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E-prescribing delays were not in the script

The benefits of electronic prescribing are numerous and well documented. National e-prescribing programmes have been shown to save time, improve patient safety and outcomes, boost transparency, reduce medication errors and aid in the detection of fraud.

But despite obvious advantages, significant initial investment and development in information technology (IT) systems and structures is required to make e-prescribing a reality.

The Irish Pharmacy Union (IPU) defines e-prescribing as “electronic prescribing, the computer-based electronic generation, transmission and filing of a medical prescription. It allows medical practitioners to write and send prescriptions to a pharmacy electronically instead of using paper prescriptions.”

E-prescribing was identified in the 2013 National eHealth Strategy as a key priority for Ireland. But five years later, the country still awaits a national roll-out.

This is not to say that no progress has been made, however. Successful pilots have taken place. More recently, the IPU and HIQA have issued consultative papers on the topic.

In addition, the HSE “are in the process of establishing the programme governance structures required to support the project team”, a spokesperson stated.

However, significant issues remain. Despite two pilots undertaken to date, HIQA appears to be recommending, in its recently-published Draft recommendations for the national, community-based e-prescribing programme in Ireland,  that another pilot occur.

Furthermore, according to a spokesperson for the Department of Health, the business case for national roll-out has yet to be approved. Possible legal changes are also under examination by the HSE.

Pilots

Two pilots have occurred to date, providing an important insight into the requirements necessary to successfully introduce e-prescribing in Ireland.

In 2012, Clanwilliam Health joined the Healthcare Innovation Hub (HIH) with a proposal to trial an e-prescribing service in Ireland.

A pilot was set up with a small group of GPs and pharmacies in Blackpool, Cork, to trial the service, labelled ‘e-script’.

It was designed as a system where the person printing the prescription asked the patient where they wanted the prescription filled and it was then sent electronically to the specified pharmacy.

A similar pilot undertaken at Mallow Primary Healthcare Centre (MPHC), developed by McLernons and CompleteGP, went live in 2016.

Run under the auspices of the Health Information Hub (HIH), Cork, the system, generating e-prescriptions, is now up-and-running at the centre. Three GP practices and nine pharmacies in Mallow are involved.

When the prescription is printed, the printer also produces a unique key on the prescription form in a single-line barcode. The data is sent to the cloud and the prescription (which is still the legal document) is given to the patient or their carer.

At all times, control over the prescription remains with the patient, and nothing happens until they present the script in the pharmacy of their choice. Only at this point is the prescription barcode scanned and the code allows the information to be retrieved from the cloud and is automatically populated into the McLernons dispensing system.

A further roll-out of the initiative to GPs and pharmacies in Mallow occurred later, when CompleteGP was contracted to provide technology to remove dot matrix printers from GP surgeries by eliminating the need for multi-layer GMS paper. 

The area for initial roll-out was limited to MPHC and catchment pharmacies. The roll-out is now paused until agreement on a central drugs database can be reached, it is understood.

Dr David Molony, GP at MPHC, said the e-prescribing service has been in place there for more than 20 months. During this time, around 200,000 e-prescriptions have been generated, Dr Molony said.

He described the project as “very successful” and “efficient”.

“It brings a huge benefit in accuracy to patients. There is no transcription involved and it has end-to-end accountability,” he said.

For a number of years, the IPU has been working with the HSE, eHealth Ireland and others to help deliver a national community-based e-prescribing system.

In April 2018, it published a  Draft IPU e-Prescribing User Requirements Specification (URS) for Primary Care.

The URS describes a comprehensive and pragmatic approach to the “unique nuances” of work practices and legislation pertinent to primary care in Ireland, specifically GP practices and pharmacies.

“Our objective is to provide the necessary direction for the design of a primary care e-prescribing system for adoption across the Republic of Ireland,” Mr Alan Reilly, Head of Information and Technology at the IPU, told the Medical Independent (MI).

Challenges

Despite such progress, the development of e-prescribing in primary care nationally is not without its challenges.

During the pilots, a number of issues arose, particularly around drug coding and how directions are printed.

Other impediments to development include the lack of an individual health identifier (IHI) number and standardised drug database.

The development of IHIs is in progress. Last year, Minister for Health Simon Harris signed a commencement order and made regulations under the Health Identifiers Act 2014 allowing for access to the register of IHIs and also for use of the health identifier within the health sector, both public and private.

But at the time, he said it “will take some considerable time to embed the number in all our health systems”.

Currently, legislation around prescribing is also holding up developments. The law currently states that prescriptions must be produced on paper and controlled drugs must be hand-written on paper scripts.

System developers are designing IT solutions that adhere to Irish law, but the question is whether it would be preferable if the law was changed in the first instance to facilitate the development of a better e-prescribing system.

Perhaps. But there is no impetus to change legislation and if it was changed, there is no workable solution in place in the event of a change in Irish law. 

Experts working in the area believe that when the system is in place, the legislation will be changed.

International

Ireland is not the only health system grappling with e-prescribing. Many countries internationally have either developed or are in the process of developing new systems.

Nine European countries and three other countries have e-prescribing in place to date, according to an international review on the subject recently published by HIQA  as part of a consultation on e-prescribing in Ireland.

In the UK, the legislation was changed and a central system inserted. Critically, the NHS had IHIs in place at the time, which made the change much easier.

However, the system encountered difficulties. Pharmacists experienced lengthy download times for scripts in pharmacies, for instance.

The aim of the Irish e-prescribing strategy is to “reduce medication errors, thereby reducing the associated costs and speeding-up patient access to medication,” according to HIQA.

HIQA’s international review notes “the EU e-prescribing programme is being rolled-out as part of three waves of deployments in Europe, between 2018 and 2020”.

“The Irish e-prescribing programme is scheduled to implement the capability to provide the epSOS [European Patient Smart Open Services] Patient Summary and ePrescriptions in Wave 3, which is due to occur in February 2020.”

The epSOS project was an EU-wide pilot project run between 2008 and 2013 “that developed and tested an e-health framework and an ICT infrastructure for secure cross-border access to patient health information between different European healthcare systems”.

Ireland, therefore, must accelerate progress in e-prescribing to meet both national and EU requirements.

HSE

The HSE is hoping to have e-prescribing in place by 2020, but has attached a caveat to the aim. 

A spokesperson for the Executive said “e-prescribing in primary care has some key dependencies which make it difficult to determine when it will be rolled-out nationally”.

“For example, it depends on the existence of a National Medicinal Product Catalogue that does not exist today, as well as various technical components that are yet to be developed.”

They added that getting all pharmacies online in advance of GPs issuing e-prescriptions is a barrier to development, while the lack of a National Medicinal Product Catalogue (due in 2020) will mean finding a workaround between all drug files in use within GP and pharmacy systems to support safe e-prescribing at both a generic and product level.

According to the HSE, the project does not have a requirement for significant funding currently, as the only cost is for internal staffing.

A Department of Health spokesperson told MI that the budget for 2018 is €200,000.

“E-prescribing is not expected to be a capital-intensive project when compared to the cost of systems typically required for hospitals. The final budget will depend on the cost of various dependencies within the e-prescribing project and the recommendations for solutions. The budget will increase for the project as the HSE moves towards different project stages and implementation following finalisation of the business case, if approved,” the spokesperson explained.

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