At HTN Now, we were joined by the NHS England blueprinting team along with South-West London and St George’s (SWLST) Mental Health NHS Trust, for a discussion on EPMA in mental health, with a specific focus on prescribing and administering long-acting injections. Along with the blueprinting team’s co-chair Paul Charnley and assistant director of blueprinting Saj Kahrod, we welcomed Abz Salama, an advanced specialist information pharmacist from the trust.
Paul began with an overview of the blueprinting programme; it was established to support the NHS and health and social care organisations with their digital maturity by collating knowledge assets and supporting peer-to-peer learning. “It allows us to gather the experience of organisations and collect lots of useful material that they have developed along the way, which other organisations can pick up and use,” Paul explained. “It’s also intended to create a network of organisations to allow them to talk about the issues that they are facing with the projects they are working on. Ultimately, it’s there to accelerate digital transformation in the NHS.”
Looking at the programme’s objectives going into 2024, Saj highlighted plans to develop new shared learning content that engages staff through innovative and interactive channels; to develop blueprinting as a key method for sharing good practices in the primary care sector; and to create and promote and sustain a learning eco-system to strengthen opportunities for shared learning. In addition, the programme seeks to increase the blueprint portfolio to reflect good practice across the NHS; to develop bespoke blueprints to tackle national priorities such as bed management; and to support national key agendas such as EPR levelling up and a greener NHS.
Next, Saj shared some statistics about the programmes; the platform currently has 3,746 users with 209 blueprints published in total and 3,394 supporting artefact resources.
EPMA in mental health, at South-West London and St George’s Mental Health NHS Trust
Abz started by sharing some contextual history about digital health at his trust. They went live with the first phase of their EPMA system in 2016, which focused on long-stay wards, acute wards, specialist wards, home treatment teams, and clozapine repeat prescribing. In 2019, they upgraded the system to implement the prescribing of long-acting injections (LAIs) and antipsychotic depot medication with the community mental health teams.
“This was a huge win for us,” Abz commented. “We have over 1,000 prescriptions within the community – people who are taking LAIs or depot medications for their mental health. That requires a lot of paper and opens up a lot of possibilities for things to go wrong or go missing; that pushed us to upgrade.”
As of summer 2023, SWLST is embarking upon a further upgrade, to enhance their use of the EPMA system specifically for a mental health setting.
Depot and LAI prescribing
“These are all done on the in-patient chart on the EPMA system,” Abz explained. “The reason for this is that the way the current system is built doesn’t support repeat prescribing. Doing it this way allows us to continuously monitor, prescribe and administer the medicine list.”
On the advantages, firstly Abz highlighted how the system supports safer prescribing, with legible and therefore accurate prescriptions which can be reviewed from anywhere. “Once a prescriber issues the prescription, a pharmacist can pick it up and review it, and then a nurse is able to administer that medication. That can all happen within a few seconds. It’s amazing how quickly it can all go through. Before, with a paper system, once the prescription is issued, you must take it to the pharmacist or wait for the pharmacist to come to the clinic to see it so that they can supply it. Then there would be another wait for the nurse to administer it. It could be a very long process. The EPMA system really allows ease of access.
Other benefits included supporting remote access, which was particularly helpful during the pandemic; reporting tools; and auditing functionality. Explaining how the system can generate reports and audits for prescriptions, Abz said: “I’ve set them up in a way that prescribers can receive a notification when a prescription is about to expire, or if a patient hasn’t had their medication for some time. It helps us pick the little things up, just in case something needs to be changed on a prescription to make sure everything is clinically appropriate and completed to an efficient standard.”
He added: “It helps us with our general reporting and auditing as well, throughout the trust, and as part of our quality improvement programme. For example, I ran a report recently looking at our overall expenditure across several years, for certain medicines that have now become generic. So, we can look for possible ways to save money.”
Picking up on the issue of clinical safety, Abz noted that there are “great safety features” within the EPMA system. “For example, if patients have similar names, it flags it and prompts you to check that you’re looking at the right patient. It also allows you to prescribe more than one medicine at a time.”
In addition, he highlighted the role of EPMA in supporting SWLST in going green. “Negating the need for paper charts has a significant impact on our carbon footprint. On average, 1,600 paper charts were being used per year. We could potentially be saving 8,000 grams of paper, which in turn saves almost a ton of CO2.”
Next, Abz moved on to highlight some of the challenges that SWLST has faced. “The system is not designed for repeat prescribing in the community, or for flexible administration. We have developed a workaround for that, whereby we always prescribe two medications together; the regular medication and a ‘when required’ medication. That means that if the patient attends early for their appointment, we can use the ‘when required’ option to get their medication for them. We’ve also discussed this with our supplier when it comes to enhancement requests through our upgrade.”
Another drawback, Abz noted, is that the system requires users to be “somewhat technologically proficient”. Abz commented that this can be challenging with the culture in the NHS sometimes resistant towards change.
Regarding the planned upgrade, Abz shared several enhancement requests that his team have built business cases for. “There’s the repeat prescription functionality – we want a specific space on the system so that we can do this without requiring a workaround, and we want it to allow for flexible administration as well. So, if a patient does come in early, there should be leeway of a couple of days to allow us to make that prescription, depending on the frequency and the medicine itself.”
Abz and his team are also keen for the upgrade to include specific routes for administration. “With paper prescriptions, you could do this, because you could write whatever you wanted – for example, you could specify ‘left deltoid’ or ‘right deltoid’. Currently, on the system, you can only specify that it’s an intramuscular injection, and you must add extra notes to specify the site or the route.
“We also want automatic prescription re-synchronisation – so if a patient wants to come in a week early for their injection, it will recalculate when the next one is due based on that timing, rather than a member of staff having to make that edit. It’s about saving time where possible so that staff can prioritise their time to spend it with patients in the clinic or discussing medication options for reviews.”
The team have installed the new upgraded version of the system and is currently in a testing phase; Abz explained that they will be spending the next couple of months testing and trialling the new features before they roll it out officially and go live.
Other digital wins
Abz took the opportunity to highlight other digital wins within the department.
“With EPMA itself, we’ve also started using it within the last year for consent to treatment notes and images within the community. When patients are subject to the section of the Mental Health Act and subsequently consent to treatment, by law they can only be prescribed medicines for their mental health that are outlined within that document. We’ve captured images of these documents and uploaded them onto the patient’s chart. So as soon as someone enters the chart to prescribe something or to administer a medicine, they can see at a glance if this medicine is covered by law.
Coming back to the automated notes to warn staff members if a prescription is about to expire so that it can be renewed in a timely manner, Abz said: “We’ve had these prescription expiry dates reviewed within our formulary team and our drug and therapeutics committee within the trust, to allow us to extend the expiry dates from six months to 12 months. This is because we have such a huge number of prescriptions and most patients have been on them for years. They tend to stay on the medicines for life. We don’t want to end up in a situation where these prescriptions all require renewal at the same time, causing a bulk and a delay in supply.”
Abz shared how the team has moved into a new building as of December 2022, which includes the use of a pharmacy robot. “Everything is going great – the robot is saving a lot of time for us, especially out-of-hours. For example, if I were the on-call pharmacist, rather than having to make my way over to the pharmacy in the middle of the night to supply a medicine, I can source it all from my laptop and within minutes a member of staff can go down and collect the medicine from the robot.
The pharmacy department at SWLST has also co-developed an app called MindMeds. “It allows people to keep reminders of their appointments and medications, to keep up-to-date with their medicine intake, to track things like sleep and record blood tests that include side effect questionnaires. It’s also part of our greener NHS movement – there are a lot of medication passports being carried around that people use to track things like doses and blood level monitoring for certain medications. We do keep some passports to help prevent digital exclusion, but the app helps us reduce our paper use overall.
More information on the blueprinting programme, including details on how to register to access this blueprint and others, can be found here.
Many thanks to Abz, Paul and Saj for joining us.