that pharmacists can be adequately prepared and supported, allowing for a smoother transition and improved ways of working with electronic systems. References 1. Department of Health. An Information Strategy for the Modern NHS. London: HMSO; 1998.

2. Bates DW, Gawande AA. Improving safety with information technology. N Engl J Med 2003;348:2526– 2534. 3. Black AD, Car J, Pagliari C, et al. The impact of eHealth on the quality and safety of health care: a systematic overview. PLoS Med 2011;8:1–16. 4. Buntin MB, Burkes MF, Hoaglin MC, Blumenthal D. The benefits of health information technology: a review of the recent literature shows predominantly positive results. Health Aff 2011;30:464–471. 5. Ammenwerth E, Schnell-Inderst P, Machan C, Siebert U. The effect of electronic prescribing on medication errors and adverse drug events: a systematic review. J Am Inform Assoc 2008;15:585–600. 6. Koppel R. What do we know about medication errors made via a CPOE system versus those made via handwritten orders? Crit Care 2005;9:427–428. 7. Redwood S, Rajakumar A, Hodson J, Coleman JJ. Does the implementation of an electronic prescribing system create unintended medication errors? A study of the sociotechnical context through the analysis of reported medication incidents. BMC Med Inform Decis Mak 2011;11:1–11. 8. Shulman R, Singer M, Goldstone J, Bellingan G. Medication errors: a prospective cohort study of hand-written and computerised physician order entry in the intensive care unit. Crit Care 2005;9:R516– R521. 9. Weant KA, Cook AM, Armitstead JA. Medicationerror reporting and pharmacy resident experience during implementation of computerized prescriber order entry. Am J Health Syst Pharm 2007;64: 526–530. 10. Berg M. Implementing information systems in health care organizations: myths and challenges. Int J Med Inform 2001;64:143–156. 11. Haux R. Health information systems – past, present, future. J Med Inform 2006;75:268–281. 12. Massaro TA. Introducing physician order entry at a major academic medical center: 1. Impact on organizational culture and behavior. Acad Med 1993;68:20–25. 13. Hayrinen K, Saranto K, Nykanen P. Definition, structure, content, use and impacts of electronic health records: a review of the research literature. Int J Med Inform 2008;77:291–304. 14. Greenhalgh T, Swinglehurst D. Studying technology use as social practice: the untapped potential of ethnography. BMC Med 2011;9:45. 15. Holliday A. Doing and Writing Qualitative Research. London: SAGE Publications Ltd; 2002. 16. Berg M. Practices of reading and writing: the constitutive role of the patient record in medical work. Sociol Health Illness 1996;18:499–524. 17. Berg M. Patient care information systems and health care work: a sociotechnical approach. Int J Med Inform 1999;55:87–101. 18. Berg M, Aarts J, Lei JVD. ICT in health care: sociotechnical approaches. Methods Inf Med 2003;42:297– 301.

Burgin et al. / Research in Social and Administrative Pharmacy j (2013) 1–15 19. Cresswell K, Worth A, Sheikh A. Implementing and adopting electronic health record systems. Clin Gov Int J 2011;16:320–336. 20. Greenhalgh T, Potts HW, Wong G, Bark P, Swinglehurst D. Tensions and paradoxes in electronic patient record research: a systematic literature review using the meta-narrative method. Milbank Q 2009;87:729–788. 21. Cresswell KM, Worth A, Sheikh A. Actor-Network Theory and its role in understanding the implementation of information technology developments in healthcare. BMC Med Inform Decis Mak 2010;10:67. 22. Fenwick T, Edwards R. Actor-Network Theory in Education. Oxon: Routledge; 2010. 23. Engestrom Y. Expansive learning: towards an activity-theoretical reconceptualization. In: Illeris K, ed. Contemporary Theories of Learning. 1st ed. Oxon: Routledge; 2009. 24. Billet S. Toward a workplace pedagogy: guidance, participation, and engagement. Adult Educ Q 2002; 53:27–43. 25. Eraut M. Informal learning in the workplace. Stud Contin Educ 2004;26:247–273. 26. Fenwick T, Edwards R, Sawchuk P. Emerging Approaches to Educational Research. Oxon: Routledge; 2011. 27. Prout A. Actor-network theory, technology and medical sociology: an illustrative analysis of the metered dose inhaler. Sociol Health Illness 1996;18: 198–219. 28. Denscombe M. The Good Research Guide for Smallscale Social Research Projects. Buckingham: Open University Press; 1998. 29. Kitzinger J. Focus groups. In: Pope C, Mays N, eds. Qualitative Research in Health Care. 3rd ed. Oxford: Blackwell Publishing Ltd; 2006. 30. Morgan DL. The Focus Group Guidebook. London: SAGE Publications Ltd; 1998. 31. NHS employers. National Job Profiles – Pharmacy. Available at: http://www.nhsemployers.org/PayAnd Contracts/AgendaForChange/NationalJobProfiles/ Documents/Pharmacy.pdf; Accessed 22.01.13. 32. Balen RM, Jewesson PJ. Pharmacist computer skills and needs assessment survey. J Med Internet Res 2004;6:e11. 33. Devore SD, Figlioli K. Lessons premier hospitals learned about implementing electronic health records. Health Aff 2010;29:664–667. 34. Winman T, Rystedt H. Electronic patient records in action: transforming information into professionally relevant knowledge. Health Inform J 2011;17:51–62. 35. Francis SA, Dean B, Rees C. There’s more to interprofessional communication than sticky notes!. Pharm J 2001;267:460. 36. Pullinger W, Franklin BD. Pharmacists’ documentation in patients’ hospital health records: issues and educational implications. Int J Pharm Pract 2010; 18:108–115.

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Appendix 1 Focus group discussion schedule Focus group: learning to work with computerization of medical notes and prescription charts – experiences and perceptions of pharmacists in a large teaching hospital Introduction and welcome to the session Does anyone have any questions before we start? Questions with points for discussion A note about terminology. Throughout this session I will refer to the electronic patient records as exactly this. The term EPMAR will be used to refer to the electronic prescribing system here at Salford. Opening question (5 min) 1. I would like each of you to tell us your name, the area of pharmacy in which you are currently working, and also how long you have been using the electronic patient records and EPMAR programs. Introductory question (5–10 min) 2. I would like each of you to think back to when you switched from paper to electronic patient records, or if it is a little easier, when you switched from paper drug charts to EPMAR (or, If electronic patient records/ EPMAR is all that you have ever known, I want you to think back to when you first started to use it). How did you feel about the introduction of the electronic interface? - Were you happy about using it? - Did you have any anxieties about using it? What were they? - Did you feel frightened? - What was it that made you feel this way? Key questions (10 min each) Changes in work practice 3. Has the implementation of electronic patient records, and EPMAR, changed your working practice in any way? - Has it changed your workflow? - Does it take longer than the paper versions? Why?

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- Has it changed how you work at weekends? How? - Has it changed your approach to dispensary and on call work? - Has it changed your teaching practices? - Has it changed the amount of contact you have with other HCPs? - Do you think it has changed the amount of patient contact you have? Does this matter? How do you try/think you could improve your patient contact? - Has it changed how you approach to daily tasks? - Do they identify positive and negatives? - How to improve for the future? - What would you consider the positives and the negatives, or are you indifferent? Skills 4. What skills do you feel you utilize, or need, to effectively use the electronic records and EPMAR system? - Are the same skills needed for the paper v the electronic system? - IT literacy? Typing? - Prioritization skills? - Focus? - Written communication skills? Good oral communication skills? Different for the two systems? How do you approach a clinical query with a consultant? - Interpretation of information overload. Being able to pick out what information is needed and also condense what information to give. 5. Can you remember how you learned these skills? - Training provided by the hospital? - Observation of colleagues/peers? - Other courses (e.g., diploma)? - Observation of other health care professionals, e.g., consultants or senior pharmacists? - Experience and reflection? - What would you consider the best way to learn these skills is? Any thoughts on how to improve training for new pharmacists to the hospital? 6. Can you think of any of your skills that may require more work or further training? Utilization of electronic interface 7a) Thinking of only the electronic records first, what do you document in electronic patient

records? What are your main drivers for documenting? b) How do you decide what to write? (Can you give examples?) - Consider the content of what you write and the way in which you write it. - Have you had any guidance on this? If no, what would you find useful? - Litigation worries? - How do you follow up clinical notes/ entries? c) If you have been exposed to both the paper and electronic formats, do you feel that what, how and the frequency with which you enter notes has changed at all since implementation of electronic interface? d) For junior staff, depending on how they answer this, consider asking them how they would define what a patient’s medical record is. 8a) Thinking of now of only EPMAR, what do you document on the electronic prescription charts? b) How do you decide what to write? (Can you give examples) - Consider the content of what you write and the way in which you write it? - Have you had any guidance on this? If no, what would you find useful? - Litigation worries? c) If you have been exposed to both the paper and electronic formats, do you feel that what, how and the frequency of your notes of prescription charts has changed at all since implementation of electronic interface? Communication network 9. Has the implementation of the electronic system affected the way you communicate with other health care professionals (HCP)? (expand) - How do you tend to communicate with staff? How would you approach a prescription problem? - How would you approach the grumpy consultant? - Do you feel that there is reduced face to face contact? Is this important? - How does this make you feel? - How do you tend to get your message across to other HCP? What about different grades of staff? - Does this differ from communication with this group before the implementation of the electronic system?

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- Do you feel the electronic system has affected you relationships with other members of the MDT compared to the paper based system? How/Why?

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Ending questions 10. Does anyone have anything they want to say that has not been covered?