Long planned, long promised, COVID-19 has been the catalyst to propel this medicine safety game changer in practice.
Australians are typically early adaptors of new technology trends. We led the world in shifting towards a cash-free economy, using wearable technology to monitor exercise and we have one of the highest saturation rates of smartphones anywhere. Yet, paper prescriptions have stubbornly remained, with the physical transfer of a piece of paper required to facilitate legal supply of medicines.
Electronic prescriptions have been ‘coming soon’ for over a decade in Australia, with significant work having been undertaken in recent years to bring electronic prescriptions online. Ultimately, it took the COVID-19 pandemic to crystallise the immediate medicine safety and public health imperative for electronic prescriptions.
Enabling regulation and technical standards
The Australian Digital Health Agency (ADHA) has led work on electronic prescriptions for several years, coordinating a complex body of work with other government agencies, and their state/territory counterparts, to make electronic prescriptions a reality.
Two important events occurred on 31 October 2019: PBS legislation was amended to recognise electronic prescriptions as an alternative to paper and the ADHA released the technical framework for clinical software to handle eScripts.
‘The important groundwork had been laid with the legislative changes and technical framework,’ says Andrew Matthews MPS, the ADHA’s Director of Medicines Safety.
‘The challenge,’ he noted, ‘has been the sheer scope of the exercise, to implement across more than 5,700 pharmacies, 7,000 GP clinics, more than 40 software vendors, and specialists and other health providers.’ Mr Andrews has welcomed the willingness of peak bodies, health professionals, consumers, industry and government to work together to make electronic prescriptions a reality during the pandemic.
Finalising the technical framework has been essential to ensuring the system ‘just works’.
David Freemantle, General Manager eHealth at Fred IT Group and a member of the ADHA’s Technical Working Group for eScripts, reflects: ‘COVID-19 just accelerated a process that was already well down the planning track.’
Electronic prescribing will dramatically reduce many of the medicine safety problems that occur in prescribing and dispensing.
‘Medicine safety is a primary benefit [of electronic prescriptions], which is why electronic prescribing falls under the Medicines Safety strategic priority in Australia’s National Digital Health Strategy,’ says Mr Matthews.
Sepehr Shakib is an expert on electronic healthcare systems and the Professor of Clinical Pharmacology at the University of Adelaide. While his research focuses on electronic prescribing in hospital settings, he believes there are universal lessons to be learnt.
Electronic prescriptions will also support a smoother workflow as the ability to communicate a prescription from prescriber to patient to pharmacy will not be limited by distance or the location of each individual.
‘This will eliminate the need for owing prescriptions which are prone to significant administrative and PBS claiming delays,’ says Jarrod McMaugh MPS, PSA’s Project Pharmacist.
‘If you think about common scenarios, such as patients who are travelling having prescriptions posted between pharmacies in an emergency or faxed/ verbal prescriptions taking time in transit through post, there are clear patient care and administrative advantages.’
Supporting professional judgement
When Prof Shakib was involved in introducing electronic prescribing to South Australian hospitals, clinicians wanted a system that was as swift and simple as writing a paper prescription yet intelligent enough to provide complex checks to curb prescribing errors.
‘We found that was completely the wrong paradigm,’ he says. ‘What you want is a fairly rigid system where you can’t make the mistake in the first place. If some drugs can only be given by one route, the system should make it really difficult for you to do the wrong thing.’
‘How the system looks and the options it presents is way more important than investing in a whole lot of clever bells and whistles. Like a lot of healthcare, doing the simple things well is what makes the biggest differences.’
The best electronic prescribing systems, Prof Shakib says, allow easy entry of key information, have a simple and uncluttered interface, and yet allow information to be unobtrusively pulled in when needed, catering to the different levels of experience among clinicians and pharmacists.
‘Anything that requires a certain amount of discretion shouldn’t be done by a computer,’ says Prof Shakib.
‘We put people through years of pharmacy and medical school to know how drugs interact, how to use a medicine in a particular situation and how to adjust a dose for kidney function. Electronic prescribing should be flexible enough to allow a clinician to apply this knowledge when prescribing or dispensing’.
According to Mr McMaugh, ‘eScripts will mean less ambiguous prescriptions, allowing more cognitive space for pharmacists to consider clinical appropriateness and medicine safety issues. This will be further augmented through access to additional clinical information sources such as My Health Record and real-time prescription monitoring.’
Benefits of electronic prescriptions
Adjusting to eScripts
The two most significant changes to practice for pharmacists will be incorporating workflow changes to receive tokens, and to conduct the final check with reference to the electronic prescription. This means reviewing where and how pharmacists use computer terminals and electronic devices.
‘Pharmacies will need a way of receiving tokens – whether that is by phone, a dedicated computer at the ‘scripts-in’ counter, or a kiosk arrangement. Software will need to be integrated with the current physical queue and updated consistently to accommodate tokens,’ Mr McMaugh noted.
Adoption of electronic prescriptions is expected to be a slow burn. While around 90% of pharmacies and most general practices have conformant software, community uptake will be variable.
‘Many people don’t have internet at home and many of our elderly patients don’t have smartphones,’ said Yanping Sheng MPS, the sole pharmacist in Mallacoota, a small town of about 1,000 people in East Gippsland, Victoria, more than 500 kilometres from Melbourne.
‘If I want to check my email at night, all I have is a poor 3G connection. Electronic prescribing is the trend and it will happen but it will happen much more slowly in Mallacoota, just like the internet itself,’ he says.
David Freemantle notes e-prescribing doesn’t fundamentally change the four-step workflow, with systems developed to mirror the process of script in, check, dispense and script out.
‘Paper prescriptions will still continue,’ says Mr McMaugh. ‘But as electronic prescriptions provide a new, more convenient choice for patients, we can expect their use to progressively decline over time.
‘It will be a really exciting transition to safer and more patient-focused care.’
What is electronic prescribing?
An electronic prescription is a legal prescription that is fully electronic. The legal prescription exists in the National Electronic Prescription Repository and is accessed via a secure Prescription Exchange Service (i.e. eRx, MediSecure).
What is a token?
A token is a way of accessing an electronic prescription. This will be a QR barcode sent to patients via email, SMS or printed on paper. It is a similar concept to a digital boarding pass for a flight.
What is an Active Script List?
An Active Script List is another way of accessing an electronic prescription. Patients will be able to access all their electronic prescriptions from this list without the need for tokens. Patients may provide consent for health professionals (including pharmacists) to access this list.
This is a similar concept to the list of flight bookings available when logging into a frequent flyer profile.
What happens to the script if the patient deletes their token from their phone?
If the patient deletes their copy of the token, such as an SMS message, the prescription is still valid in the Prescription Exchange Service. The prescriber is able to resend the token to the patient.
Can the pharmacist reissue a token for a repeat prescription if it is deleted?
Can copies of tokens be stored at the patient’s regular pharmacy?
Yes. The patient has the ability to share tokens with the pharmacy.
How are repeats generated?
Electronic prescriptions containing repeats will generate and send a new token or update the Active Script List once the medicine has been dispensed
Are electronic prescriptions legal in all states and territories?
All states and territories are working towards adoption of electronic prescriptions. At the time of publication, all states except Queensland and South Australia had adopted enabling regulations.
How do I prepare for electronic prescriptions?
More than 90% of community pharmacies are eScript-ready. Pharmacists should ensure dispensing software is up to date, HPI-O exists, the Health Identifier service is connected, QR codes on barcode scanners are enabled and determine whether computer terminal changes are needed to support workflow.
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