What Makes Hospital Medication Management Complex? (Talking Healthtech Summit)

There are “five rights” of medication use: the right patient, the right drug, the right time, the right dose, and the right route. It might seem obvious, but in practice, an error can occur at the level of each of these “right”s. 

At the last Winter Talking HealthTech Summit - an Australian one-day online conference, Melissa Fodera, Chief Pharmacy Informatics Officer (CPIO) Western Health Australia, Božidarka Radović, Better Meds Product Lead at the health IT company Better and Gidi Stein, CEO of MedAware highlighted the challenges that still need to be overcome to improve medication safety in the hospital setting.

The Australian Commission on Safety and Quality in Healthcare estimates that between 2% and 3% of all Australian hospital admissions are medication-related. In the UK, it is estimated that adverse drug reactions account for 10-20% of hospital in-patient admissions, according to the Chief Pharmaceutical Officer’s National Overprescribing Review, which was published in September 2021. 

Speaking more broadly, unsafe medication practices and medication errors are a leading cause of injury and avoidable harm in health care systems worldwide. According to WHO, the cost associated with medication errors has been estimated at $42 billion USD annually on a global level.

The complexity of the hospital 

Medication management doesn’t end with a doctor typing a prescription into a computer. A clinical pharmacist needs to review what was prescribed, if the right drugs in the right dose are chosen for a specific patient. Sometimes, laboratory results need to be checked before prescribing a drug and to prevent errors at the point of dispensing, hospitals use pharmacy robots and digitized ward cabinets. In essence, a large number of hospital systems are involved in medication management. 

Hospital systems involved in medication management.

The highest safety standard for medication management is the so-called closed-loop medication management, which is achieved when each part of the medication journey is digitalized. 

Western Health is the major healthcare provider covering a population of  900,000 people. It provides a comprehensive, integrated range of clinical services at all levels of care and is highly digitized. However, some parts of medication still run on paper, and electronic prescribing is not paperless, said Melissa Fodera. Digital transformation is still in progress. 

Any digital transformation manager of a hospital or vendor trying to enter the hospital IT space needs to understand processes from various perspectives, emphasized Božidarka Radović. The hospital team and end users need to know what is reasonable to expect from electronic prescribing and medication administration systems (ePMA). For one thing, ePMA is only one part of a larger puzzle. The vendor and the hospital need to have an implementation team that prepares a detailed implementation plan, which starts with a gap analysis. The third important aspect is customization and localization. “Even though roughly 80% of the processes are pretty similar everywhere, 20% usually have local specifics,” said Božidarka Radović. 

Clinical Decision Support

While the futuristic ideas of healthcare innovation expect patients to receive tailor-made, highly precise treatment recommendations upon hospital admission and during a hospital stay, technology is not there yet. To avoid liability issues and err on the side of safety, decision support systems often fire more alerts than needed, causing users to suffer from alert fatigue and ignoring warnings. This can result in errors and patient harm. 

When clinical decision support gives a wrong alert a few times, users lose trust in it. “My residents accept 15 to 20 patients at night, each having 10 to 15 medications. The sheer number of patients makes it almost impossible for a clinician or a pharmacist or a nurse or a physician to actually really dive deep and understand the patient's situation, the different medications that they're taking, and the different risks that are imposed on these medications,” said Gidi Stein, CEO of MedAware. 

Companies such as MedAware help refine the number of alerts by taking into account information in the patient’s electronic record and lab results. However, if a hospital uses several systems from different providers, which are not integrated, those recommendations can be less specific.

What’s next for medication safety?

“I've seen medication errors where the alert of a clinical decision support system didn't fire, when it should have, and an incidence occurred for something that was rarely prescribed. When something is very rarely prescribed, that's when you're not so familiar with how it is prescribed. And that's when you really need that decision support to help you. Alerts need to be very specific to be useful, but on the flip side, if you only capture such a small group of alerts, there are also the times when you need it and it may not fire,” Melissa Fodera added to the debate about needed improvements in medication-related decision support systems. The next thing she sees as most important in improving medication safety is the implementation of closed-loop systems and barcode scanning, so the drug and the patients are scanned before administration.

Božidarka Radović sees changes in software design as the next big change in the evolution of medication management software. “I would point to two things: data and modularity. We need data to understand what was happening behind the prescribing process. What, when, and why it happened. Things can be similar in different countries but still are different enough for us to need additional insight to understand and address them. The second thing is modularity - meaning that we create a piece of a puzzle for the improvement of each process.”

For Gidi Stein, the spotlight needs to turn to patients. “I think the next frontier is finding technology to empower patients and caregivers, to be more involved in their medication management and be more proactively involved in the safety of their own treatment,” he concluded.

This is only a summary, tune in to the full panel discussion in iTunes: