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21st October 2024
Francine de Stoppelaar is co-founder of Project Asclepius – an excellence platform driving digital transformation and automation of medication management processes – as well as an honorary associate professor at the University of Leicester and an associate at Deloitte for digital transformation of hospital services and medicines optimisation. She speaks to Saša Janković about her trailblazing work in this area and where she sees the biggest potential.
With a background in clinical pharmacology and over 25 years’ experience across the NHS, private healthcare and academia, Francine de Stoppelaar’s career exemplifies the intersection of clinical expertise, innovation and strategic leadership.
As the co-founder of Project Asclepius and former chief pharmacist at Cleveland Clinic London, she has become a leading voice in the digitalisation of hospital processes – particularly in the realm of pharmacy and medication management – and has laid the groundwork for a future where technology and healthcare professionals work in partnership to deliver safer, more efficient patient care.
A long-time champion of the broader potential for multidisciplinary collaboration and the use of digital tools to address unmet patient needs, Francine’s passion for digital transformation in healthcare was ignited during her time at Cleveland Clinic London, which she joined in 2018.
As well as being chief pharmacist, she led the operational activation of the hospital prior to its 2022 opening, in a role that encompassed everything from building, procurement and hiring teams to the integration of equipment and new systems – all of which she spearheaded alongside the added challenges of Brexit and the Covid-19 pandemic.
However, her primary focus remained on pharmacy, where she oversaw the development and implementation of a fully digitalised, closed-loop medicines management system that leveraged digital and automated solutions to enhance patient safety, workforce efficiency and sustainability.
The first of its kind in the UK, this groundbreaking digital pharmacy system included automation at every stage – from prescription verification to bedside administration – allowing for real-time monitoring of medications and dramatically reducing the risk of errors.
‘In fact, after two years the hospital reported only two incorrect administration errors in over one million medication administrations, both of which had no damaging effect to the patient and were easily corrected,’ Francine recalls.
Nonetheless, since most medicines management processes in hospitals across Europe are still based on manual operations to some extent, Francine admits projects like these are ambitious and uncommon.
‘State of the art technologies and innovative solutions are readily available, but their adoption is still limited, partly due to highly fragmented practices and workflows, but also because they are complex and costly,’ she says. ‘That’s why many hospitals in the UK and Europe still rely on outdated analogue systems, but these can lead to inefficiencies and medication errors, which is why it is essential that we bridge the gap between what’s technologically possible and what’s being implemented on the ground.’
This vision has been foundational to Francine’s work with Project Asclepius – an initiative she cofounded with Patrick van Oirschot and Patrick Koch after leaving Cleveland Clinic London at the start of 2024.
‘While some European countries are further ahead than others in managing medication effectively in a hospital setting, there are no consistent cross-European guidelines or effective ways to share best practice,’ says Francine.
‘The aim of Project Asclepius is to contribute to a faster and safe adoption of digital and automated medication management systems in hospitals across Europe, initially by focusing on best medication management practices enabling personalised therapies based on unit doses, with other areas of medication management to follow in future.’
The key to its success, according to Francine, lies in the integration of technology and human expertise. ‘Digitalisation doesn’t remove the human factor,’ she explains. ‘Rather, it enhances our ability to work smarter, not harder, by reducing repetitive tasks and allowing healthcare professionals to focus on patient care.’
One of Francine’s driving motivations has always been improving patient safety.
‘As the healthcare landscape becomes increasingly complex, with workforce shortages and rising costs, the need for more efficient and safe systems becomes critical,’ she says. ‘For example, medication errors in the UK alone are responsible for the loss of approximately 1,700 lives each year.’
For Francine, addressing this through the automation and digitalisation of hospital processes is an ethical imperative. ‘By integrating technologies such as automated dispensing cabinets and real-time scanning at the bedside, we have helped to create systems where every step of the medication process is tracked and checked digitally,’ she says. ‘This approach minimises the possibility of errors, whether from a lack of human oversight or system inefficiencies, because if a medication hasn’t been verified and dispensed by a pharmacist, it simply can’t be administered.’
Through Project Asclepius, she advocates for the wider adoption of such ‘closed-loop’ systems, which not only improve patient outcomes but also have significant impacts on workforce efficiency. For instance, nurses and pharmacists can spend less time on manual tasks and more time focusing on direct patient care. As Francine points out, ‘automation doesn’t eliminate jobs but rather redeploys skilled workers to areas where they are most needed, thereby improving both patient experience and operational flow’.
Another recurrent theme in Francine’s work is the importance of collaboration. ‘Effective healthcare cannot be siloed, and this is especially true when it comes to pharmacy,’ she says, adding that: ‘Pharmacy is the red thread running through a hospital, so that while pharmacy teams handle ‘back office’ tasks such as procurement, logistics and stock management, their work always directly impacts clinical care.’
The challenge, however, is that many hospitals operate in a disjointed way, with different departments using incompatible systems. ‘In my consultancy work with Deloitte I’ve seen numerous inefficiencies resulting from this lack of interoperability, including duplicative processes and wasted staff hours,’ she says.
Her solution is to ensure that all digital systems within a hospital – whether for stock management, prescribing, patient records or anything else – are able to connect and ‘talk’ to each other.
However, she stresses that this requires buy-in not just from pharmacy leaders but from the entire multidisciplinary team. ‘Physicians, nurses, IT specialists and hospital managers must all be aligned in their approach to digital transformation and leaders need to bring everyone on board,’ she insists. ‘Without the support of senior management and the wider clinical team, even the best digital tools won’t succeed.’
Looking ahead, Francine believes that standardisation across hospitals and pharmacies will be key to addressing both workforce and patient safety challenges.
Through Project Asclepius, she is pushing for pan-European standards that would allow hospitals to adopt best practices for digitalisation more easily, which she says ‘includes everything from standardised unit doses and barcoding systems to harmonised procurement processes’.
But she is also realistic about the challenges. A survey by the European Association of Hospital Pharmacists concluded that most hospitals still don’t have plans to implement automation systems, and Francine acknowledges that ‘this is a long game, with huge complexities, particularly in terms of funding and policy’.
But, she says, ‘the potential benefits – fewer errors, better patient outcomes, and a more efficient healthcare workforce – are enormous.’
Ultimately, Francine’s approach to digitalisation within a hospital setting is both visionary and pragmatic. While she is passionate about the potential of technology to transform healthcare, she is also deeply aware of the human factors involved. At the heart of her work is a commitment to ensuring that digital systems serve not just patients, but also the healthcare professionals who care for them.
20th February 2023
Frail older people often have multiple comorbidities and thus take multiple medications, some which may be inappropriate and lead to adverse effects. Optimising medication in the frail older person is vital and leads to safer clinical outcomes
Frailty is a distinctive health state correlated to the ageing process in which there is a decline in the body’s physical and psychological reserves.1 It is estimated that 10% of people aged over 65 years have frailty, which increases to half of those over 85 years.2
Frailty in older people is characterised by reduced resilience to external stressors, reduced mobility and reduced functional reserve.1,3 Older frail patients are extremely vulnerable to minor events such as an infection or new medication.1 This results in frequent hospital admissions with geriatric syndromes such as falls, immobility, incontinence, confusion and susceptibility to adverse effects of medicines.1 Frail patients are at a higher risk of adverse outcomes including major changes to their physical and mental health. Ultimately, this increases the length of hospital admissions as recovery is a slower process, increasing risk of mortality. Older frail patients are typically more functionally dependent on others and might reside in a care facility.2,4
Establishing frailty
Establishing whether an older patient has frailty is important in order to meet their care needs and this can be undertaken using simple methods such as the Frailty Phenotype and Prisma-7.4,5 The Frailty Phenotype involves evaluating five criteria: unintentional weight loss; physical activity; exhaustion; weakness; and walking time.4 Similarly, the Prisma-7 is a questionnaire comprising seven questions that patients can self-complete. For both assessment tools, a score of ≥3 suggests the patient is frail. Additionally, after completing a comprehensive geriatric assessment (CGA) a scoring system can be used to examine the severity of frailty using tools such as the Rockwood Clinical Frailty Scale, Edmonton Frailty Scale and Gait Speed Test.6 CGA is the gold standard that includes a holistic, multidisciplinary team assessment of the older patient, showing a 30% higher chance of being alive and in their own home at six months (number needed to treat = 13).6
Why is polypharmacy an issue in frailty?
Polypharmacy is defined as taking five or more regular medications, which is commonly observed in older frail patients because multimorbidity leads to increased number of prescribed medication.7–10 Older patients are commonly observed having multiple medications, due to them having multiple comorbidities. Traditionally, polypharmacy was defined as taking more than five medications. More importantly, a thorough assessment is required to identify whether the medication is appropriate or inappropriate. Appropriate polypharmacy refers to each medication having a clinical indication that has an evidence base.11 Inappropriate polypharmacy refers to medication where the risk is greater than the benefit and there is little or no evidence base.11
Studies have shown that a significant number of medications taken by older frail patients lack clear indication, hence causing further complications for older frail patients. The results from a study carried out by Hanlon et al indicated that more than 90% of frail inpatients took at least one inappropriate medication.12 Furthermore, 5–11% of medications taken by older patients were identified as unintentional duplication of treatment for the same indication.13,14
Polypharmacy over the years has been characterised as a key element contributing to adverse events. However, it is difficult to establish whether the adverse events are a result of taking multiple medications or the progression of comorbidities in older frail patients. Appropriate polypharmacy can be achieved if individual needs, preference and goals of care are assessed accurately and appropriately. In patients who are generally mobile and functionally independent, prescribing multiple drugs will not be problematic. In contrast, frail patients would require a different approach as the predominant goal of medical therapy may be relieving symptoms of disease progression and maintaining function.7
Prescribing multiple medicines in older patients to some extent has contributed to hospitalisation and mortality. The risks involved with polypharmacy in older frail patients includes adverse drug reactions and also has the potential to cause long-term cognitive impairment, delirium, falls, urinary incontinence and unintentional weight loss.8,11 This is largely a consequence of the increased sensitivity to medication due to age, multiple comorbidities and impaired hepatic or renal function.6,11
Another risk associated to polypharmacy involves the following interactions: drug–drug, drug–disease and drug–geriatric syndrome (for example, use of anticholinergics in patients with risks of urinary incontinence and falls).14,15 The risks of adverse drug reactions can also be exhibited by specific classes of medicines such as, anticholinergics, anticoagulants, antiplatelet, antihypertensive and antidiabetics, which can be more harmful than beneficial when prescribed in older frail patients.1,6,12,16
Medicines optimisation and frailty
The prescribing of medicines has increased substantially due to an aging population with multimorbidity. This has a massive cost implication to the healthcare economy. Medicines optimisation is a process that aims to achieve ‘a person-centred approach to safe and effective medicines use, to ensure people obtain the best possible outcomes from their medicines’.17 In England approximately 10 million people have two or more long-term conditions, 1 million with frailty and 0.5 million are at end of life.18 Therefore, medicines optimisation is significant to improve medication adherence through multidisciplinary working, which leads to better health outcomes and reduces medication wastage.11,17
Importance of deprescribing in frailty
The use of medicine in older people aims to reduce disease progression, cure disease or manage symptoms, as the prevalence of chronic disease develops with age.16 However, it is important that the selection of medication is appropriate as older people are also at greater risk of experiencing adverse drug events. Inappropriate prescribing involves the use of interacting drug combinations, ineffective drugs and multiple drugs for the same indication without adequate optimisation.10 As a result, this leads to an increase in the pill burden and hazardous prescription cascades.
The factors that influence the choice of medical treatment in older people include therapeutic aims, pharmacokinetics, pharmacodynamics, and efficacy.11 These factors are subject to change with age and vary significantly between individuals of the same age. Therefore, reviewing all medicines in older people is fundamental to achieve safe and appropriate therapeutic goals.
Deprescribing is a complex process that requires careful consideration to balance the potential risks versus benefits of withdrawing medications to improve clinical outcomes.2
The barriers that may discourage healthcare professionals to deprescribe medication include:15,19
Medication reviews and shared decision-making
Where multiple medicines are used to treat long-term conditions, it is important to establish the patients understanding of their condition and address any concerns about their medication to support their adherence.20,21 Over time, the patients’ needs and suitability of medication will change, exploring these during the consultation aids successful medicines optimisation and deprescribing. For example, if non-adherence is identified, investigating the reason improves patient–clinician relationship, health benefits and reduces hospital admissions as older patients may stop and start their medication without consulting a doctor using their own understanding of the medicines prescribed in managing their symptoms.20
In order to achieve these outcomes, the National Institute for Health and Care Excellence (NICE) has provided guidance for carrying out structured medication reviews. Ideally, medication reviews should be carried out annually as standard practice and more frequent reviews should be considered if necessary, particularly in older frail patients with chronic or long-term conditions and polypharmacy.20,21 Various tools can be used to identify polypharmacy and assist with deprescribing such as STOPIT, STOPP/START and BEERS criteria.
NICE guidance on shared decision-making states that during a medication review, all patients should be given the opportunity to be involved in making decisions about their medicines.Assumptions on the patient’s values, preferences, level of participation and capacity to make decisions should be avoided. The principles specified in the Mental Capacity Act 2005 should be used to assess the patient’s capacity to make each decision.20 These discussions help to identify what is important to the patient about managing their condition(s) and their medicines.
The Kings Fund also highlighted that there is strong evidence suggesting that better outcomes are achieved when patients actively contribute in manging their health in comparison to those who are inactive recipients of care.22 Therefore, shared decision-making should become the principal mechanism where this is ‘no decision about me, without me’ to ensure that patients get the care they desire and require.22 All healthcare professionals undertaking medication reviews should implement this in their practice to standardise care.
How the pharmacist is key to providing better medications management
When initiating treatment in older people the lowest effective dose should be prescribed and then titrated up slowly to prevent adverse drug reactions. This approach provides cost-effective treatment with better health outcomes.23 Pharmacists play a key role in the selection and optimisation of medication that is safe and appropriate in frail older people as well as safely deprescribing any inappropriate medication.
Learning points
References
First published on our sister publication Hospital Pharmacy Europe
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