Purpose

This publication outlines the functionalities that clinical digital systems need to support optimal antimicrobial stewardship (AMS) in primary and secondary care.

The associated recommendations are intended for AMS teams, chief clinical information officers and clinical informatics teams, commissioners, NHS England’s digital medicines delivery and AMR programme boards, and software providers for primary and secondary care. They were developed in consultation with clinical staff to reflect their priorities (see appendix 1 for further detail).  

Users and commissioners should consider how their systems match these recommendations and identify how to address any gaps in functionality. Software developers should review the recommendations to understand what future developments and improvements may be required.

The document should be read alongside the Digital framework for antimicrobial stewardship – what good looks like, which sets out an organisational and system approach to ensuring good digital functionality for antimicrobial stewardship.

Context

Effectively tackling the challenge of antimicrobial resistance (AMR) requires a co-ordinated and strategic approach across healthcare settings. Antimicrobial stewardship (AMS) is an important element of this work.

The current UK 5-year national action plan for AMR (NAP) states that the next 5 years are crucial for ensuring AMR is considered an important part of digital transformation and that there is a need to adopt digital technologies that enhance AMS practices.

Within this NAP, there is a target to reduce total antibiotic use in human populations by 5% from a 2019 baseline and increase the proportion of narrow spectrum antibiotics used to 70% of total use Additionally, there are commitments to use decision-support, risk stratification tools, diagnostic tests and improved diagnosis coding to inform shared decision making and support the targeting of antimicrobials to patients most likely to benefit. Extracting and making better use of data from clinical digital systems is also needed to inform surveillance and AMR policy development.

While a multi-faceted approach is required to tackle AMR, understanding the role of IT in healthcare professional-patient interactions where antimicrobials are prescribed – and how IT systems can support good practice – is critical to success.

Recommendations

1. Antimicrobial prescribing: clinical digital systems should support clinicians with antimicrobial prescribing by offering appropriate treatment choices and durations and making it easy to record prescribing decisions.

Clinical digital systems across primary and secondary care should be tailored at a local level to promote optimal treatment based on the clinical diagnosis, local or national guidance and patient-specific considerations (such as allergy or previous history of colonisation with resistant organisms). They should facilitate prescribing by indication to expedite and standardise prescribing.

Clinical digital systems in secondary care should support the use of the start smart then focus principles (assess, investigate, prescribe and document), including mandatory documentation of working diagnosis and indication for prescribing, plus the intended duration at the point of prescribing. They should also be able to support restricting the prescribing of high-risk antimicrobials (for example, pending specialist authorisation) and accurate recording of antimicrobials supplied using patient group directions.

Clinical digital systems used in primary care and outpatient settings should facilitate the use of delayed or back up prescribing strategies.

2. Antimicrobial review: clinical digital systems should support clinicians to review and revise antimicrobial prescriptions.

Clinical digital systems in secondary care should support identification and prioritisation of patients who require a review at key timelines, such as:

• at 48 and 72 hours after starting treatment
• upon result of a key diagnostic test or monitoring parameter (for example, drug serum levels)
• due to a significant change in clinical condition

They should facilitate the review process by providing key information and decision-support tools. They should also make it easier to record and carry out review decisions in line with national guidance (cease, amend, refer, extend, IV to oral switch).

When caring for patients with complex infections, it’s crucial that digital systems can:

• support the electronic referral of patients to AMS teams or infection specialists
• flag key clinical advice on treatment plans

3. Coding: clinical digital systems must better integrate and streamline the coding process into the clinical workflow.

Coding is performed inconsistently due to its complexity, competing workload and time pressures; this represents a significant surveillance gap.

In primary care, clinical digital system workflows should be structured so that diagnosis coding occurs before a prescription is generated for an antimicrobial. In secondary care, clinical digital systems should require documentation of a working diagnosis linked to the prescription, with the ability to review and revise this at the time of the clinical review.

All antimicrobial prescriptions should be linked to a coded diagnosis to allow for audit and analysis of prescribing data and outcomes.  

4. Templates: clinical digital systems should enable the use of templates tailored to specific clinical conditions, helping to streamline and enhance the consultation process.

Templates allow for a structured process where relevant information is captured and SNOMED coded to enhance the efficiency and accuracy of electronic health records. These templates should support digital record keeping, appropriate use of diagnostic tests and decision-support tools. They should also help with shared decision-making and avoid duplication of work such as prescription generation.

5. Guidelines, diagnostic and decision-support tools: clinical digital systems should integrate guidelines, diagnostic testing and decision-support tools into the clinical workflow.

Appropriate use of diagnostic tests, clinical decision-support tools and treatment guidelines can support effective consultations, shared decision-making and AMS. These should be integrated into the digital system and be visible at key stages of the clinical workflow to streamline consultations, avoiding the need to rely on additional bolt-on software or external websites.

6. Displaying timely and relevant clinical information: clinical digital systems should make it easy for clinicians to view relevant clinical, radiological and laboratory information during consultations for infections.

Access to recent and relevant results (for example, microbiology culture and sensitivity results, full blood count, organ function, therapeutic drug monitoring results, vital sign and imaging) and longitudinal antimicrobial prescribing and administration information is important to safe and efficient clinical review and AMS. It should be contained in 1 easily accessible place. This area should also contain review documentation and treatment plans to support appropriate prescribing and facilitate the review of antimicrobials in secondary care.

7. Patient-facing tools and resources: Clinical digital systems should help increase the uptake of patient-facing tools and resources within the system by improving functionality and ease of use.

Sharing information and selfcare and safety netting resources with patients and carers, as well as involving them in decision-making, are important elements of AMS, especially when a delayed or no antimicrobial strategy is used. Digital tools should establish a remote communication channel with patients and integrate information sharing into the clinical record. This approach will support triage to the most appropriate clinician and care setting and ensure effective follow-up post consultation.

8. Interoperability: Clinical digital systems must be capable of interoperability and data sharing both within and between different care settings to support AMS.

Details of previous microbiology results, healthcare associated infections and antimicrobial treatment are essential for making safe clinical decisions around antimicrobial prescribing.

There should be fidelity of information transfer for important issues like penicillin allergy delabelling and treatment plans for complex infections, to ensure records are updated and accurate across care settings.

Interoperability between electronic prescribing and other clinical digital systems – such as Laboratory Information Management Systems, guideline software applications and clinical care databases – is also key to making best use of digital technology to support AMS and should be prioritised.

9. Surveillance and reporting: Clinical digital systems should support surveillance of and reporting on key metrics relating to antimicrobial prescribing, with options to both present data visualisations live within the system and interrogate raw data.

The ability to interrogate digital systems to produce data is a powerful tool for AMS. Benchmarking and identifying trends at an individual prescriber level and aggregated at clinical speciality and organisation level can identify unwarranted variation and opportunities to drive improvement.

Outputs from reporting tools must be fully customisable, with the ability to present high-level information graphically while retaining the ability to analyse more granular or raw data in other software, where needed. All clinical digital system providers should offer pre-built standard reports (for example, patients having two or more antibiotic courses in 3 months in primary care, or patients on IV antibiotics for longer than 48 hours in secondary care), so users can easily compare key metrics no matter what digital system is used.

10. Alerts and alert fatigue: Clinical digital systems must proactively reduce the volume of AMS alerts directed at clinicians by optimising other elements that improve the clinical workflow.

Clinical digital systems should prioritise alerts that are focused on patient safety at relevant timepoints during a consultation or pathway of care. Targeted alerts can effectively communicate temporary changes or time-sensitive information, such as updates in guidelines or seasonal campaigns. Clinical digital systems should offer the facility to generate, target and fully customise alerts and direct these to appropriate groups.

11. Agility and adaptability: Clinical digital systems must be sufficiently agile to respond to emerging risks and allow local adaptation to meet local population health needs.

Clinical digital systems should be sufficiently agile to promote innovation and respond to emerging risks, such as medicines shortages, outbreaks of infection, and rapidly changing treatment guidance. This should include the ability to draft changes at a national level while allowing local refinement and implementation at organisational level.

Agile software development helps healthcare adapt quickly, improving care with new technologies. To prevent unwarranted variation that could impact patient safety, a structured approach is needed, ensuring standardised core functions across platforms while supporting innovation.

Next steps

Digital transformation and improved interoperability between clinical digital systems is critical to the NHS’s future delivery and productivity, and it is vital that the opportunities to advance AMS are built into digital roadmaps.

Optimising the use of clinical digital systems to support AMS requires more than implementing core functionality across clinical digital systems. The Digital framework for antimicrobial stewardship – what good looks like sits alongside this digital vision to support organisations get the best out of clinical digital systems by ensuring they are well led, have smart foundations, support safe practice, support people, empower patients improve care, and support healthy populations.

Delivery of these developments will not be a quick fix. Users and commissioners of clinical digital systems will need to make best use of existing functionality and ensure healthcare professionals are appropriately trained. Integrated care boards will also need to make use of the suggested strategy for AMS in the digital framework.

This comprehensive approach will help optimise clinical digital systems for better patient care and tackling antimicrobial resistance.

Appendix 1 – Developing the digital vision

The digital vision for AMS in England project

The NHS England Antimicrobial Prescribing and Medicines Optimisation (APMO) team commissioned NHS Midlands and Lancashire Commissioning Support Unit (MLCSU) to deliver an in-depth piece of research to gain a better understanding of:

• how IT systems currently support AMS activities
• whether there are any gaps in functionality
• what is essential and desirable to support prescribing
• the benefits and barriers of current systems
• what the future should look like

The aim of this work was:

• to identify what clinical digital systems in primary and secondary care do well currently to support AMS
• to identify and prioritise the core functionality that all systems should feature

Clinical digital systems in scope

The project focused on clinical digital systems used in primary and secondary care in the NHS as these settings account for 92% of antimicrobial prescribing in England. Clinical digital systems were defined as:

• the integrated prescribing and electronic patient record systems in primary care
• electronic prescribing and medicines administration systems with and without electronic health record functionality in secondary care
• additional ‘bolt-on’ software used in both settings to provide additional functionality

Clinical digital systems in other care settings and mobile software applications were excluded from this phase of the project. The role of artificial intelligence (AI) was not explored due to the limited adoption of AI for AMS in the NHS to date.

Stakeholder insights

Healthcare professionals from multiple disciplines (8 medical, 31 pharmacy and 2 data analysts) participated in 6 online focus groups and 2 structured interviews in December 2022. 419 healthcare professionals (including 129 medical, 221 pharmacy, 60 nurses and 1 data analyst) responded to a web-based survey between January and February 2023.

This research identified greater diversity of electronic prescribing systems in secondary care, where respondents were using 23 different electronic prescribing systems compared to primary care, where 2 systems dominate the market. This contrasted with the use of “bolt-on” decision-support software, which was rare in secondary care, with cost being cited as a barrier to uptake. Stakeholders reported high use of “bolt-on” systems in primary care where use of multiple products was often necessary to provide all required functionalities.

Stakeholders cited that the barriers to the implementation of system-wide AMS solutions were:

• variation in systems used within integrated care systems
• challenges with interoperability
• lack of standardised coding

There was clear support for standardisation of AMS solutions, with 88% of survey respondents stating that it is important to have national standards for AMS in clinical, electronic prescribing and bolt-on systems.

Stakeholders also reported significant scope to improve the use of digital systems to support AMS in England both in terms of improving functionality and using digital technologies to meet workforce challenges in AMS teams. For example, 20% of survey respondents spent more than 5 hours undertaking AMS activities that could be automated. There was also a clear need to better understand the impact of digital interventions to support AMS as, though these were frequently deployed, it was rare for processes or outcomes to be evaluated.

Project findings

There is a clear appetite among the AMS workforce for national standards. Creating these will be challenging given the diversity of systems in use, the conflicting requirements of different healthcare professionals, and the challenges associated with assessing the impact of digital AMS solutions.

Work to improve AMS through digital solutions will require continued engagement with healthcare professionals and suppliers of clinical digital systems, robust assessment of outcomes, and widespread sharing of best practice among users.

Publication reference: PRN01399i