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Short Communication International Journal of
Pharmacy Practice International Journal of Pharmacy Practice 2015, 23, pp. 225–227
Paediatric prescribing practice and opinions of paediatric prescribers on ePrescribing Alice Mary Burridgea, David Terryb and Keith Wilsona a
Aston Pharmacy School, Aston University and bPharmacy Academic Practice Unit, Birmingham Children’s Hospital,Birmingham, UK
Keywords electronic prescribing; evidence-based practice; independent prescribing Correspondence Miss Alice Mary Burridge, Aston Pharmacy School, Aston University, Aston Triangle, Birmingham B4 7ET, UK. E-mail: [email protected] Received July 25, 2013 Accepted July 10, 2014 doi: 10.1111/ijpp.12150 Ethics approval This study was approved by School of Life and Health Sciences ethics committee (Aston University) and the clinical governance department (Birmingham Children’s Hospital).
Abstract Objective The aim of this study was to provide an initial insight into current UK paediatric prescribing practice. Methods In 2012 focus groups were conducted at Birmingham Children’s Hospital (UK specialist hospital) with both medical and non-medical prescribers and analysed using thematic analysis. Key findings Both sets of prescribers used a wide range of resources to support their prescribing decisions.Dosing information was most commonly checked,and a lack of specialist paediatric information was reported in existing resources. All groups had high expectations of the support functions that should be included in an electronic prescribing system and could see many potential benefits. Participants agreed that all staff should see the same drug alerts. The overwhelming concern was whether the current information technology infrastructure would support electronic prescribing. Conclusions Prescribers had high expectations of electronic prescribing, but lacked confidence in its delivery. Prescribers use a wide range of resources to support their decision making when prescribing in paediatrics.
Introduction Although little is known about resources used when making paediatric prescribing decisions, a USA-based study reported that current resources are not sufficient to aid prescribers when determining individual paediatric patient doses.[1] In the UK the General Medical Council recommends using the British National Formulary for Children, electronic systems and experienced colleagues to prescribe safely.[2] Internationally electronic prescribing and computerised decision support has been shown to improve prescribing practice.[3] There is a paucity of published research concerning UK paediatric prescribing practice. This study was undertaken to inform future research on the introduction of electronic prescribing in a UK specialist paediatric hospital (Birmingham Children’s Hospital (BCH)). The aim was to provide insight into both current practice and prescribers’ opinions of electronic prescribing.
non-medical prescribers (NMPs) (eight and nine participants) (Table 1).
Results and Discussion After transcription, focus groups were analysed using NVivo (version 9) software (QSR International, Doncaster, Australia). An inductive approach to thematic analysis was taken to bring together the coded data towards themes. Both the medical and NMP focus groups included participants with a range of experience in paediatric prescribing; from NMPs in training to medical staffs with over 10 years’ experience. NMPs had varying prescribing habits, whereas medical prescribers reported prescribing on a daily basis.
Resource use
Methods Four focus groups were conducted at BCH in 2012, two with medical prescribers (eight and five participants) and two with © 2014 Royal Pharmaceutical Society
Paediatric prescribers used a wide range of resources to support their prescribing decisions. Participants frequently referred to using the British National Formulary for Children International Journal of Pharmacy Practice 2015, 23, pp. 225–227
226
Table 1
Exploring UK paediatric prescribing practice
Theme plan for focus groups
Theme plan for focus groups: Profession, level of prescribing experience Usual prescribing habits How often do you need to find extra information or guidance before prescribing? What type of information do you look up most frequently? Where? What types of paediatric information are difficult to access? What prescribing support tools would you expect to find in an electronic prescribing tool? How would you expect to view this? Potential benefits? Do you have any concerns about the implantation of electronic prescribing?
and local guidelines to support dosing decisions; however, there was less frequent reference to using resources for information regarding interactions or administration. No clear differences between the use of resources by medical prescribers and NMPs could be established. There were however differences between the perceived difficulties faced when prescribing for paediatric patients. NMPs reported that lack of access to information found in notes or on the pharmacy computer system (Ascribe) was the most frequent issue faced when prescribing, whereas medical prescribers reported a lack of paediatric prescribing information for conditions such as renal or liver impairment and lack of access to a specialist pharmacist out of hours. ‘The pharmacists are a fantastic resource we use them all the time but then at the weekend they’re not there, which I find quite bizarre’. NMPs also mentioned a lack of specialist paediatric prescribing information, but it was less prominent in their discussions.
Expectations of electronic prescribing Both medical prescribers and NMPs agreed that an electronic prescribing system should provide dose guidance as a key support feature. They expected an electronic prescribing system to be capable of using patient data such as weight/age/ body surface area to calculate an appropriate dose, features described as in use in electronic prescribing by Stultz and Nahata.[4] Both groups of prescribers expected the system to interact with existing systems such as results and imaging to provide advice and to save moving between systems.‘I want it to be interactive, particularly with results systems. So I don’t have to log out of that’. All participants agreed that the same prescribing alerts should be displayed to all prescribers regardless of experience or specialty. There were long discussions in both sets of focus groups about the best way to display and interact with alerts. Some participants stated that when overriding alerts a reason should have to be typed in to the system as a record of the active decision. In line with recent publications the theme that emerged was that alerts © 2014 Royal Pharmaceutical Society
should be triaged and then the different types of alerts should require a varying level of interaction from the prescriber in order to respond to them.[5,6]
Potential benefits of electronic prescribing Both medical and NMPs agreed that a key benefit would be the ability to see if a medicine had been administered to a patient. NMPs identified easy access to patient’s medication history and the ability to monitor individual practice as the most significant benefits to them, but medical prescribers did not mention these. Medical prescribers did mention that being able to see a snapshot of the patients you are covering without having to search for them would be very useful. Another benefit mentioned by both groups was the potential to improve the speed and accuracy of medication supply to patients.‘It will be safer and quicker once you’ve learnt to use it’.
Current concerns about moving to electronic prescribing For the overwhelming majority of participants, the major concern about moving to an electronic prescribing system focussed upon practical information technology (IT) issues. All participants voiced concerns about the current IT infrastructure and its ability to support an ePrescribing system. There were also concerns about IT support that was described as ‘relaxed’. The third IT-related issue was access to computers. ‘You’re going to have to queue up to get on the system’. Participants felt current availability of computers would not be sufficient for ePrescribing. Several participants mentioned positively the possibility of using an electronic tablet. Security of the system was also important to both groups, but they also wanted the logon process to be efficient. A concern raised by medical prescribers was how the system would handle retrospective prescribing after an emergency scenario? Non-IT-related concerns focused on staff training, alert fatigue and user testing of the system to ensure that prescribers were familiar with it before they had to use it.
Limitations This study was conducted in a single NHS paediatric hospital and reflects the current practice there, so the results may not be generalisable to all NHS paediatric hospitals.
Conclusions Prescribers had high expectations of ePrescribing systems, but also lacked confidence in its delivery. The primary concerns were: infrastructure capability, IT technical support and access. The process of managing alerts was highlighted as important within the participants’ discussions, mirroring International Journal of Pharmacy Practice 2015, 23, pp. 225–227
Alice Mary Burridge et al.
227
current literature that recognises the importance of alert presentation and its effect on workflow.[7–9] These themes will be explored further to ensure that system design is in line with expectations.
Declarations
Acknowledgements The authors would like to thank the staff at Birmingham Children’s Hospital for their participation in this study and Dr Fiona Reynolds for her help in coordinating the study.
Authors’ contributions
Conflict of interest The Author(s) declare(s) that they have no conflicts of interest to disclose.
Alice Burridge drafted the manuscript and significant contributions to editing the manuscript were made by David Terry and Keith Wilson. All Authors state that they had complete access to the study data that support the publication.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
References 1. Barrett J et al. Prescribing habits and caregiver satisfaction with resources for dosing children: rationale for more informative dosing guidance. BMC Pediatr 2011; 11: doi: 10.1186/14712431-11-25. http://www.biomedcentral .com/1471-2431/11/25 (accessed 29 April 2013). 2. General Medical Council. (2013). Good Practice in Prescribing and Managing Medicines and Devices. http://www.gmcuk.org/Prescribing_Guidance__2013__ 50955425.pdf (accessed 10 February 2014).
© 2014 Royal Pharmaceutical Society
3. Caldwell N, Power B. The pros and cons of electronic prescribing for children. Arch Dis Child 2012; 97: 124–128. 4. Stultz JS, Nahata MC. Computerised clinical decision support for medication prescribing and utilization in pediatrics. J Am Med Inform Assoc 2012; 19: 942– 953. 5. Shah NR et al. Improving acceptance of computerized prescribing alerts in ambulatory care. J Am Med Inform Assoc 2006; 13: 5–11. 6. Schedlbauer A et al. What evidence supports the use of computerized alerts and prompts to improve clinician’s prescrib-
ing behaviour? J Am Med Inform Assoc 2009; 16: 531–538. 7. Van De Sijs H et al. Overriding of drug safety alerts in computerized physician order entry. J Am Med Inform Assoc 2006; 13: 138–147. Mar–Apr. 8. Mille F et al. Analysis of overridden alerts in a drug-drug interaction detection system. Int J Qual Health Care 2008; 20: 400–405. doi: 10.1093/intqhc/ mzn038. 9. Shah NR et al. Improving acceptance of prescribing alerts in ambulatory care. J Am Med Inform Assoc 2006; 13: 5– 11.
International Journal of Pharmacy Practice 2015, 23, pp. 225–227
Short Communication International Journal of
Pharmacy Practice International Journal of Pharmacy Practice 2015, 23, pp. 225–227
Paediatric prescribing practice and opinions of paediatric prescribers on ePrescribing Alice Mary Burridgea, David Terryb and Keith Wilsona a
Aston Pharmacy School, Aston University and bPharmacy Academic Practice Unit, Birmingham Children’s Hospital,Birmingham, UK
Keywords electronic prescribing; evidence-based practice; independent prescribing Correspondence Miss Alice Mary Burridge, Aston Pharmacy School, Aston University, Aston Triangle, Birmingham B4 7ET, UK. E-mail: [email protected] Received July 25, 2013 Accepted July 10, 2014 doi: 10.1111/ijpp.12150 Ethics approval This study was approved by School of Life and Health Sciences ethics committee (Aston University) and the clinical governance department (Birmingham Children’s Hospital).
Abstract Objective The aim of this study was to provide an initial insight into current UK paediatric prescribing practice. Methods In 2012 focus groups were conducted at Birmingham Children’s Hospital (UK specialist hospital) with both medical and non-medical prescribers and analysed using thematic analysis. Key findings Both sets of prescribers used a wide range of resources to support their prescribing decisions.Dosing information was most commonly checked,and a lack of specialist paediatric information was reported in existing resources. All groups had high expectations of the support functions that should be included in an electronic prescribing system and could see many potential benefits. Participants agreed that all staff should see the same drug alerts. The overwhelming concern was whether the current information technology infrastructure would support electronic prescribing. Conclusions Prescribers had high expectations of electronic prescribing, but lacked confidence in its delivery. Prescribers use a wide range of resources to support their decision making when prescribing in paediatrics.
Introduction Although little is known about resources used when making paediatric prescribing decisions, a USA-based study reported that current resources are not sufficient to aid prescribers when determining individual paediatric patient doses.[1] In the UK the General Medical Council recommends using the British National Formulary for Children, electronic systems and experienced colleagues to prescribe safely.[2] Internationally electronic prescribing and computerised decision support has been shown to improve prescribing practice.[3] There is a paucity of published research concerning UK paediatric prescribing practice. This study was undertaken to inform future research on the introduction of electronic prescribing in a UK specialist paediatric hospital (Birmingham Children’s Hospital (BCH)). The aim was to provide insight into both current practice and prescribers’ opinions of electronic prescribing.
non-medical prescribers (NMPs) (eight and nine participants) (Table 1).
Results and Discussion After transcription, focus groups were analysed using NVivo (version 9) software (QSR International, Doncaster, Australia). An inductive approach to thematic analysis was taken to bring together the coded data towards themes. Both the medical and NMP focus groups included participants with a range of experience in paediatric prescribing; from NMPs in training to medical staffs with over 10 years’ experience. NMPs had varying prescribing habits, whereas medical prescribers reported prescribing on a daily basis.
Resource use
Methods Four focus groups were conducted at BCH in 2012, two with medical prescribers (eight and five participants) and two with © 2014 Royal Pharmaceutical Society
Paediatric prescribers used a wide range of resources to support their prescribing decisions. Participants frequently referred to using the British National Formulary for Children International Journal of Pharmacy Practice 2015, 23, pp. 225–227
226
Table 1
Exploring UK paediatric prescribing practice
Theme plan for focus groups
Theme plan for focus groups: Profession, level of prescribing experience Usual prescribing habits How often do you need to find extra information or guidance before prescribing? What type of information do you look up most frequently? Where? What types of paediatric information are difficult to access? What prescribing support tools would you expect to find in an electronic prescribing tool? How would you expect to view this? Potential benefits? Do you have any concerns about the implantation of electronic prescribing?
and local guidelines to support dosing decisions; however, there was less frequent reference to using resources for information regarding interactions or administration. No clear differences between the use of resources by medical prescribers and NMPs could be established. There were however differences between the perceived difficulties faced when prescribing for paediatric patients. NMPs reported that lack of access to information found in notes or on the pharmacy computer system (Ascribe) was the most frequent issue faced when prescribing, whereas medical prescribers reported a lack of paediatric prescribing information for conditions such as renal or liver impairment and lack of access to a specialist pharmacist out of hours. ‘The pharmacists are a fantastic resource we use them all the time but then at the weekend they’re not there, which I find quite bizarre’. NMPs also mentioned a lack of specialist paediatric prescribing information, but it was less prominent in their discussions.
Expectations of electronic prescribing Both medical prescribers and NMPs agreed that an electronic prescribing system should provide dose guidance as a key support feature. They expected an electronic prescribing system to be capable of using patient data such as weight/age/ body surface area to calculate an appropriate dose, features described as in use in electronic prescribing by Stultz and Nahata.[4] Both groups of prescribers expected the system to interact with existing systems such as results and imaging to provide advice and to save moving between systems.‘I want it to be interactive, particularly with results systems. So I don’t have to log out of that’. All participants agreed that the same prescribing alerts should be displayed to all prescribers regardless of experience or specialty. There were long discussions in both sets of focus groups about the best way to display and interact with alerts. Some participants stated that when overriding alerts a reason should have to be typed in to the system as a record of the active decision. In line with recent publications the theme that emerged was that alerts © 2014 Royal Pharmaceutical Society
should be triaged and then the different types of alerts should require a varying level of interaction from the prescriber in order to respond to them.[5,6]
Potential benefits of electronic prescribing Both medical and NMPs agreed that a key benefit would be the ability to see if a medicine had been administered to a patient. NMPs identified easy access to patient’s medication history and the ability to monitor individual practice as the most significant benefits to them, but medical prescribers did not mention these. Medical prescribers did mention that being able to see a snapshot of the patients you are covering without having to search for them would be very useful. Another benefit mentioned by both groups was the potential to improve the speed and accuracy of medication supply to patients.‘It will be safer and quicker once you’ve learnt to use it’.
Current concerns about moving to electronic prescribing For the overwhelming majority of participants, the major concern about moving to an electronic prescribing system focussed upon practical information technology (IT) issues. All participants voiced concerns about the current IT infrastructure and its ability to support an ePrescribing system. There were also concerns about IT support that was described as ‘relaxed’. The third IT-related issue was access to computers. ‘You’re going to have to queue up to get on the system’. Participants felt current availability of computers would not be sufficient for ePrescribing. Several participants mentioned positively the possibility of using an electronic tablet. Security of the system was also important to both groups, but they also wanted the logon process to be efficient. A concern raised by medical prescribers was how the system would handle retrospective prescribing after an emergency scenario? Non-IT-related concerns focused on staff training, alert fatigue and user testing of the system to ensure that prescribers were familiar with it before they had to use it.
Limitations This study was conducted in a single NHS paediatric hospital and reflects the current practice there, so the results may not be generalisable to all NHS paediatric hospitals.
Conclusions Prescribers had high expectations of ePrescribing systems, but also lacked confidence in its delivery. The primary concerns were: infrastructure capability, IT technical support and access. The process of managing alerts was highlighted as important within the participants’ discussions, mirroring International Journal of Pharmacy Practice 2015, 23, pp. 225–227
Alice Mary Burridge et al.
227
current literature that recognises the importance of alert presentation and its effect on workflow.[7–9] These themes will be explored further to ensure that system design is in line with expectations.
Declarations
Acknowledgements The authors would like to thank the staff at Birmingham Children’s Hospital for their participation in this study and Dr Fiona Reynolds for her help in coordinating the study.
Authors’ contributions
Conflict of interest The Author(s) declare(s) that they have no conflicts of interest to disclose.
Alice Burridge drafted the manuscript and significant contributions to editing the manuscript were made by David Terry and Keith Wilson. All Authors state that they had complete access to the study data that support the publication.
Funding This research received no specific grant from any funding agency in the public, commercial, or not-for-profit sectors.
References 1. Barrett J et al. Prescribing habits and caregiver satisfaction with resources for dosing children: rationale for more informative dosing guidance. BMC Pediatr 2011; 11: doi: 10.1186/14712431-11-25. http://www.biomedcentral .com/1471-2431/11/25 (accessed 29 April 2013). 2. General Medical Council. (2013). Good Practice in Prescribing and Managing Medicines and Devices. http://www.gmcuk.org/Prescribing_Guidance__2013__ 50955425.pdf (accessed 10 February 2014).
© 2014 Royal Pharmaceutical Society
3. Caldwell N, Power B. The pros and cons of electronic prescribing for children. Arch Dis Child 2012; 97: 124–128. 4. Stultz JS, Nahata MC. Computerised clinical decision support for medication prescribing and utilization in pediatrics. J Am Med Inform Assoc 2012; 19: 942– 953. 5. Shah NR et al. Improving acceptance of computerized prescribing alerts in ambulatory care. J Am Med Inform Assoc 2006; 13: 5–11. 6. Schedlbauer A et al. What evidence supports the use of computerized alerts and prompts to improve clinician’s prescrib-
ing behaviour? J Am Med Inform Assoc 2009; 16: 531–538. 7. Van De Sijs H et al. Overriding of drug safety alerts in computerized physician order entry. J Am Med Inform Assoc 2006; 13: 138–147. Mar–Apr. 8. Mille F et al. Analysis of overridden alerts in a drug-drug interaction detection system. Int J Qual Health Care 2008; 20: 400–405. doi: 10.1093/intqhc/ mzn038. 9. Shah NR et al. Improving acceptance of prescribing alerts in ambulatory care. J Am Med Inform Assoc 2006; 13: 5– 11.
International Journal of Pharmacy Practice 2015, 23, pp. 225–227
