ePrescribing of Chemotherapy

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ePrescribing of Chemotherapy The Leeds Experience
Julie Mansell, Lead Chemotherapy
Pharmacist, Leeds Cancer Centre
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• Background at Leeds Teaching Hospitals
• SJUH Opmas 1993
• Cookridge Design partners Chemocare 1995
• Introduced to breast cancer clinic, gradual
  rollout
• Cookridge site ? oncology SJUH, haematology
• 60 consultants
• 5000 patients per annum
• Oncology, haematology, BMT, trials including
  early phase
• Treatment given orally, day case, in-patient
  and ambulatory
• All chemotherapy prescribed using Chemocare

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• Improved safety
• 2006 Journal of Quality and Safety in Healthcare
• Effect of computerisation on the quality and
  safety of chemotherapy prescription
• Oncology centre in Lausanne
• Examined chemotherapy errors before and after
  implementation
• Classification of errors
• Major drug name, dose, route of
  administration
• Before 141 errors in 940 prescriptions (19
  major)
• After 6 errors in 978 prescriptions (0 major)
• Error rate reduced from 15 to 0.6

Marc Voeffray et al. Effect of computerisation
on the quality and safety of chemotherapy
prescription Qual. Saf. Health Care
200615418-421
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• Complex prescribing ideal target
• Narrow therapeutic index and highly toxic
  potential for harm is great
• Wide range of doses e.g. Methotrexate 10mg to
  12g/m2
• Dose, interval, route varies with tumour type
• Dosed on BSA, weight, fixed
• Several medicines in most regimens
• Supportive medicines to deliver safely
• Multiple day treatment with different medicines
  on different days
• BEP Bleomycin D2, 8,15 Etoposide D1,2 3
  Cisplatin D1, 2
• Modifications for myelosuppression, renal
  liver impairment frequent
• Common use of acronyms
• Classes of agents with very different uses
  e.g.rituximab/trastuzumab

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• National Drivers
• Manual for Cancer Services
• Rolling quality assurance programme for cancer
  services
• Purpose - enables quality improvement both in
  terms of clinical and patient outcomes
• 2004-2007 40 ePrescribing
• Chemotherapy Services in England Ensuring
  quality and safety
• National Chemotherapy Advisory Group 2009
• Group established to advise DH on development
  delivery of high quality chemotherapy services
• Handwritten prescriptions for parenteral
  chemotherapy should be replaced as soon as
  possible by pre-printed forms or, preferably, by
  fully validated electronic prescribing systems
• Chemotherapy measures 2011 11-3S-139 to 142
  Electronic Prescribing covers criteria for
  system and SOPs

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• Benefits and successes (1)
• Reduces prescription errors
• Legible
• Faster for complex treatment

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• Benefits and Successes (2)
• Quality assurance
• Consistency of prescribing
• Controls access to protocol for certain
  diseases only
• Central control of change
• Set maximum doses/ routes that cannot be
  overwritten
• Reduces variation in clinical practice
• Template sign-off by consultant, 2 pharmacists
• Calculation of patient variables e.g. GFR, BSA

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• Benefits and Successes (3)
• Pharmacy specific
• Integrated worksheet and label preparation
• Automatic dose rounding
• RAPID RESPONSE REPORT NPSA/2008/RRR04
• Doses of vinca alkaloids should be prepared for
  use by dilution in small volume
• intravenous bags, rather than in syringes

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• Additional benefits
• Audit and review of practice
• Identifies case series for research projects
• SACT dataset
• Facilitates service re-design
• Improves prescribing efficiency in clinic
• Easily accessible treatment view on admission

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• Specific Challenges/Limitations
• Reluctance/resistance to change
• Technophobes!
• Age range/ skills of staff across MDT
• Slower for simple treatments
• Find Clinical and Managerial Champions
• Employ national drivers
• Promote additional benefits
• Patience and perseverance!
• Training burden
• Time consuming start up/new staff/upgrades
• Level 1 competency (prescribing scenarios)
• Employ (if possible) a designated ePrescribing
  lead

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• Specific Challenges/Limitations
• Loss of knowledge
• Doses of chemotherapy never learned
• Supportive medicines not appreciated
• Teach and test the basics
• Errors
• ePrescribing different errors ? NO errors
• If template incorrect - affects multiple
  patients
• Depends on quality of input e.g. 0mg/ height
  and weight mistakes
• Foster a quality culture
• Check and check again
• Review common themes

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• Specific Challenges/Limitations
• Technical challenges
• Difficult to set up templates for complex
  regimens
• Chronomodulation / trial dose bands
• National system unable to make many in-house
  tweaks
• No administration module ? paper copy for
  records
• Be creative, but maintain safety

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• Future Challenges
• Paper-lite
• Long established use of prescription as
  communication tool
• Reluctance to change
• Use clinical (multi-professional) champions
• Use local drivers efficiency
• Project group