E-prescribing for children

Neil A Caldwell, Consultant Pharmacist, Children’s Services, WUTH

Honorary Lecturer, LJMU

June 2013

What’s different?

What’s different? What’s not?

Different• Prescription commonly has many iterations.• Initial guesstimate informed, influenced and

modified by multiple individuals over time course: formulation, concentration, volume, brand (taste/palatability), availability or administration time.

• What is margin for variance? What is legal?

Different• Clear, unambiguous order but.....you see

what you assume prescription should be.

• 10kg child prescribed: Clarithromycin (125mg/5mL) liquid, give 62.5g po bd.

• 4 doses charted + checked as given.

DifferentCDS such as advanced dosing model logic.

Criterion Definition

Indication Condition that makes particular dose advisable

Care area Physical location of patient, used to infer intensity

Chronological age Age in years, months, days since birth

Post-conceptional age Age in years, months, days since clinician estimated conception

Dosing weight User defined, may not reflect actual weight

Renal impairment Qualitative assessment by ordering provider: impaired or not impaired

BMC Med Inform Decis Mak 2011; 11: 14

Different• Dose rounding: how, when, who, where?

• Do you round up or down? Influenced by pharmacology, concentration, dose and volume.

• Are “rules” different for different medicines or indications?

Different• Fewer medicines: 4 medicines comprise

>50% of scripts in DGH for children. 150 medicines are 98.5% of prescriptions.

• Adult surgeons often prescribe for children!

• Off label use of medicines, evidence lacking, risk of significant overdose.

What’s not different• Same goal. To create an inpatient or discharge prescription.• Drug catalogue: same products for children and adults, dm+d

description. • Patient PAS system: admissions, transfers, patient identification. • Prescribing style: drug, dose, route, frequency. • Basics of documenting administration, same but differences in times

and double signing.• Basic decision support: allergy checking and interactions. Worries

about alert fatigue.

Personal opinion...• Target children first in system design.• If works for children, will work for adults, but not

vice versa.• Perfect system is pipe dream. Should never

replace practical common sense.• Wherever possible, design out common

“mistakes.”

An observation..“Evolution of EP mirrors child development. After

long and protracted birth EP arrived, and initially throve. During infancy it suffered minor setbacks and a serious scare. It’s now come through these tribulations intact if a little chastened. As EP leaves the toddler years behind it faces a challenging world knowing that with support and guidance it can look forward to childhood with optimism.” Arch Dis Child 2012;97:124–128

E-prescribing must cover your Rsright patient

right medication

right dose

right volume

right route

right time

right documentation