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POTENTIAL ADVANTAGES AND DRAWBACKS TO ELECTRONIC MEDICINE MANAGEMENT

SYSTEMS FOR UK LONG-TERM CARE FACILITIES: A LITERATURE REVIEW

Medha Kothari
Aston Business School, Aston University, UK
[email protected] (Corresponding)

Dr. Ian Maidment

Aston University, School of Life and Health Sciences, UK
[email protected]

Prof. Prasanta Dey

Aston Business School, Aston University, UK
[email protected]

ABSTRACT
Purpose: The use of health information technology (HIT) is increasing in care home settings; although
slower than other healthcare providers including hospitals, acute and ambulatory settings. With a
growing amount of long-term care facilities keen to research or implement HIT, this literature review
aims to provide an overview of possible benefits and drawbacks long-term care facilities could
encounter if choosing to implement HIT.

Methodology: A literature review using technology, medication management and residential care
search terms was conducted in November 2017 using the following databases: Proquest, PubMed and
Scopus.

Discussion and Conclusions: This literature review suggests that long-term care facilities are at various
stages in the transition to using electronic medicines management resources and there are mixed
results on the impact of implementing these systems. Possible benefits highlighted are reductions in
medication errors and auditing functionality, whilst potential drawbacks could include behavioural
consequences on residents. There are inconclusive results on cost efficiency and time requirement
measures.

Future Work: Future research examining both the impact on care processes and in turn the effect of
any changes on resident outcomes when using electronic systems are greatly needed.

Keywords: health information technology, electronic medicines management, electronic medication

administration records, care home, long-term care facilities
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1.0 INTRODUCTION
Information management is fundamental to health care delivery (Chassin and Galvin, 1998). All
industries have experienced an increase in technological use in recent years, the healthcare industry
is no exception (Hamilton, 2006). Many primary and secondary care facilities, including hospitals,
pharmacies, doctors’ surgeries and care homes are transitioning to use electronic systems for patient
medical records and medicines management (AHIMA, 2012).

Older people in care homes are amongst some of the most vulnerable members of society and studies
have found an unacceptable prevalence of medication errors within care homes (Alldred et al., 2009;
CPA, 2014). Care home residents are on average taking seven to eight medications daily (CPA, 2014).
With residents often having multiple and complex conditions, managing medication becomes
increasingly difficult for the resident and they are usually dependent on care home nurses (Jevon et
al., 2010). Medication management is a crucial component to caring for residents within care homes
to ensure the individual’s condition is controlled as best as possible.

Medicines management is “an evidence-based approach to prescribing which balances the safety,
tolerability, effectiveness, cost and simplicity of treatments (NHS Choices, 2017),” as well as helping
patients manage their medications better (The King’s Fund, 2017). Good medicines management
means that patients receive better, safer and more convenient care (NHS Choices, 2017). There are
many processes part of medicines management from the care home perspective which include:
obtaining medicines by ordering prescriptions and medicine deliveries from the pharmacy; storing and
disposing of medicines; recording medicines; actions to be taken if a medicine administration error is
identified; patient self-administration or nurse administration processes (JAC, 2017; Royal College of
Nursing, 2017). The process of effective medicines management within care homes can be complex
and difficult to master (Keogh et al., 2013).

Care homes each have their own medicines management system, however the general tasks are as
follows: [1] ordering, [2] prescribing, [3] dispensing and supply, [4] storage, [5] administration of
medicine to resident and [6] monitoring of effect of medicines (Alldred et al., 2009). A key component
common to each task above is relevant documentation (Alldred et al., 2009). Relevant documentation
is necessary to keep patient records organised with the correct information regarding medicines but
also to improve coordination between all stakeholders involved in medicines management (RPSGB,
2016). These stakeholders include the general practice surgery, pharmacy and care home staff
involved in receiving and administering medications (RPSGB, 2016).
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Previous and current literature continuously identifies the importance of patient-safe and cost-
effective medicines management within all primary and secondary care settings (Alldred et al., 2009;
CPA, 2014; NICE, 2015). Medication management within care homes is further complicated by the
involvement of multiple healthcare professionals who are not collocated (nurses, general
practitioners, pharmacists) (Gilmartin et al., 2013; Tariq et al., 2013). Current literature also identifies
the importance of integrated care for people with complex conditions (Goodwin et al., 2014).
Integrated care involves cross organisation working and is particularly important between all
stakeholders involved in an individual’s medicines management, such as doctors, pharmacists, care
home nurses and managers, district nurses, etc. (NICE, 2015).

The correct employment of technology in medicines management could encourage integrated care
and efficient medicines management (Waterson et al., 2012). As many care homes already have or
are currently in the transition phase of paper-based to electronic medicines management, it is
important to understand the strengths and limitations of each system from a care homes perspective,
as well as key aspects, including cost implications of the new electronic medicines management
systems. This literature review therefore focusses on potential benefits and drawbacks care homes
may face when transitioning from the traditional paper-based medicines management system to an
electronic medicines management system.

1.1 Paper-based Medicines Management

Paper-based records include several pages of records for each resident. These pages might include
some or all of the following charts or sheets: (1) a medication administration time chart; (2) a primary
medication chart; (3) a packed medication signing sheet; (4) a non-packed medication signing sheet;
(5) a short-course medication signing sheet; (6) a pro re nata medication signing sheet; (7) telephone
orders; and (8) nurse-initiated medication signing sheet (Qian et al., 2015).

Medication Administration Record (MAR) charts are a list of medicines an individual is taking (CPA,
2014). It details when the medication should be administered and allows for the person giving the
medication to record if the medicine was administered or not (Alldred et al., 2009). Each MAR chart
will have a designated space to sign to signify the completion of each medication during a pre-defined
time slot (e.g. morning) (Qian et al., 2015). A nurse signs his/her initials to indicate a medicine has
been administered (Qian et al., 2015). If medicines are not administered, nurses must provide a
reason, usually a designated letter which provides the explanation (e.g. ‘N’ for no stock, ‘R’ for refused)
(Qian et al., 2015). See figure 1 and 2 for examples of MAR charts.
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The chart usually is a 28- day cycle for one resident, highlighting repeat medicines, ad-hoc, and ‘when
required’ medicines. MAR charts are popularly used within care homes (RPSGB, 2009), and are either
produced electronically by the pharmacy dispensing the residents medication or hand-written by the
home. Any ad-hoc medicines started between the monthly supplies, will usually be added to the MAR
chart by care home staff, usually a trained nurse (Camphill School Aberdeen, 2013). Evidence shows
MAR charts produced by the pharmacy are more efficient as they avoid transcription errors and
difficult to read handwriting (Alldred et al., 2009). The process is also timely compared to home staff
manually preparing MAR charts (CPA, 2014).

















Figure 1 – Example of a MAR chart








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Figure 2 – Example of a MAR chart
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1.2 Electronic Medicines Management

Electronic medicines administration record (eMAR) systems vary dependent on the company
providing the software. Most systems display a home screen after an initial login page (Tariq et al.,
2014). This home screen will have options to different pages including medication rounds (Tariq et al.,
2014). The medication round page is usually shows the list of residents who need medication during
the selected medication round time (Qian et al., 2015). Each resident record will have the medication
‘status’, resident room, first and last name. The ‘status’ can be blank, complete or missed to indicate
if the resident has taken their medication or not (Qian et al., 2015). Additionally, some systems will
display a resident photograph, and often the photograph will be in colour to indicate needs medication
and greyed out to indicate the resident has been given their medication (Qian et al., 2015).

In each resident’s record page, there is usually medical details including allergies, special instructions,
medication history with drug name, frequency, dose, and a checkbox to indicate the completion of
medication administration, and a free text section for notes (Qian et al., 2015). If any medications
during a medication round are not ticked, systems usually prompt a message asking for a reason which
is then automatically included in the residents progress notes by the electronic system (Qian et al.,
2015).

After completion of medication rounds, and throughout the day, it is vital to synchronise the systems
to ensure all electronic devices with the system implemented have the most recent set of information
(Qian et al., 2015). To avoid chaos during system failures or power outages, daily backups must also
be run (Qian et al., 2015).

Most electronic systems are synced to a certain extent with the care home and pharmacy, although
the interface each stakeholder views is different whilst most GP systems are not yet linked to care
homes or pharmacy (Jevon et al., 2010) except for electronic prescriptions sent to pharmacies
(NHSBSA, 2017). However this means users will have access to a complete medicines record for any
individual patient (Al-Hamadani et al., 2015) which may ultimately help in documentation and
communication.

2.0 METHODOLOGY

2.1 Literature Search

A broad search of the literature was initially conducted by the primary author to determine keywords
(electronic medication management, electronic medicine administration, computing technologies,
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health information technology, medicine management, medicine administration, residential care

facilities). The final comprehensive literature search was conducted in November 2017 using the
following databases: Proquest, PubMed and Scopus.

2.2 Search Terms and Strategy

The search terms identified in table 1 were used under the topic field on the various databases.
‘Technology’ search terms were combined with ‘medication management’ search terms and with
‘residential care’ search term. All publications included are journal articles. Opinion letters, book
chapters, commentaries, models or proposals for research were not included.

‘Technology’ search terms:

Technology, health information technology, health information technology computer systems,
electronic, electronic systems, computing technologies
‘Medication Management’ search terms:
Medication management, medicine management, medication administration, medicine
administration
‘Residential Care’ search terms:
Residential care, care home, residential home, secondary care, nursing home, care facilities,
residential care facilities, long-term care providers, long-term residential care facilities
Table 1 - Search Terms

2.3 Inclusion and Exclusion Criteria

Only studies involving technology used in residential care facilities were used. Additionally, the
technology studied must pertain to medicines management and/or administration. No criteria for
patient groups or research designs were applied. No limitations on publication year were applied to
achieve an inclusive range of results. Studies focused on technology used in care at home were
excluded, as well as studies in which technology is not the primary focus of the study.

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2.4 Search Results

Total amount of hits
(n = 241)
Proquest: 173; PubMed: 24; Scopus: 44




Studies excluded after titles and abstracts
screened
(n = 219)




Total amount of hits after titles and
abstracts screened
(n = 16)




Amount of hits after duplicates removed
(n = 13)




Studies included in paper
(n = 13)

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3.0 LITERATURE REVIEW

3.1 Potential Benefits

Long-term care facilities have lagged behind other providers in comprehensive adoption of health
information technology (HIT) and existing technology may be underutilised (Darren Liu and Nicholas
G. Castle, 2009). Many studies have explored the use of HIT in acute and ambulatory settings, however
there is a lack of information regarding its’ use and slow adaptation in long-term care facilities
(Bezboruah et al., 2014).

Quality of care, cost effectiveness, efficiency, clinician satisfaction and other outcomes have been well
documented in acute care and ambulatory settings that are using HIT (Hamilton, 2006). HIT has the
potential to streamline healthcare by helping patients obtain medications, renew medications, and
for healthcare professionals to retrieve medical histories during emergency situations (Shekelle et al.,
2006). Studies have also indicated HIT has the potential to reduce medical errors (Armstrong and
Chrischilles, n.d.; Bates et al., 1998; Bates and Gawande, 2003; Kaushal et al., 2003; Koppel et al.,
2005). However, there is a dearth of empirical research regarding the impact of HIT in long-term care
facilities (Brandeis et al., 2007).

The University of Cardiff evaluated electronic medication administration systems and equipment
implemented in 50 care homes and their supplying pharmacies in South Wales (Al-Hamadani et al.,
2015). Potential benefits to the care home from the electronic medication management solution
included: safer and quicker administration of medicines through an automated checking process;
improved efficiency via automatic stock control, booking in and prescription ordering; electronic
records can be produced by the system allowing for better audit trails than paper-based MAR charts;
and there were improved medicines handling with no repackaging of medicines from manufacturers
packing (Banner, 2015).

A study interviewing care home residents reported that only 51% of residents were aware of a hand-
held device being used by staff, suggesting that for many residents the impact of technology was so
minimal as to be unnoticed (Pillemer et al., 2012). Of residents who were aware: 70.8% agreed the
handheld device helps staff to better manage their care; 72.8% were pleased that staff use the
handheld devices to better track and manage their care and 69.3% reported that staff using the
handhelds did not interfere with the time they spent with him or her (Pillemer et al., 2012). Majority
(62.2%) felt their care stayed the same, 30.6% believed it improved, 7.1% felt it declined (Pillemer et
al., 2012). From resident perspectives, use of computerised technology does not appear to overall
have led to resident dissatisfaction or poor communication (Pillemer et al., 2012).
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Some studies have examined the key advantages and disadvantages to implementing electronic
medicines management systems in care homes. Care transitions might be better managed with
electronic access to information using HIT (Resnick et al., 2009). Furthermore, electronic reminder
prompts may improve the responsiveness of provider behaviour in long-term care facilities (Field et
al., 2009; Linder et al., 2007). Some studies have found improved legibility of medication
administration charts, improved access to medicines information at the point of care and reporting
functionality (e.g. missed dose reports to reduce the incidence of missed doses) (Burns et al., 2007).

Further to improvements in reporting, a study found improved nurse compliance with documentation
requirements (Qian et al., 2015). It has been suggested that the actual way that eMAR are used by the
staff on the floor may impact the effectiveness of it and can potentially prevent realisation of the
expected benefits (Qian et al., 2015). Improvements in reporting also included increased
documentation space with electronic medication management systems (Qian et al., 2015). The unit
using electronic systems was also associated with significantly less time spent on locating and reading
documentation in comparison to the paper-based unit of the study (Qian et al., 2015). However, in
contrast, several studies from non-long-term care settings have found mixed results on time spent on
paperwork and documentation, with some studies actually showing increased documentation time
(Overhage et al., 2001; Poissant et al., 2005; Tierney et al., 1993).

A notable improvement to paper-based medicines management present in many studies is the

auditing functionality in electronic systems (Elliott et al., 2016). Long-term care facilities have found
the ability to create daily, monthly and annual reports using electronic systems very useful and believe
this function can help determine regular performances within and across care settings (Richardson et
al., 2015).

Literature on efficiency measures for electronic medicines management systems in long-term care
facilities is very limited, if at all available. A systematic review on the impact of HIT found empirical
cost data was limited and data on other efficiency measures, such as time utilisation was mixed
(Chaudhry et al., 2006). This systematic review however was evaluating the impact of HIT within
hospitals and therefore the data cannot be directly extrapolated to long-term care facilities. However,
similarly, empirical cost data is yet to be seen for HIT in long-term care facilities.

Evidence suggests medication administration errors can be reduced by use of electronic systems
(Jevon et al., 2010). One study found the electronic system provided freedom from the error of signing
twice, reducing the possibility of forgetting to medicate a resident and facilitated nurses to record the
time of medication administration to residents (Qian et al., 2015). The potential for other types of
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errors when using electronic systems is currently unknown as no formal investigations have taken
place (Jevon et al., 2010). However, long-term care facilities will only use systems which are reliable,
easy to use and do not add significantly to staff workload (CPA, 2014). Many systems have been
successful in meeting these criteria and therefore are being implemented within homes.

3.2 Potential Drawbacks

Although service providers continually promote their products and evidence has shown likely benefits
to implementing HIT within healthcare settings, long-term care facilities should be adequately
informed and prepared from non-biased sources when considering electronic systems.

The transition period when implementing electronic systems can be difficult, especially for staff
members (CPA, 2014). Harrison et al. (2007) found “disturbingly mixed reports” on HIT outcomes in
health care settings, with research showing unanticipated negative consequences of implementation,
some of which resulted in actual harm (Harrison et al., 2007; Pillemer et al., 2012). Several of the
negative consequences documented by Harrison and colleagues could potentially affect nursing home
residents, including changing or disrupting oral communication among clinicians or with patients;
causing cognitive overload for providers by emphasizing “over-complete” information entry; and the
inflexibility of electronic records, causing lost detail about resident conditions (Pillemer et al., 2012).

Training is essential for all staff members who will be using the system. Training is usually provided by
the company implementing the system and although technology is a part of every industry, it can be
difficult for care home staff to adapt to the new system (Yang et al., 2012). Familiarising themselves
with the system does take time and mistakes can still occur, especially when new to the system or
certain electronic devices such as handheld scanners or laptops (Jevon et al., 2010).

Additionally, if the system is poorly implemented initially and the transition between the paper-based
system to the electronic system is not smooth, this can cause many errors and added complications
leading to a stressful environment within the long-term care facility during this period (Baysari et al.,
2016; Yang et al., 2012).

Moving from handwritten charting to electronic health records could lead to changes in coordination
of care and thus affect common problems to long-term care facility residents such as falls or
behavioural disturbances (Brandeis et al., 2007). Most problematic for the long-term care context,
given the importance of person-centred care (Tellis-Nayak, 2007), is evidence of changes in the
provider-patient relationship, as professionals become more occupied with the computer and less
oriented toward the patient (Ludwick and Doucette, 2009). Thus, it is possible that HIT could lead to
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less personalised and more routinized care, as well as less direct observation and interaction with
residents, and in turn to negative clinical outcomes such as increased falls, diminished function, and
dissatisfaction with care (Pillemer et al., 2012).

One study found a statistically negative effect, where there was no change in behavioural disturbances
when using electronic systems in comparison to facilities using paper-based systems which showed
improvements on a measure of behavioural disturbances (Pillemer et al., 2012). However, without
detailed observational data on the effect of HIT on staff behaviours, it is not possible to determine the
mechanism for this finding (Pillemer et al., 2012).

Drawbacks to the electronic medication administration system could include the cost associated with
implementation of the system in the care home and subscription/maintenance fees (Jevon et al.,
2010). One study quoted a medical home interviewee stating: “the maintenance of all those interfaces
– the costs are ridiculous…” (Richardson et al., 2015). Data on expected costs however is lacking in the
field, which could be the reason long-term care facilities are slow to adapting HIT (Bezboruah et al.,
2014).

Other concerns from studies on electronic medicines management systems included inadequate
information about residents on the system, late addition of new resident’s medication profiles in the
records and nurses forgetting to medicate a resident due to potential power outages on portable
devices (Qian et al., 2015).

4.0 DISCUSSION AND CONCLUSIONS

There is a scarcity of literature examining the impact of HIT specifically within long-term care facilities.
Results of existing studies have shown mixed findings, one specifically concludes that electronic
medication administration records may not change nursing time spent on various activities in a
medication round or substantially alter the medication administration processes, but can generate
both benefits and unintended adverse consequences (sections 2.2 and 2.3) (Qian et al., 2015).
Furthermore, although there are mixed findings on nursing time spent on various activities using the
electronic system compared to paper-based systems; some studies have suggested that time
requirements decreased as physicians grew used to the electronic system (Chaudhry et al., 2006),
which may be similar to findings within long-term care facilities in the future.

Another study used quality outcome measures (ADL function, falls, resident mood, behavioural
symptoms, and mortality) to distinguish differences in control groups versus HIT groups to assess
changes in quality of care. No measurable improvement in resident condition was found as a result of
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using HIT, suggesting that claims for HIT to have direct benefits on residents should be taken with
caution (Pillemer et al., 2012). Similar to a number of studies on HIT in acute and ambulatory care,
there appears to be no demonstrable positive effect of the technology on residents directly. If this
finding is supported by future research, studies of cost and efficiency will be of key importance to
make the case for HIT in nursing homes (Pillemer et al., 2012).

Potential advantages as outlined in this literature review include: the ability to automate some
processes, including stock control and prescription ordering in some cases (Banner, 2015); the fact
that many residents do not notice the use of handheld devices may suggest they do not have a
negative impact as well as many residents believing the handheld device helps in their care (Pillemer
et al., 2012). Additionally, care transitions may be better managed with use of HIT and reporting and
documentation may be easier (Burns et al., 2007; Resnick et al., 2009). Studies have also found long-
term care facilities appreciate the auditing functionality of HIT (Elliott et al., 2016). Studies have also
highlight a reduction in medication administration errors, however potential for other types of error
with the use of HIT have not been investigated (Jevon et al., 2010).

The transition period between paper-based systems to electronic medicines management systems
can produce an array of drawbacks. It is often difficult for both staff members and residents, which
can result in behavioural disturbances (Brandeis et al., 2007; Harrison et al., 2007; Pillemer et al., 2012;
Yang et al., 2012). Implementing HIT can be poorly done which can lead to a stressful environment
within the long-term care facility (Baysari et al., 2016). With HIT, there is also the risk of moving from
patient-centred and personalised care to more routinized care and less direct observation and
resident interaction (Ludwick and Doucette, 2009; Pillemer et al., 2012; Tellis-Nayak, 2007). Other
concerns include problems arising from power outages and depletion in portable devices (Qian et al.,
2015).

Furthermore, there are mixed results in the efficiency of documentation with electronic medication
systems compared to paper-based systems (Pillemer et al., 2012; Qian et al., 2015). Cost and time
requirement measures are also scarce in research and show mixed results (Bezboruah et al., 2014).

This literature review suggests that long-term care facilities are at various stages in the transition to
using electronic medicines management resources and there are mixed results on the impact of
implementing these systems. Some long-term care facilities have fully implemented electronic health
records and electronic medicines management systems, others are solely relying on the tradition
paper-based systems, and some are using a mixture of both electronic and paper-based systems.
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However, with the world using an increasing amount of technology in day to day life, it is anticipated
that all long-term care facilities will undergo the transition to at least some extent in the near future.

4.1 Future Work

As more long-term care facilities begin using electronic medicines management systems, system
providers will be continuing to improve their systems to meet the demands of healthcare
organisations. A study examining a needs assessment of HIT for improving care coordination in
patient-centred medical homes discovered needs for tools in the following areas: monitoring,
notifications, collaboration, reporting and interoperability (Richardson et al., 2015). Improvement
within these areas suggest potential practical benefits in future care coordination within long-term
care facilities as well as between all primary and secondary healthcare organisations (Richardson et
al., 2015). Future research examining both the impact on care processes and in turn the effect of any
changes on resident outcomes when using electronic systems are greatly needed (Pillemer et al.,
2012).

5.0 CONFLICTS OF INTEREST

None

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