“The concept of ePMA is not one that needs a lot of effort in order to gain buy-in. It is pretty well-understood across health systems that hand-written prescriptions are, in the context in which we now work, dangerous; they should have no place in this millennium,” said Julia Scott from Dartford & Gravesham NHS Trust.
Julia Scott is an Associate Director of Clinical Quality Assurance and Innovation at Dartford & Gravesham NHS Trust. We spoke to her about the experience with Better Meds after successfully rolling out the ePMA (electronic prescribing and medication administration) system over a single weekend using a “big bang” approach. A dedicated clinical team carefully transcribed more than 500 paper drug charts and 8,000 prescriptions into the system during the two days, and 200 healthcare staff from across the integrated care system joined forces to support the go-live.
It’s been a few months since the go-live. What has been your and your team’s experience? What has been the general response to the transition?
The response to ePMA has been overwhelmingly positive, and the transition to this new way of providing care has been pretty smooth overall. We knew that the Better Meds user interface was highly intuitive, so we expected users to have very little difficulty with the core functionality, and those expectations were very much met. My favourite quote from one of our consultants is, “I think ePMA is wonderful. It is sometimes little short of miraculous and does all sorts of beautiful things.” I love that; it encapsulates exactly how I feel about Meds!
Furthermore, user feedback tells us that staff felt the benefits from day one, including no more missing drug charts, no more waiting for a drug chart whilst someone else uses it, complete and accurate record keeping and audit trails etc. One of our nurses told us how excited she was about ePMA coming, as she would never have to go home worrying that she might have made an error because of a hard-to-read prescription – so to have that immediate benefit of prescription legibility is huge for us.
Are there any features of Better Meds that have particularly resonated with clinicians?
From the point of view of prescribers, I think the most frequent feedback to date has been about how helpful order sets are. Order sets/order sentences are a relatively simple thing but are so powerful in terms of enabling various safety features and nudging towards safe behaviours. We don’t want clinicians to rely 100% on the content of order sets, and the need for clinical judgment and expertise remains. But they are an incredible tool for reducing overall cognitive burden and reducing reliance on potentially flawed memory (or counter to that, reducing the need to spend time looking things up when you can’t remember), both of which are hugely important for clinicians who may be tired, hungry, stressed, lonely, etc. Something as simple as order set functionality could, when multiplied up to the whole organisation scale, have a genuine impact on reducing clinician burnout.
A couple of other highlighted cool features are around pain management and palliative care. The totalling up of doses of drugs given PRN (‘pro re nata’ – medicines given when needed, rather than on a regular basis), if you’ve listed a daily maximum dose, is really useful in areas such as pain management with opioids. The feature for prescribing multiple drugs in a single subcutaneous infusion, something that is essential to keeping many patients comfortable during end-of-life care, is also beautifully designed. This feature does take a bit more guidance for clinicians than others, but this is not a simple area of prescribing and should always require care, thought, and consideration.
From the point of view of drug administration processes, one of the favourite features seems to be how easy it is to order medication supplies from Pharmacy. From a personal point of view, I love the overall ability to build genuine hard stops into prescribing processes via Meds Config, the Better Meds medication configuration module. My go-to example, as we have worked through this project, of what ePMA should do for safety is around the drug methotrexate, which is commonly used for conditions such as rheumatoid arthritis. It needs to be taken just once per week; if a patient is inadvertently prescribed the drug daily instead, it can be fatal, and this is one of the ‘classics’ of medication safety. With Better Meds, I now have a hard stop that simply will not allow you to prescribe this drug at a frequency of anything other than once per week.
How did you engage clinicians and staff during the implementation of Better Meds? Were there any strategies you used to ensure buy-in and ease the transition?
The concept of ePMA is not one that needs a lot of effort in order to gain buy-in. I feel it is pretty well-understood across health systems that hand-written prescriptions are, in the context in which we now work, dangerous; they should have no place in this millennium. As such, the messaging through the course of this project has never been ‘Should we do it?’ but ‘Why haven’t we done it already?’. As time passes and staff move around the healthcare system and work at organisations that are more digitally advanced, if they then move to an organisation where care processes are still heavily paper-based, they experience frustration both in terms of old-fashioned care processes and the unnecessary workload it puts on them. The buy-in from these users was an absolute given!
I’ve also never felt a need to gain buy-in for our system choice in particular. As I mentioned earlier, the Better Meds UI is highly intuitive and beautifully designed – it speaks for itself. I have senior pharmacy colleagues in other organisations who are very jealous of us for being able to use Better Meds!
As we approached go-live, our engagement work with frontline teams was led by our team of Digital Clinical Practitioners. This group of healthcare professionals, on secondment from frontline roles within our organisation, were piloting a new role for us (with credit for the inspiration to Dan Pugh and the team at South Tees Hospitals NHS Foundation Trust!), expanding the capacity of our Digital Health Team, aiming to both prepare the organisation for the change of ePMA, but also to act as the first line support for clinical colleagues having any issues with ePMA post-go-live. They developed their knowledge of business change processes, became expert users of the system, and helped to bridge the gap between project/technical teams and clinical teams by creating our ‘Digital Hub’. Initially, this was a fixed location hub in our staff canteen, where staff could drop in for questions and queries, to see Better Meds in our test environment, or to seek support with completing their training. But true engagement doesn’t wait for users to come to it – it meets users where they are. So the DCPs created the #HubOnWheels, which went out to all of our wards to provide that same offer of support and to have an open dialogue around ePMA, but in the clinical environment. We found this to be a really useful way of reaching people and seeking feedback and is absolutely something we’d love to keep rolling in the future – literally!
Were there champions within the trust (besides you!) who helped drive engagement?
Absolutely, there were champions throughout the organisation. As we gained momentum through 2024, our entire Executive Team were active champions, as were our Non-Executive Directors, especially those who work in our quality and safety domain and have been monitoring the project’s progress over the years.
But on top of this, we had our #DigitalHeroes – all of whom are Trust champions for ePMA. This hashtag represents a concept, a social movement, an idea for a comprehensive approach to representing and developing our capacity and capability for digital transformation (or my preferred phrase – ‘clinical transformation, digitally enabled’). It encompasses our Digital Health Team, the digital transformation professionals who are experts in bridging the gap between technical and clinical; our clinical informatics officers, who are all senior doctors in our clinical divisions who lead on clinical safety and digital transformation on their divisional governance structures; and our Digital Clinical Practitioners, a new role we are piloting to develop those digital health experts and provide a pipeline and succession plan for these specialist roles. It also includes our huge number of Digital Super Users, the group of registered healthcare professionals who we train to support their colleagues during new system launches by becoming both our ‘highly competent system users’ and who also learn about wider change management tools and techniques with our Clinical Quality Improvement team. In the future, I hope this will also include our wider community; we are planning to host some T-Level students in our team early next year, and I very much see them as part of our #DigitalHeroes.
How has this project reinforced your trust’s commitment to clinical excellence and patient safety?
Our Trust’s new strategy, launched in April 2024, has digital and data transformation as a strong theme throughout. We know that digital systems and good use of data are both key enablers to clinical excellence, and our strategy acknowledges that. Our Trust Board set ePMA deployment as one of the key goals for the first year of our strategy, along with several other goals related to deploying digital tools to support our patients and clinicians.
The project has shown us just what can be achieved when clinical transformation is enabled by high-quality digital systems and deployed thoughtfully, with appropriate skill and resources. It has shown us how quickly we can begin to experience the benefits of digitalisation after a go-live. It also makes the areas where we are still very heavily reliant on paper stand out in stark relief.
As a result of this contrast, the conversation about some of our other healthcare IT system projects seems to have had the volume turned up since Better Meds went live. People recognise that we really cannot deliver improvements in clinical excellence and safety at scale without the right digital tools. We have had a strong pull from areas that are not currently live with ePMA to get it into their hands ASAP, as well as other pieces of our Miya Precision platform. ePMA has set the bar for what can be done and how to do it.
How do you envision this system evolving clinical workflows or improving healthcare delivery over time? Does it align with your plans or priorities for meeting future clinical needs?
From my professional point of view, one of the most exciting things about ePMA has always been how it could transform clinical pharmacy processes through clinical prioritisation. By using the data to identify those patients most in need of, e.g., specialist pharmacist input, we will be able to make the best use of the precious and limited resource that is a Pharmacy team. I know that the 3.16 release of Better Meds is actually going to do this prioritisation for us in a far more sophisticated AI-driven way, so I think our next step may just be to get that upgrade!
In November, the new UK Secretary of State for Health & Social Care outlined three ‘strategic shifts’ needed in the NHS: a shift from analogue to digital; a shift from care in hospital to care in the community; and a shift from treatment to prevention. This aligned with our existing strategy as a Trust, and even with past strategy over the last decade, to focus beyond the walls of the hospital and inpatient beds, looking at increasing delivery of specialist care in the patient’s home, with a stronger focus on illness prevention and admission avoidance, and on addressing issues of health equity.
For DGT, Better Meds is at the vanguard of our analogue to digital shift, that one is a no-brainer. In terms of that shift towards care in the community, the current Meds solution will be a key part of our care processes for virtual wards, and I’m excited about how future developments could expand on suitability for that virtual care setting. In terms of a shift to prevention, I think one of the key things here for us is about how Better can give us access to the data that can drive that, especially as they are at the cutting edge of open-source EHR data.
From your perspective as an Associate Director of Clinical Quality Assurance and Innovation, what has been the most rewarding part of implementing the Better Meds ePMA system? How has this project aligned with your own values or goals in healthcare?
One of the personal drivers of this project for me through the last 3 years has been a commitment we made to the relative of a patient who died following a medication error and the memory of other significant medication-related harms that I have investigated in the past. I knew that ePMA would help us with reducing the risk of many types of medication errors in a way that nothing else could. As well as reducing error through fairly broad-brush improvements such as legibility, audit trail, reminders etc., more critically, it enables improvement through the ability to create genuinely strong, systemic barriers to error, where this could simply not be achieved with paper prescribing.
James Reason, one of the greats of organisational safety, described the need to be ‘preoccupied with error’ in order to drive safety in high-reliability organisations, and that phrase has always resonated with me (the phrase was in my Twitter bio for many years!). A preoccupation with errors and how to reduce and prevent them has been a thread through my career and one of the goals of my work, whatever my role has been. Leading and delivering a project that truly enabled me to impact errors at a systematic level was a genuine honour and will always be a career highlight for me. It was also Reason who described the ‘Swiss Cheese Model’ of accident causation – ePMA allows us to block up holes in the cheese! But it is also important not to be complacent about the risk of error and assume ePMA has blocked all of those Swiss cheese holes. We must acknowledge that it introduces brand new error types that simply would not occur on paper (e.g. mis-selection of a drug from dropdown menus – picking penicillamine instead of penicillin is the classic example here). With that acknowledgement we must then try to plan accordingly to further mitigate the risk, working with the clinical team at Better to share learning about errors, near misses, and ideas on how to further improve.
What are some key lessons you’ve learned through this project? How has it shaped your approach to managing future healthcare projects?
Oh, there are so many. The big one for me personally… never give up! This was a very long project for us, and we suffered some significant unavoidable delays due to the COVID-19 pandemic, as well as some technical infrastructure and governance issues. But even when all that was in the past, and the project was gathering pace towards the finish line, there were times when new issues or barriers arose when I felt ready to throw the towel in. Those are the times when I had to really dig in, remember the goal, remember why we were doing this, and remember to ask for help. A pep talk from someone in my core support network was something I needed a few times in those last few weeks, as well as remembering to be kind to myself and recognising when I needed a break or some downtime of my own.
In terms of my own approach to future projects, the key things I’m thinking about at the moment are about continuing to grow our internal capacity and capability for this type of transformation, working with peers across our healthcare system to look at opportunities for collaboration, and making sure every project continues to be driven with quality and safety for our patients at the heart. If the work isn’t about making improvements in care for the people we serve and for the colleagues who provide that care, I’m not interested in it!
What advice would you offer to other NHS trusts considering the implementation of an ePMA system like Better Meds?
Make sure a commitment to safety is the driving force behind the project. Invest as much time, if not more, in addressing the human side of the change as you do in the technical change. ePMA is not a Pharmacy project; it’s a whole system medicines optimisation project. Make sure you have the Business Intelligence resources and infrastructure in place to extract data and turn it into actionable information, as some of your biggest benefits will be in use of this data. And yes, you CAN do a big bang!
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