Introduction

Healthcare settings have witnessed remarkable technological advancements in recent years, including the introduction of electronic medication management systems. These systems promise to enhance patient safety and streamline the complex processes that nurses and midwives navigate daily. Examining the effectiveness and shortfalls, including the challenges of implementing current EMM technologies, can provide a glimpse or guide to what future technological advancements may be in store for medication management.

Electronic medication management (EMM)

Medication management within the healthcare setting is critical in ensuring that medications are used safely and effectively. It involves all aspects of the medication process, including prescription, ordering, dispensing, supplying, storage, administration, and documentation. Beyond these logistical aspects, medication management also includes continuous review, monitoring, and evaluation of medication efficacy and safety¹. Whilst medication is a standard treatment option utilised within a healthcare setting, medication errors and adverse events surrounding medication management are well documented^1-2. Despite its routine nature, the process is fraught with potential for errors due to the complexity of medication processes and protocols and the human factor in managing them². Additionally, numerous healthcare professionals are involved in medication management, from nurses and midwives to physicians and pharmacists, which further increases the risk of human error. To address these issues, EMM has been introduced as a way to improve not only patient safety but with the added bonus of operational efficiency.

Electronic medication management is the use of computerised systems to aid and enhance the process of medication management. When electronic systems provide a seamless, automated flow of information, ensuring accurate medication delivery from prescription to administration, it is referred to as a closed-loop medication management system^3,4. Closed-loop medication management systems lower the risk of errors by reducing or eliminating the chance of human error wherever possible at each step of the medication process³. To harness the benefit of a true closed-loop medication management system, the utilisation of various computerised and electronic assistance would involve the following:

• Electronic prescribing
  Prescribers use electronic prescriptions in place of paper prescriptions, now legal in all states and territories of Australia⁵. Electronic prescribing reduces administrative burden as it eliminates manual handling of paper prescriptions from the prescriber to the pharmacy and removes transcription errors as the medication order is seamlessly incorporated into the pharmacy dispensing software⁵.
• Barcode or Radio frequency identification (RFID) scanning
  This technology is employed for both dispensing and administration of medications. Pharmacists scan medications to ensure that the correct medications are dispensed. Clinicians use barcode medication administration (BCMA) to match medications with the patient accurately, with some systems automatically recording the medication as administered⁶. Scanning barcodes while administering medication offers considerably reduced medication errors and improved efficiency.
• Electronic medication administration records (eMARs)
  Electronic medication administration records provide a clear, easy-to-read, and standardised medication record for clinicians, eliminating the need to decipher handwritten medication orders. Time savings are realised using the built-in alerts to show when medications are due and easy direct access to electronic drug reference documents and guidelines.
• Clinical decision support systems (CDSSs)
  These systems offer real-time alerts and guidance to healthcare providers at all stages of the medication process, supporting physicians with prescribing, pharmacists with dispensing and clinicians with administration.
• Automated dispensing cabinets (ADCs)
  These devices securely store medications near patient care areas, which further improve safety and streamline the medication administration process.

Electronic medication management integration

Further to the above, the integration of EMM systems with health information systems enhances data visibility and supports better decision making across care settings using the following:

• Telepharmacy, utilising telecommunications technology, provides pharmaceutical care, including medication review, patient counselling, and prescription verification by a qualified pharmacist⁷. This can extend pharmacy services and is particularly beneficial in improving access for those in remote and rural areas.
• Smart pills with embedded sensors provide real-time data on medication adherence and physiological responses, which is valuable for managing chronic diseases and clinical trials.
• Predictive analytics using machine learning can anticipate potential medication errors or adverse drug reactions, enhancing patient safety.
• Mobile phone health applications empower patients to manage their medication schedules actively and engage with their healthcare providers.
• Biometric verification systems ensure accurate patient identification during medication administration.

Nursing and midwifery engagement with EMM

Potential time-saving benefits
As with implementing any electronic system, there will be challenges to overcome. Nurses and midwives must be assisted before, during, and after implementation with training and support. Change management processes need to be utilised to counteract initial resistance. Nurses and midwives have voiced their fear of having reduced time with patients with the introduction of an EMM; however, one time and motion study showed that time allocation following the implementation of an EMM system did not change significantly, showing that nurse’s fears of having less time with patients were unfounded⁸. There is also anecdotal evidence that nurses, midwives, and other health professionals involved in medication management can be reluctant to embrace EMM, particularly in the aged care sector.

Aged care and EMM
Aged care organisations have utilised EMM systems for several years; however, due to legislative restrictions on electronic prescribing, these systems have not been fully integrated into a closed-loop process. Consequently, a hybrid approach has been adopted, combining manual and electronic methods. Specifically, medical or nurse practitioners are required to manually sign medication orders on a hard copy medication chart. This chart is subsequently scanned and transmitted to the pharmacy, where the information is manually entered into the pharmacy’s electronic medication dispensing system. From this point onwards, the process becomes electronic, encompassing the dispensing of medications, maintenance of electronic medication records, and electronic signing for the administration of medications. The hybrid system has led to errors, such as instances where the medication chart was not sent to the pharmacy and medication was not dispensed, and also where manual data entry at the pharmacy introduced human errors. Transitioning to a fully integrated EMM system would effectively eliminate these issues, ensuring a more accurate and reliable medication management process.

Challenges in aged care EMM
With the recent legislative changes supporting fully integrated electronic prescribing, many aged care organisations are transitioning to EMM systems, often necessitating a change in software. Feedback from several recent implementations across Australia indicates that some visiting health professionals have shown resistance to the change. Medical and nurse practitioners and pharmacists are contracted to provide services to residents but are not employed by aged care organisations. Implementation challenges have arisen around reluctance to attend training and resistance to transitioning to a new system.

Visiting health professionals anticipate remuneration for their time when providing services in aged care, including attendance at training sessions. Some aged care organisations had not foreseen this expense, as these professionals are not employees. Consequently, these organisations have had to incur additional costs to ensure their participation in training sessions. Even with compensation available, some professionals could not attend training sessions and had to rely on staff to demonstrate and teach the application in real time. This approach to training is suboptimal, potentially leading to knowledge gaps, increased user errors, and additional pressure on other professionals.

While pharmacists have welcomed the transition to electronic prescribing, as it eliminates the need for manual input into the pharmacy software, this change has somewhat shifted the burden of data entry to the prescribers, some of whom have expressed resistance. Change management processes should be utilised to facilitate prescribers’ transition to the new system, as failure to do so could result in severe consequences. Most EMM software used in aged care requires all prescribers to utilise the electronic prescribing functionality for the system to be fully implemented. If even one prescriber does not adopt the system, it could result in a complete stoppage or, worse, reverting to the previous hybrid solution. While it would be ideal to only utilise prescribers willing to use the system, this may not be a viable option in some rural and remote areas.

Nursing and midwifery involvement in EMM design
Despite the challenges, the aged care sector has been widely embracing the change to a true closed-loop medication system, which includes eMAR, ePrescribing, and the pharmacy component, as it represents a significant advancement in aged care medication management. In aged care, nurses are reporting the benefits of this integrated approach, such as increased efficiency and improvements to resident care. As nurses and midwives across all health sectors use EMM systems more and observe the improvements these systems bring, it is hoped that they will begin to guide future developments.

Nurses and midwives frequently have constructive suggestions for enhancing EMM systems. Their involvement is crucial for improving current systems and envisioning the future of EMM technology. As primary users, they offer invaluable insights into system usability, providing developers with critical feedback on what functions effectively and what requires improvement. Even straightforward actions, such as offering feedback on the user interface, can significantly influence future design iterations⁹.

The future of EMM
Artificial intelligence (AI) is expected to have a transformative impact on EMM systems. AI is the simulation of human intelligence in machines that are programmed to think and learn like humans¹⁰. AI enhances accuracy, efficiency, and personalised patient care and is being applied in the following areas:

• Clinical monitoring and decision support
  AI enhances clinical decision making by providing nurses and midwives with real-time support for medication dosages, schedules, and potential drug interactions. It improves patient monitoring by analysing data from various sources to alert healthcare professionals about adverse reactions or the need for adjustments in treatment, ensuring higher standards of patient safety and care.
• Automated documentation and personalised care planning
  AI automates the cumbersome task of medication documentation, ensuring accuracy and freeing up time for patient care. It also aids in the creation of personalised care plans by analysing extensive patient data, including past medical history, ongoing conditions, and genetic information. This helps nurses and midwives tailor their care to meet each patient’s specific needs, enhancing the effectiveness of treatments.
• Job satisfaction and work efficiency
  By automating routine tasks, AI significantly reduces the administrative burden on nurses and midwives, allowing them more time to focus on patient care. This, in turn, improves workflow efficiencies, contributes to greater job satisfaction, and reduces burnout by enabling nurses and midwives to engage more meaningfully with their patients.
• Education for both nurses/midwives and patients
  AI-driven training programs provide nurses and midwives with continuous learning opportunities, using simulations that reflect real-world scenarios to enhance their skills and knowledge. Additionally, AI-powered tools can assist in educating patients about their medications and health management, supporting nurses and midwives in their roles as patient educators. These tools can deliver personalised educational content, making it easier for patients to understand and adhere to their treatment plans.

Conclusion

Within healthcare settings, EMM systems have been implemented to improve patient safety and streamline operations, improving the safe and effective use of medications. They employ digital technologies to simplify the medication management workflow into a fully integrated medication management system. Combining EMM systems with health information systems enhances data transparency and aids decision making. Although implementation presents challenges, particularly evident in the aged care sector, these can hopefully be mitigated through effective change management techniques, as the benefits significantly outweigh the drawbacks. Nurses and midwives who witness these benefits firsthand are well-positioned to provide valuable recommendations for enhancing EMM systems. Their involvement is crucial for refining current systems and shaping the future of EMM technology, particularly with the integration of AI.

Authors

Dr Jen Bichel-Findlay FAIDH CHIA

References

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