Evaluation of Benefits of Integrating Health Central System

1.  Introduction:

In our review of the literature, we identified the most relevant information to help us in compiling the design brief. Using multiple methods of investigations such as Stakeholders Mapping and  Ethnographic research.

  Luma System of innovation (Anon, 2017)

Our scope of research highlighted and identified many stakeholders integrating to improve the structure, process models and legislations shaping the script system currently in use. we researched very thoroughly the following relative factors in addressing the end-users’ pain:

• Health system of Australia and Pharmacists qualities;

• Stakeholder research, and positions Industry bodies;

• Scope of services, settings, and distribution;

• Legislations and rules on pharmacy location and ownership and Pharmacy and analysis of the number of pharmacies in comparison to population data;

• Wholesaler supply arrangements: wholesaler supply arrangements;

• Adoption of technology: adoption of electronic technology in pharmacies, including reforms, innovations, and trials to improve access to scripts, affordability and quality use of medicines.

2.0   Stakeholder Mapping

Identifying the stakeholders plays an integral part in approaching our review to achieve the best understanding of what environment brings together an efficient model to provide the end-user with a secure and effective system.

 Since our initial research mapped above, we’ve identified more stakeholders and positioned the patient at the centre of our attention to the following stakeholders:

         Government bodies and government representatives

         Finance, including banks, insurers, and financial service providers

         Retail and small business organisations

         Peak bodies, including those in health, patient and consumer sectors

         Professional associations with a relationship to community pharmacy

         Education and training providers working with the health sector

         Digital health, e-health, technology, and digital transformation

While the current five year, 6th Community Pharmacy Agreement, between the Commonwealth of Australia and the Pharmacy Guild of Australia is due to expire on 30 June 2020. The Australian Government committed to lead early and inclusive negotiations to sign a new agreement by the end of 2019 (New (7th) Community Pharmacy Agreement).

Continued consultation will occur over the coming months to provide advice to the Government on how the new Agreement can improve access to affordable medicines and health care services, and support the quality use of medicines by patients in the next five years, and beyond.

Our design brief objective is to focus on the improvement of technology adoption by creating a health central-system, whereas our key stakeholders (Patient) has access to a centralised platform.  A GP would issue a script in person or online, the script would then be available at the  (health central-system/My Health Record)  at any time where past scripts would be marked as consumed. other features could be used such as setting the preferred pharmacy, hospital… to achieve the best outcome for the end-user. 

The second objective is providing education/training to all stakeholders to achieve the best outcome to ensure the success of the implementation of the online system. It could be achieved by engaging all stakeholders through the education system as well as in the workforce. The second part of education would be engaging the stakeholders (patients in particular) to make sure they’re aware of the services currently on offer, through marketing campaigns, their local clinics, pharmacies, and hospitals.

 through our research phase, we realised that there seems to be a lack of information about services currently available to the patients regarding their scripts, the 20 days rules and other facilities to avoid repetitive visitations to the pharmacists.  (Www1.health.gov.au, 2019)

By implementing our proposed Health central-system, which could be implemented as part of (My Health Record) we hope to achieve the following outcomes which align with the government’s department of health agreement:

       progress in electronic and digital health technologies, including the importance of access to real-time prescription dispensing information and potential acute care treatment needs by health care professionals.

       integrated care and multi-disciplinary care within the primary care team, including Primary Health Network linkages, and pharmacists’ scope of practice, such as prescribing in partnership models of care, in specific situations.

       increasing access to services in rural and remote areas, including pharmacy workforce planning and distribution arrangements.

       increasing transparency and accountability and developing metrics to better support planning, quality improvement, and reform. Financial and performance data and program evaluation information were identified as important to measure or inform health outcomes.                      

3.1 progress in electronic and digital health technologies:

Despite its size and complexity, the Australian health sector has invested considerably less than other sectors (e.g. telecommunications and financial services) on information technology over the past 20 to 30 years, and as a result the progress of health IT implementation across Australia and associated service quality, safety, and efficiency gains lags behind that of comparable industries. Notwithstanding this, investment in eHealth is now increasing and eHealth initiatives widespread, although at various stages of implementation across Australia. (KPMG 2015)

Chart 6.1: Health expenditure, by country Source: Commonwealth Fund (2016), 2015 International Profile of Health Care Systems and OECD 2016, Health Expenditure and financing; The World Bank 2016, Data bank  (KPMG 2015)

Globally, there has been increased uptake of electronic technology within the health and pharmacy sectors.  Main outcomes have included the development of: 

      EHRs, which store patient information that can be shared between various health professionals that come into contact with a patient over their health care journey; and 

      E-prescriptions, which includes systems which replace the traditional handwritten or printed methods of generating a prescription for a patient to take to their dispensing pharmacist, and also systems which store prescription information electronically but still require a paper prescription.  

      Other e-health and e-pharmacy interventions, including telemedicine and telehealth, eHealth strategic plans and electronic reminder devices.  

Table 6.6: e-prescription availability and uptake, by country

Source:  Deloitte Access Economics research and analysis.

In Australia, My Health Record is the Australian EHR system that connects medical practitioners, hospitals and other health care providers.  In the same way as Australia, many countries (including Canada, Denmark, France, the Netherlands, Ireland, Spain, Sweden, the UK, and the United States) use EHRs or EHR equivalents within their health system, with varying degrees of uptake. 

Different functionality within EHR frameworks also exists,  In Canada, e-prescriptions are stored within the EHRs.  In 2014, it was estimated that 62% of all Canadians had medicine dispensing profiles in their EHRs (KPMG 2015)

Achieving such a milestone in Australia would greatly improve the current MY Health Record System.

3.2  Capabilities, education and training:

Introducing a new Health Central-System or updating the currenrt (My Health Record) to include the changes required would have a great impact on the pharmacy workforce. Such reforms need to be considered in terms of the future capabilities required of the workforce, and any effects it might have on education and training, the scope of practice and credentialing. Both for Pharmacists (registered under the National Registration and Accreditation Scheme and governed by the Pharmacy Board of Australia), and the Pharmacy Assistant and PharmacyTechnician workforces need to be taken into consideration.

Also, consideration needs to be given to ensuring that quality and safety in clinical practice are always supported through any change process and that Australian.

professional standards are upheld. This includes ensuring compliance with any guidelines released by the Pharmacy Board of Australia (including the ‘Guidelines for the dispensing of medicines’), professional practice standards, state and federal legislation regarding medicines (including schedule 3 medications), and the Australian Pharmaceutical Advisory Council’s guidelines (including the ‘Guiding principles to achieve continuity in medication management’).

3.3 interoperability between health care providers (Specifically):

This is by far the most obvious missing link that would forever eliminate the obvious rivalry between doctors and pharmacists in Australia, Systems Such as HIEs which have been set up across the USA and allows medical practitioners, including pharmacists, to access a patient’s information.  Information such as lab tests, other medical tests and prescriptions can be transferred to other medical practitioners.  

Telemedicine and telehealth for pharmacy services are being increasingly used in several countries.  These interventions are primarily used to assist with prescribing in rural or remote locations.  Some countries, such as Ireland, have rolled out specific e-pharmacy programs that support national medicine product catalogues, e-prescriptions in primary care, hospital group closed-loop pharmacy, patient portals, digital record systems and prescribing analytics.

Other technological initiatives have been implemented throughout Canada.  One such initiative is a prescription dispensing machine in Ontario.  These machines, called PharmaTrust MedCentres, are remote dispensing systems and allow users to communicate with a pharmacist who might be located elsewhere via videoconferencing.  They have been installed in rural communities and allow access to pharmacists in communities where pharmacies may be scarce.

In Spain in recent years, several community pharmacies have begun to experiment with remote dispensing robots.  These machines are placed in a community pharmacy and dispense the required medicines directly to the pharmacist with the touch of a button, with no need for the pharmacist to search for the products.

Most relevant to our propositions was in the UK where observed evaluating the use of robotics in pharmaceutical dispensing.  In Wales specifically, the ‘Efficiency Through Technology’ fund has been developed to promote electronic communication between GPs and hospitals with community pharmacies. (KPMG 2015)

Other benefits of Technological advancements in patient’s script dispensing that are widely researched and well-published include:

               a reduction in medication errors;

               a reduction in variance in prescribing practice;

               improved legibility, completeness and availability of medicine orders;

               improved communication with patients about their medication;

               improved decision-making facilitated by information resources; and

               more efficient and effective interactions among the care team, including pharmacy.

4.0 Problem Framing:

Once we’re immersed into our problem research and possible solutions, There are important learnings that can be harnessed from those who have implemented effective systems to ensure a greater likelihood to successfully implement of one platform for all stakeholders.

Other insights following Health central-system implementation plan and solutions mapping, in order to converge in the right direction using statement starters and affinity mapping by codifying our research data using Rose, Thorn and Bud:

•      How to implement “Consumer-focused approach to health central-system implementation”

it is widely reported that a patient-centric approach results in higher clinical quality and efficiency, a safer patient environment, greater employee engagement, and improved financial results. The use of health central-system has the potential to facilitate the patient experience through reducing the potential for error and adverse effects to facilitating a more seamless and secure pathway through the care continuum.

• How might we establish Strong governance, executive leadership, and sponsorship?

a large project such as a health central-system implementation requires strong ongoing leadership. This should be considered a key requirement for the implementation of such a project. However, pharmacists as experts in the safe use of medicines are key stakeholders and decision-makers and should be considered for key leadership roles in the health- central-system implementation project and should assume a principal role on the project board.

•   How to achieve “Strong change management support” to get, stakeholders ‘on board’ and to accommodate different interpretations of health central-system practice. Organisations that engaged end-users during the planning and development stage had more success implementing Electronic Medical Record systems and achieved greater buy-in and acceptance of the systems. Nurses were found to be strong candidates for leadership and engagement roles, or ‘change champions’, particularly in the planning phase of implementation given their central role at the front line of care and established relationships with pharmacies, and may-be suitable champions for the health central-system. It was found that staff at all levels should be taken along on the journey to raise awareness of the project and to generate buy-in. This could be achieved through regular communication, setting realistic goals and monitoring progress through measurable metrics.

•        How might we “Ensure sufficient resourcing for the life of the project”, implementation is a resource-intensive endeavour. The success of the project, if it is insufficiently resourced (with both financial and human resources) is at stake. Adequate resources and strong governance mechanisms should be in place and used from the start of the health central-system implementation.

•   In what ways might we  “Engage all key system users early in the project” To ensure that the impacts of the health central-system on non-clinical care providers aren’t underestimated?

Early involvement of diverse stakeholders also assists with communicating project rationale, and to determine realistic resource estimates and time commitments by key users which in time will facilitate project implementation and minimise conflicting work and project priorities. This is particularly true for the pharmacy workforce which bears a disproportionate workload associated with the implementation and ongoing operations of a Health central-system.

•      How to ensure “Ongoing staff training” across the project?

The training include, but not limited to all health professional groups involved throughout the implementation process, as well as ongoing training to keep key users up to date on changes and upgrades to the system. The pharmacy department can identify areas and applications of best practice which can be used to provide training and develop training guides.

•     How can we plan “Progressive implementation”.

Health central-systems are complex in nature, particularly end-to-end health central-systems. A continuous rollout builds confidence in the system and allows for identification of problems, giving, following realistic timeframes.The literature shows a trade-off between the speed and efficiency of implementation and the level of acceptance by staff – the more progressive the implementation, the more likely staff are to accept and use the new technology.  A ‘big bang’ approach has been associated with the greatest losses in productivity whereas a hybrid approach, starting with a limited introduction and then followed by a complete roll-out the following year, was associated with significant productivity gains.

•         How to achieve “Workflow impacts”?

 Mapping the  workflow process exercise should occur early and regularly monitored throughout the project. The workflow process mapping exercise must:

      Recognise impacts for all users of the system (nursing staff, medical staff, pharmacy staff, and other allied health);

      Take into account how current practices and interactions between users may be impacted;

      Account for differences for high dependency areas such as intensive care and mental illness; and consider the impacts and interaction of the health central-system with other systems and processes. (KPMG 2015)

5.0  Identify risks and challenges

Similar challenges have befallen Australian health care providers implementing Health Cental-System systems to those implementing similar systems internationally.  In Australia, the causes of unsuccessful Health Cental-System projects have been attributed to one or more of the following^:

      Legislative reforms, specifically the location and ownership rules as well as the 20 days rules applied to repeat scripts.

      Collaborative trials between all stakeholders

      Re-visiting the technology currently used from e-commerce and data-sharing platforms

      Logistics and storage or redesigning the supply chain process

      Reform to the paper-based script system currently still in use

      Reforms to corporate and licensing laws concerning healthy competition in the market

      lack of executive-level sponsorship;

      lack of clinical ‘champions’;

      insufficient planning and resources;

      insufficient funding or cutting corners to meet the budget;

      technical—lack of devices at point-of-care;

      human—failure to engage additional personnel for user support sustainability, audit, and enhancement;

      failure to adequately involve end-users;

      failure to improve manual systems before computerisation;

      inadequate change management;

      failure to perform implementation and post-implementation; and

      assessment and remediation. (KPMG 2015)

A range of other key considerations found in the Australian context, and detailed below, include:

      Workflow mapping that reflects the medication management continuum and patient-centred care;

      the impact of Health Central-System on the required capabilities, education and training, scope of practice and credentialing of the pharmacy workforce (and any other impacted workforces);

      Technical functionality of Health Central-System and impact on workflow;

      The specialist needs of services and high dependency units- including intensive care and emergency departments, children’s and mental health services. (Deloitte 2017)

3.4.1 Interaction with other systems

Workflow process mapping should consider the impacts and interaction of the health central-system with other systems. The Australian Commission on Safety and Quality in Healthcare’s Electronic Medication Management System: A Guide to Safe Implementation flags that of particular importance are consideration of systems interactions for diagnostic and pathology orders and results; adverse drug reactions and

allergies records; medication histories on admission; and discharge prescriptions and summaries.  It should also be integrated with pharmacy dispensing systems. This is to ensure that the information that is needed to make clinical and medication decisions is available and where possible integrated with the Health central-system solution.

3.4.2 Patient safety and medication errors

The most commonly cited benefit of Health Central-System is the reduction in potential errors and adverse events, the majority of which are classed as preventable.

According to KPMG report: “In Australia, literature also shows that the introduction of new technologies has introduced different types of errors, in particular in the early stages of Health Central-System implementation. A post Health Central-System implementation retrospective analysis of 359 incident reports across two hospital sites in urban Melbourne found that the vast majority of medication errors occur at the nurse administration (71.5%) and prescription (16.4%) stages of delivery, with notably few medication errors reported by pharmacists, and only at the non-HEALTH CENTRAL-SYSTEM site (n=1, 0.4%).

An analysis of the impact of two e-prescribing systems in two Australian teaching hospitals found a statistically significant reduction in total prescribing error rates by over 55%.

A study in the United Kingdom also found that introducing an electronic prescribing system gives rise to new types of errors and risks to patient safety. Effective implementation, therefore, requires an awareness of these errors- which in the study were found to be sociotechnical incidents, including training of new users; missing electronic signatures; an inability to effectively use the interfaces designed; and limitations on prescribing privileges in the system. Such errors can be addressed by designing out and testing the new system, ensuring effective training and revising clinical protocols if needed.” (KPMG 2015)

4. Summary:

Apart from the stakeholders being outspoken about the lack of satisfaction from the current script systems and regulatory laws in place, The literature shows that there is currently strong support for health central systems and related electronic programs and their components in Australia, including from governments and key professional associations, as well as considerable interest and support internationally.

As well as a reduction in medication errors, several key benefits of the centralised electronic platform and electronic script issuance and dispensing are cited, including a reduction in variance in prescribing practice.

There’re visible benefits out of introducing new technologies to link all the different stakeholders (GP’s and Pharmacistsin particular) such as  improved legibility, completeness and availability of medicine orders; improved communication with patients about their medication; improved decision-making facilitated by information resources; more efficient and effective interactions among the clinical care team, cost-effectiveness, improved clinical information sharing; minimised transcription errors; reduced duplication, reduction of waste and system-wide inefficiency; prevention of the misalignment of records; and standardised, legible and complete orders.

By upgrading to a central platform while incorporating supply chain, most of the negative competition damages caused by the legislation in terms of 20 days rule and location rule as well as the ownership rule could become Obsolete.

References:

       Pharmaceutical Benefits Scheme 2019, ‘ RPBS Explanatory Notes’, Viewed 14 September 2019, <http://www.pbs.gov.au/info/browse/rpbs/rpbs-explanatorynotes>.

       Pharmacies Australia Industry Research Reports  2019,  Industry report 2019, IBISWORLD,  viewed 14 September 2019,<https://www.ibisworld.com.au/industry-trends/market-research-reports/retail-trade/other-store-based-retailing/pharmacies.html> IBISWORLD database.

       Australian Department of Health 2016,  Review of Pharmacy Remuneration and Regulation Submission no 218, Viewed 14 September 2019,

       <https://www1.health.gov.au/internet/main/publishing.nsf/Content/review-pharmacy-remuneration-regulation-submissions-cnt-5/$file/218-2016-09-23-chemist-warehouse-submission.pdf> .

       Buss, V., Shield, A., Kosari, S. and Naunton, M 2018, ‘The impact of clinical services provided by community pharmacies on the Australian healthcare system: a review of the literature’, Journal of Pharmaceutical Policy and Practice, Vol. 11, pp. 1.

      Anon 2017,  ‘How to Use the LUMA System of Innovation for Everyday Design Thinking: Webinar Recap’, Blog Post,  Viewed 15 September 2019, <https://blog.mural.co/use-the-luma-system-of-innovation-for-everyday-design-thinking>  

       Australian Government Department of Health 2019, Department of Health | New (7th) Community Pharmacy Agreement, Viewed 15 September 2019, <https://www1.health.gov.au/internet/main/publishing.nsf/Content/New-7th-Community-Pharmacy-Agreement>

       Australian Government Department of Health 2015, ’KPMG -Pharmacy eHealth Workforce Initiatives Project’, viewed 15 September 2019,

<https://www.health.nsw.gov.au/workforce/alliedhealth/Documents/pharmacy-ehealth-literature-review.pdf>.