Does your eMAR cover all aspects of Medicines Management?

Introduction
Any eMAR technology should handle long-stay residents as well as short-stay residents such as respite care or temporary discharges. The eMAR should configure to home specific locations. The eMAR should cover processes such as identifying a resident/ identifying the correct medication for individual residents; adding a resident; alternating medication; the flow of information between pharmacy and home; how healthcare professionals can view and access resident information; whether notes and reminders can be added to records; how medication is dispensed; medication ordering; adding photographs; alerts and audit processes; uploading documents such as covert meds. Medicines management in care homes is dependent on processes at the GP surgery and the pharmacy. The eMAR workflow and processes should reduce risk of errors across settings.

Workflow for Care Home Medicine Management
ATLAS is designed to enable care homes to perform all the tasks to replace paper MAR charts. This includes: 1) Adding and editing resident details on the eMAR or ATLAS Central, 2) Overseeing Safe Administration, 3) Ordering of monthly medicines and prescription requests, 3) Ensuring end to end flow of Information and monitoring and 4) Pharmacy Stock and Medicines Waste Management.

Adding and editing resident details on the eMAR or on ATLAS Central
Each care home unit has a dedicated device where only residents located within that location will be allocated too. There is a facility to search for the resident by surname or room number on the ATLAS device. On ATLAS Central there is the facility to search by care home unit, name and room number. From the Resident menu – staff select add resident details including the following: the first name, middle name, known as, surname, Date of Birth, NHS number, surgery, prescriber, conditions, and allergies.

• A resident status is selected from a list “present in the home”, “absent”, “in-hospital” “discharged” or “archived”.
• If the status is in-hospital/ Discharged – a wizard takes the user through a workflow where they must specify the medicines and quantities that are booked out and if a MAR chart is required to be printed. Similarly, if the resident returns from hospital and the status is changed to “Present” then a wizard takes the user through a process where medicines are booked in and quantities are inputted.
• An up to date photo of the resident can be taken and attached to the resident’s profile to be used in identification of the correct resident.
• A note can be added to the resident’s file with details of preferences and clinical needs (e.g. covert meds assessment) which is displayed every time the resident’s profile is accessed. These notes must be acknowledged each time by the staff.
• An “Add Drug” functionality uses a drug database so that staff select the correct medicine, strength and form of the medicine. Staff are also able to specify if the dosage is “when required” and or “a variable dose”. The dosage text is then inputted, and the dosage schedule is selected which specifies the quantity of the medicine to be administered and the time. The schedule settings can handle complex dosages such as alternate days, weekly, and monthly schedules.
• The drug setting includes how the medicine is to be managed – e.g. on the device where the dosage times are prompted. If the manage option is “on paper” or “self-medicating” then the medicine is not prompted to be administered on the device, instead the records show that it is accounted for on paper. There is also a setting option “Homely remedy” which displays the medicine in the “Homely remedy” tab of the resident’s profile.

 Safe Administration for Medicine Management
• Safe Administration of medicines to residents using barcode validation at the point of administration through the ATLAS device. The process ensures that the right medication is being administered to the right resident, at the right time and right dose.
• Identification of the resident is carried out by scanning of the resident’s name label on the box containing the resident’s medicines. This then shows the photo, name, date of birth, and allergy information relating to the resident. Staff can carry out a visual check to ensure the correct identification of the resident.
• The medicines that are due to be administered at a specific time are displayed with a red background on the resident’s list of medication.
• Staff are then required to scan the barcode on each medicine instruction label to validate that the medicine belongs to that resident and is due for administration.

If the wrong medicine is scanned the following checks are made and alerts are displayed on the device:
i. Wrong resident – medicine belongs to another resident
ii. Medicine not due – the medicine is not due currently
iii. Too soon – intervals between dosages have not been observed
iv. Medicine stopped – the medicine is not an active therapy
v. Barcode not recognised – manufacturer’s barcode scanned instead of instruction label

• If the correct medicine is selected, then information relating to the quantity of the medicine to be administered is displayed.
Staff then prepare the medicine and place the medicine in a pot. They then repeat this process for all the medicines that are prompted to be administered.
• Once all the medicines are accounted for, the pot of medicines are taken to the resident for observed medicine taking.
• If a medicine is “not given” at this stage, staff can choose this option and specify a reason from a list of options. They can also write a note in the patient’s record specifying more details.
• If a medicine is not given, the system asks if the dose has been disposed of or not for stock control purposes.
• The medicine not administered is marked with an orange background so that staff know it has been attempted to be given and can try to administer it again if appropriate.
• Once all the medicines have been accounted for, then the staff member chooses “confirm pot” which is the equivalent of signing the MAR chart with the details of the administration.
• On confirmation of administration, stock figures for each medicine are adjusted appropriately.

Ordering of monthly medicines and prescription requests
The aim of the eMAR workflow and process is to ensure that prescription requests are made on time, staff have stock control figures to be critical about the medicines requested, to provide the most accurate and up to date information for surgeries and to be able to audit the requests made and to share the information with the pharmacy.

• Staff are required to place their prescription requests by 8 of their monthly cycle on the ATLAS device.
• Each medication belonging to the resident appears with a red background until it has been accounted for. Staff simply indicate if it is required or not. Staff can view current stock levels and the number of days this represents so that they can make an informed decision regarding if they need a prescription for the medicine.
• Once all the medicines have been accounted for, the monthly medication order is processed on synchronisation and the information is shared with the pharmacy system.
• On ATLAS Central a document of the monthly prescriptions needed is generated and can be printed out for forwarding to the GP surgery.
• On ATLAS Central care homes can view the status of each order for example if a prescription has been received, if it has been dispensed, if it has been delivered or if it is outstanding and not issued from the surgery.

Flow of Information from ATLAS device at the care home, to ATLAS Central and the Consolidation and Application of Pharmacy Administration (CAPA) pharmacy system
• Information from the pharmacy and care home systems flow both ways via ATLAS Central which is effectively the central health record.
• This means that any activities such as changes to medication therapy carried out at the care home are updated on to both ATLAS Central and CAPA pharmacy system.
• Similarly changes to therapy via a dispensed prescription are uploaded on to ATLAS Central and the ATLAS device at the care home.

The sharing of the care home and pharmacy system via ATLAS Central has several implications:
i. The pharmacy can see exactly what therapy the resident is on. This then allows the pharmacy to make informed interventions if the prescription details do not match the resident’s care home records.
ii. The care home can see the status of prescriptions, their prescription requests
iii. Information security is ensured on ATLAS Central through measures that includes the need for 2-factor authentication before allowing access to the site.
iv. From ATLAS Central, care home managers can give access and set the level of access to patient information for individuals within their organisation or externally including healthcare professionals such as prescribers and pharmacists.
v. ATLAS Central also hosts several e-learning resources both on the eMAR system and on medicines handling and management. It also has several resources, help files and best practice guidance.
vi. From ATLAS Central authorised users can carry out audits on demand as they are able to see every administration with details showing name of staff, date, time, dose and the packet used to administer the medicines as well as the image of the prescription that authorised the dispensing. Audit is further facilitated through the use of the ATLAS Scorecard which aggregates 16 medicines related activities in to one score and care home managers are able to have an “at a glance view” of medicines management in their care homes with the ability to drill down further on the data to see the issue, the staff member, resident, medicine and time of day that needs to be addressed.

Pharmacy Stock and Medicines Waste Management

Pharmacy dispensing is carried out through the CAPA pharmacy system that each pharmacy operates. This system is unique in that it links with ATLAS and there is one shared resident medication record. This link provides many benefits which are explained below in the context of the workflow.
• The pharmacy system has the details of the prescription requests made at the care home
• Prescriptions are received at the pharmacy and their images are scanned on to the CAPA system.
• The details of the prescriptions are inputted
i. The images of prescriptions are now available to review at the care home
ii. The system automatically allocates the prescriptions as monthly or interim supply
iii. The system now compares the details of the prescriptions to the resident’s shared medication record.
iv. If the prescription details do not match the resident’s current therapy, the pharmacist is alerted to carry out a clinical check and confirm if the prescription details are correct or erroneous. Thus, prescribing errors are detected.
v. Once clinical checks have been made, the pharmacy sets the medication administration schedule according to the prescription dosage and this prompts administrations on the ATLAS device at the care home.
vi. Barcode validation is then used in the dispensing process to ensure accuracy and tracking of each medicine supply to the care home.

Booking Stock at the Care Home
i. Once medicines have been dispatched from the pharmacy, their details appear on the booking in screen of the ATLAS device.
ii. Staff are simply required to scan the barcodes on the instruction labels.
iii. Medicines are booked in and stock levels are updated.

It is these integrated workflow processes that have been shown by independent evaluation carried out by Cardiff University, to improve safety by eradicating 21/23 error types, improve accountability by reducing missing entries by 80% and by improving efficiency and saving an average of 65 staff hours per care home.

Keep an eye out for Invatech's follow up news on ATLAS eMAR Integration and the Person-Centred approach.

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