A collaborative Australian-UK study to measure

the impact of eMM on the work of hospital

pharmacists

eMedication Management Conference

14-15 March 2017, Sydney

Research Team Members

UK Team: S Shah, A Girling, A Slee, J Coleman, K

Cresswell, B Schofield, L McCloughan, A Sheikh

Australian Team: L Li, E Lehnbom, M Prgomet,

J Westbrook

EMMs are promoted for their ability to improve

work efficiency and safety

- Less time on administrative tasks

- More time for patient care - Fewer errors

Research Evidence of Impact on Work

• Quantitative evidence is sparse

• Most studies on doctors’ work in ambulatory care and critical care

• Know little about the impact on nurses

• Hospital pharmacists’ work likely to be significantly affected, but little research quantifying how work changes

Capturing the multi-dimensions of work challenging

Self-reported patterns of work unreliable

Direct observations of work more accurate

Methodological Challenges

Where?

With what?

With whom?

What task?

Interruptions

Work Observation

Method By Activity

Timing -

Direct Observations Nurses & Doctors

70 nurses observed for 276.9 hours 59 doctors observed for 356.3 hours

Measured changes in how nurses and doctors distributed their time across work tasks in controlled pre and post eMM studies

• Nurses and Doctors with eMM experienced no significant

changes in % of time spent on:

Medication Tasks;

Direct Care;

Professional Communication

Compared to control wards without eMM

• Doctors with eMM spent more time with other doctors

(p=0.003) and with patients (p=.009).

• Nurses with eMM spent less time with doctors (p=0.0001).

Results

8

Serious prescribing errors

Intervention wards – significant 44% (p=0.0002) reduction in serious prescribing error rate 25/100 admissions 14/100 admissions (95%CI 21-29) (95%CI 10-18) No significant change on the control wards (p=0.4)

What is the impact of eMM on

pharmacists’ work?

Are changes consistent across sites?

International Collaboration

Aim: To undertake parallel observational studies

of pharmacists in hospitals in the UK and

Australia using the same methods

Methods Pharmacy work task classification developed

Iterative approach between UK & Australian teams

Australian & UK similar pharmacist training & practice

11 broad categories of work – defined by inclusion/exclusion criteria

Pilot tested & incorporated into WOMBAT software on handheld tablet computer

Examined changes in % of time in task categories pre/post

13

Example of task definitions

History taking Process of taking a medication history, reconciling

medications at anytime Includes Excludes All things historical

Collecting data from a patient, carer or relative to record on a medication history and reconciliation form (paper or electronic) Faxing/phoning GP, local pharmacy

Accessing summary care/electronic health record

Verifying medications taken prior to admission

Includes reconciliation of a patient’s own drugs

Asking about allergies

Asking about medications that have been started in hospital

Review

Transcribing

Providing medication information

Hospital pharmacists shadowed by

trained observers using WOMBAT

tool

Pre- and post- WOMBAT observational study of pharmacists

UK

Hospital

Australian

Hospital

No. of beds 600 538

No. of

pharmacists obs 11 12

No. Obs. Hours

Pre 135.7 80.4

No. Obs. Hours

Post 119.3 74.1

16

Changes expected Post eMM

Pharmacists:

Review medication charts online

Access medication information in real time

Integration of order verification/medication order review with dispensing

Potential Effects on Work:

Release time to spend on patient education/discussion

Reduce time in medication review as fewer errors, legible orders

Results

Changes in % of pharmacists’ time on tasks, with others

and interruptions pre post eMM

Significant pre/post change

*P<0.05 ** P<0.01 UK Hospital

Pre – Post %

Australian Hospital

Pre – Post %

Medication reviews 27.1 32.6* 12.5 27.5*

Non-clinical tasks 15.7 NC 21.0 NC

Work-related discussion 3.5 2.6** 12.5 NC

History taking 19.4 29.5** 7.6 13.3**

Supply medications 9.9 5.8** 6.0 3.1*

Time with patients 7.3 NC 5.6 10.2**

Time with doctors 4.9 NC 7.3 14.8**

Time with nurses 3.5 NC 6.5 12.4**

Tasks interrupted 3.2/hr 2.7/hr** 4.2/hr NC

NC = No Change

Considerable differences in countries at baseline which persisted

Australian pharmacists engaged in more inter-professional interactions & interrupted more frequently

Major changes in the same direction – increases in medication review and history taking

UK 30% on history taking v 13% Aust- performance indicator for review of patients in 24 hours

Reduced time in medication review not evident

Australian pharmacists spent more time with patients post

Key Findings

Pharmacists’ views of eMMS from a

Children’s Hospital

Team: M Baysari, R Hardy, L Richardson, R Lake

Background

17 pharmacists

Interviews around 4 months post eMM

Included outpatient, inpatient, oncology and

pharmacy managers

Questions about: overall impression of

eMM, changes to work, safety risks/benefits

Themes which help to understand the quantitative data

22

Changes to work

Addition and changed tasks:

Helping doctors and nurses use the

eMMS;

• “I think we were also expected to understand, especially

from the doctors’ perspective, they call us a lot and say,

“How do I do this, how do I use this?”

• “There’s 10 to 20 minutes of helping doctors figuring –

navigating – that I otherwise wouldn’t have had to do”.

23

Training

Training viewed as insufficient and completed too early

• “Although I did have some training sessions earlier on

that was too far away from the actual implementation of

the system to be of any use”

• “But that’s also hard because we haven’t been trained

properly anyhow so we get doctors ringing on a daily

basis, saying, “Can you tell me how to do this discharge?”

I would love to help them but we haven’t had adequate

training to be able to”.

24

Improved safety

Most pharmacists said that the eMMS improved

visibility of medication information

• “You can now see all of the patient’s medications which is

really nice when you have a complex patient who might

be on multiple medications and their drug interactions and

things, whereas previously we were just seeing one

section of the chart, and kind of making a judgment based

on that”.

Observational studies and interviews allow testing

of hypotheses about expected work practice

change.

Comparisons provide insights into the potential

impact of context, implementation processes and

system design on work

Research Teams Using WOMBAT

aihi.mq.edu.au/project/wombat-work-observation-method-activity-timing

UK - This is a summary of independent research funded by the

National Institute for Health Research (NIHR) under its Programme

Grants for Applied Research scheme (RP-PG-1209-10099).

The views expressed are those of the author(s) and not necessarily

those of the NHS, the NIHR or the Department of Health.

AUSTRALIA – This research was partly funded by an NHMRC Program

Grant

FUNDING STATEMENT

27

Thank You!

Johanna.westbrook@mq.edu.au