Digitalisation of medicines: artefact, architecture and time.

This edition includes two papers reporting research from a 5-year study of electronic prescribing in English hospitals.2 3 The papers each address a significant safety and quality issue drawing data from the wider study. These issues are the level of coordination and integration that electronic prescribing systems achieve,3 and the emergence of ‘workarounds’ as managers and clinical users adapt electronic prescribing systems’ capabilities to their needs and working environment.2 The risks to patient safety posed by these systems, their implementation and use are further explored in a third associated paper published elsewhere.4 Workarounds were found to be either ‘informal’ or ‘formalised’ practices, the former derived from user innovations, the latter promoted and endorsed by management. Both types involved the use of other ‘intermediary systems’, such as paper or other software.2 While workarounds can create new risks and are an opportunity for safety issues to emerge, the study does acknowledge the positive role of workarounds in permitting poor usability of systems to be addressed, as ‘intentional strategies to help users gradually get used to a new system’, and as a means to support local innovation and tailoring. The issue of integration of information is a common theme that crosses both studies. Workarounds, arguably, serve to better integrate information into work practices while the interfacing of multiple digital systems can provide a more coherent and timely flow of information. The research reports that even integrated hospital-wide systems were found not to interface well with external systems.3 It is important to note that the systems considered for integration with electronic prescribing in these studies are not necessarily medicines’ systems (eg, in pharmacy) — they include also administration, imaging, laboratory or specialty systems, and the systems are not differentiated in terms of the data they hold — whether about medicines, or patients or other operational data. For the organisation, the choice between the integration provided by integrated hospital-wide EHR (Electronic Health Record) packages or interfacing (‘knitting together’ different standalone software — sometimes described as a ‘best of breed approach’) was found to pose a complex set of trade-offs among a ‘range of considerations, of which patients safety is only one’.3 These studies provide valuable and detailed accounts of the state of the art in electronic prescribing in England. They also offer an opportunity to reconsider how we conceptualise the role of digital technology in improving the way medicines are used. To do so, we identify three interlinked contemporary themes to add to or recast those emerging from these papers and described above. The three additional themes are (1) considering the medicine itself as a ‘digital artefact’, (2) the significance of time in medicines use and (3) the architectures of the digital systems supporting medicines use. Taken together these may invite a change in scope and focus of the discussion of electronic prescribing — to move from task orientation (prescribing, administration, discharge) to an institution-wide or even system-wide perspective that emphasises data and communications infrastructures in support of new services and processes specifically for ‘digital medicines’.