INTRODUCTION
The transition from a paper-based medication prescribing and administration model to an electronic system represents a major change initiative for an organisation. This transition requires a whole-of-hospital change management approach, factoring current organisational culture and pre-existing models for change initiatives, while maintaining patient safety as a paramount consideration. Electronic medication management (EMM) systems represent a highly desirable functionality that is accepted by the health sector as advantageous for improving many aspects of medication safety, including medication reconciliation and cost-effectiveness.1–5
While many hospital sites, particularly in North America, favour a single ‘big bang’ delivery of the electronic medical record (EMR) and EMM at the same time, most Australian hospitals to date have implemented EMM prior to an enterprise-wide EMR.6,7 In the Australian context, this has led to long lead times for adoption and post-go-live maturity.8 In Western Sydney, the experience of implementing EMR prior to EMM had ingrained a culture of digitisation and electronic documentation. The advantage of allowing EMR to be embedded in a hospital prior to EMM improves digital literacy and reduces the risks associated with EMR adoption alongside EMM, when the latter is eventually implemented.
Roll-out strategies across the globe for EMR and EMM traditionally involve two main methodologies9,10:
‘Big bang’ – an all at once implementation across the organisation, usually activated on a single day or week. This option is likely to be disruptive to the entire hospital and would require comprehensive testing and a large training burden in a short timeframe.
Phased (or staged) – usually a ‘ward-by-ward’ implementation over weeks or months until the whole hospital is converted to the electronic system. By the very nature of this method, it necessitates a hybrid medication system – patients that move between wards will require transcription of their medications from paper to EMM and vice versa. This is a high-risk scenario for medication safety and duplicates work effort during the transition period.
Simple EMR implementations are more conducive to the ‘big bang’ approach, where clinical documentation is not complicated by medication charts. EMM implementations in Australia have so far favoured a phased ward-by-ward approach. Advantages and disadvantages of both the traditional roll-out models are shown in Table 1.
While the phased strategy at previous sites has been somewhat iterative and allowed lessons to be learnt, it has led to change fatigue within the project team as well as for end users. This phased strategy often does not begin in the emergency department (ED), which is left as one of the last wards to convert to EMM. This leads to patient admissions with paper medication charts requiring conversion to electronic prescribing in EMM wards – that is, duplicate prescribing on a daily basis throughout the transition period.
The success of EMM implementation is highly dependent on adequate support for staff during training and through the go-live period. Any intended benefits are at risk of not being realised if change management, user adoption and go-live support are poor. The use of proactive, well-informed superusers to assist in EMR change management and support in the implementation phase is a well-documented concept with significant advantages.11–13 Previous EMM sites in Australia had implemented with a baseline of 1:10 ratio in their superuser strategy. In order to empower superusers with adequate knowledge, they are required to undergo extra training, understand all aspects of application functionality and the rationale for design decisions. In the go-live phase, superusers perform better as supernumerary staff members acting as support to their colleagues while maintaining minimal or nil patient load. This project took all the experience and lessons learnt from the previous implementation sites in formulating a facility-specific superuser strategy to support the design, testing and roll-out of EMM using a patient-centric approach.
The project’s clinical reference committee and focus groups had identified that patient safety was the ultimate consideration in EMM implementation; hence, the roll-out strategy must align with this philosophy and maintain patient and medication safety as the overriding principle for its design. The tenet of ‘one patient, one chart’ was held paramount – that a patient must only have either a paper medication chart or an electronic medication chart. This led to the development of an innovative model – the ‘patient-centric’ roll-out method. The objective of this paper is to describe the rationale, method and implementation of this model for EMM roll-out.