Dietitians can improve accuracy of prescribing by interacting with electronic prescribing systems

Inpatient study

We asked renal dietitians working on the renal wards to record recommendations they made in the medical notes for medication changes over a period of 4 months from 1 January 2016 to 30 April 2016. Data were collected using an electronic audit tool, developed in Microsoft Excel by the investigating team. We then asked our informatics department for reports to determine when drug changes had been made in the EHR.

After this period, we asked the dietitians to propose medications directly into the EHR over a 7-month period (figure 1), or use notes against an existing drug for dose changes (figure 2). The audit tool was adapted to collect additional information. We then asked for informatics reports to understand if this has had any effect on the time to change medications.

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The prescribing of medication is initiated through the prescription tab in PICS where medications can be initiated, changed, reviewed or paused. Proposals can be made by authorised dietitians and nursing staff by selecting the proposal tab and adding the proposed drug, with suggested dose and frequency. The system also provides the option of adding annotation notes to explain reasons for proposing a drug.

For dietitians to suggest that an existing drug should be paused, or a dose changed, the drug is highlighted in the medication list, and using the review function, a review note can be added. A small grey eye icon appears in the patient’s medication list and against the patient’s name on the ward list.

Outpatient study

We studied how dietitians recommend changes to medications in outpatient dialysis units. We asked dietitians to collect reasons for medication changes and what had prompted these requests. We recorded how dietitians communicated these request changes to medical staff and then audited how long these changes took, and how quickly the proposed medication changes were implemented. An audit tool was used to collate all information.

In the second half of the study (January 2016 to July 2016), dietitians were asked to use the EHR to update drug histories (figure 3) at points of patient contact at four satellite dialysis units after QA meetings, in telephone conversations with patients and in consultations with patients with medication lists from primary care using an audit tool. Data were compared with informatics reports for accuracy for the 6 months preceding the study and for the duration of the study.

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All patients from unit 3 were asked to bring their GP medication lists in at the beginning of the study period. Dietitians updated the hospital EHR and discrepancies were noted. Patients were asked to bring their GP medication list again after the 6 months study period and the accuracy of the medication lists was compared again. Discrepancies were compared for each patient and average discrepancies were calculated.

We used informatics reports to determine how many changes dietitians made in comparison with other healthcare workers interacting with medication lists.

Inpatient results

In the first 4 months of the study, data for 12 patients were collected who had proposals for medication changes made in the medical notes. Two of these patients were excluded; one was placed on a palliative care programme, and in the other phosphate improved spontaneously and cessation of phosphate binders was no longer relevant. For the 10 patients studied, dietitian medication advice was followed in only three patients.

Where dietetic recommendations were followed, this took an average of 20 days. In one patient, the recommendation was followed after the dietitian reiterated the advice on the ward round.

In the seven remaining patients, where dietetic advice was not followed, the advice was to stop a phosphate binder in two patients and start a phosphate binder in five patients. At discharge, the dietetic advice was still relevant in five of these seven patients.

Following this audit, dietitians changed practice to propose medications directly into the EHR.

In the 7-month study period, 14 proposals and seven review notes for changes to dose, were made by dietitians. Four of these fourteen proposals were converted into prescriptions (one on day 2; one on day 3 and two on day 7). For dose changes following a review note, four of the seven were made (one on day 1; two on day 3 and one on day 7).

Of these eight proposals and review notes which were acted on, four were discussed in multidisciplinary team meetings, resulting in swifter action.

Of note, clinicians often had to be prompted by dietitians to enact suggested changes proposed in the EHR—for example, by talking to doctors on the wards directly.

In summary before the use of the EHR, dietitian advice was followed in 25% of patients and took 20 days from advice to action and this rose to 38% of patients with advice being followed within 4 days on average. Of note, the study numbers here are small, so that the significance of this requires further study (figure 4).

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Outpatient results

Data from 89 patients were collected. Of all the recommendations made by dietitians, 27% involved initiation of a new prescription; 34% involved stopping current medication and initiating an alternative medication; 21% represcribing the calcimimetic drug Cinacalcet and 16% adjusting medication doses (2% had more than one of these actions).

Dietitians suggested changes to medications for various reasons. These included a response to changes in monthly blood levels for phosphate, calcium, parathyroid hormone and folate levels; in response to medication intolerance and because patients were running out of hospital-supplied medications.

Most changes to medication (69%) were discussed and suggested during QA meetings. Dietitians also informed consultants about the need for medications changes via email (31%), particularly where patients were running low on medications and needed supplies before the next QA meeting.

Following discussions about prescription changes it took between 4 and 11 days (average 7.5 days) for letters requesting medication changes to be typed, checked and sent out to GPs (simultaneously appearing in the EHR). This varied between units (figure 5). Emailed requests took longer than face to face discussions.

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The length of time that it took patients to receive medications was between 2 and 18 days (average 10 days) across the four units studied.

Medication changes were much swifter when they were made through the hospital pharmacy (unit 3 had only requested repeat prescriptions for Cinacalcet, which is supplied through the hospital, and patients received their medication within 2 days of this decision). These medications are usually posted to the patient/dialysis unit or collected by healthcare professionals travelling from UHB, QE to dialysis units where they are given directly to the patients.

Updating drug histories

Before the study period, there was minimal activity in updating drug histories in the EHR with an average of 15 drug histories a month being updated by dietitians. This increased to an average of 41 updates per month after start of the study in January 2016.

During the study period, dietitians updated drug histories in 132 patients. One hundred and two patients had previous drug history recorded in the audit tool and of these 26 patients had no previous medication history recorded in the EHR—that is, dietitians were the first to enter a drug history. In the other 76 patients, 50% had had their drug histories updated in the previous 1–3 months, 26% within 1 month, 13% within 3–6 months, 7% longer than 6 months, and 4% (three patients) had had no medication review recorded in the EHR for more than 2 years.

In general for most of the 76 patients, the previous episode of updating was completed by a doctor; only 11 patients had had an update by a dietitian.

Most of the 132 patients updated by dietitians (64%) had one drug updated, 18% two drugs updated, 4% three drugs updated and 14% had four or more drugs updated.

Of the 132 patients 67% of patients had updates following a QA meeting. Dietitians either updated medication lists immediately after QA meetings if this had not already been done within the QA, or during dietetic review with the patient to explain QA changes. For 23% of patients the dietitian reviewed or checked a GP medication list that patients brought in. For 10% of patients, errors in hospital medication lists were identified and corrected in the electronic drug history.

Accuracy of medication lists was reviewed for 11 patients identified from dialysis unit 3 who had their medication list updated over the study period. All of the 11 patients had discrepancies, ranging from 1 to 5 discrepancies at the start of the study. After the study period only 3 of the 11 patients had discrepancies. Accuracy of medication lists improved significantly from 2.4 discrepancies per patient at the start of the study to 0.4 discrepancies per patient after the study period.

Inpatient proposals

From the initial pilot it was clear that the majority of dietetic advice recorded in the medical notes was not carried out by the medical teams despite its ongoing-relevance to the patients. In the small proportion of patients where advice was followed, this generally took a long time and required further intervention by dietitians before medication changes were made. Changing dietetic practice to propose medications directly into EHR resulted in a greater number of patients having dietetic advice acted on and the process was much quicker than with the initial study. However, the sample size was small and further validation of these findings is required.

Fifty percent of these medication proposals were discussed during a multidisciplinary team (MDT) meeting and resulted in more prompt action. Our study shows that dietitians can therefore exert greater influence on patient care if they can make medication change suggestions directly in the EHR. However, the overall numbers of proposals acted on remained small and some direct contact from the dietetic team was still needed for changes to be made.

The EHR is therefore not a complete solution. Streamlined processes and efficient technology are tools that can help but they cannot change behaviour without simultaneous change in operational processes.10 In combination with operation change, EHRs have been shown to change behaviour, making prescribing practices safer11–13 and reducing missed medications.14

Design of the EHR is important and the criteria for a good EHR can vary for different user groups.15 In general, EHRs that have been designed by clinicians and with patient care as a driver are better received. Clinicians require EHRs that are interoperable and reliable.10

Outpatient dialysis

Our study confirms that dietitians can contribute to changes in medications for dialysis patients and effectively communicate these changes to patients and the medical team. They are in close communication with medical consultants and suggest changes to medications during QA meetings or inform consultants via email of suggested urgent medication changes. MDT meetings were the most reliable method for requesting medication changes, as these are where patient-focused discussions take place.

In our study we identified complex reasons why medications are not changed quickly, which include delays in GPs receiving letters; delays while GPs change medication doses requested via letters; patients continuing discontinued medications against advice in order to finish old supplies and patients refusing to take new medications owing to concerns about possible side effects. These findings are similar to previously recognised barriers to effective use of medicines.4

One of the most challenging aspects of improving medication safety is to ensure that accurate information about a patient’s medication travels with the individual throughout the healthcare system and that any changes are shared with other providers.16 Our study confirmed that dietitians can contribute to medication accuracy by interacting with the EHR and effectively updating drug histories. The number of drug histories updated increased significantly during the study period, and updates were accurate in comparison with informatics reports.

Studies have found that a frequent cause of error in a medication list was the misreporting of medicine details by patients, and also the failure of clinicians to update the medication list when changes were made.17 Previous studies have compared medication lists in the renal clinic with GP medication lists and found that 75% of patients had discrepancies identified, with an average of 2.4 discrepancies per patient.18 The number of medication discrepancies per patient in our study before the intervention period was similar to these previous studies.2 4 However, the accuracy of the patient medication lists improved significantly after dietitians started updating drug histories.

To improve the accuracy of medication lists, active participation of all members of the healthcare team and of the patient is needed throughout the patient journey. It is important to include all clinicians involved in the care who can potentially change medications when patient travel between various specialties.17 19 Lee et al 20 studied renal patients’ views on medicines reconciliation on admission and discharge. Although electronic prescribing was viewed positively overall, patients felt frustrated that errors were being made with their regular medication, despite providing correct information to healthcare professionals, demonstrating that electronic prescribing cannot negate human error because health professionals transcribe medication details incorrectly into the electronic prescribing systems. Patients also reported that both before and after introduction of an electronic system, there were communication problems between primary and secondary care, due to lack of system interoperability. Consequently, patients and carers had poor understanding of medication regimens after discharge, with potentially detrimental consequences for adherence.20

Our study supports the idea that dietitians should propose medications and this could be extended to other specialties to improve quality of patient care. Furthermore, since 2016, dietitians have had supplementary prescribing rights, where on completion of an approved postgraduate education and training programme, they can advise the patient on their diet, and supply the patient with prescriptions against an agreed clinical management plan without the need to refer back to a prescribing physician.21 A combination of both proposals and prescriptions is likely to improve patient safety by reducing delays in care, reducing hospital and GP appointments, streamlining the patient pathway and improving patient experience.7

This idea can be extended to the wider MDT—for example, dialysis centre staff have regular contact with patients and have knowledge of their medical histories and dialysis-related medications.6 By allowing the whole of the MDT to contribute to the EHR, the dataset in the EHR is more comprehensive, and this is likely to improve the quality of patient care.