With national e-prescribing on the horizon, is pharmacy ready for the next big wave of technological change?
Sydney pharmacy proprietor Nick Logan met a pharmacist from Sweden at a social event a few years ago, and what she said made him think about the need to push forward with e-prescribing in Australia.
“She said that she graduated in 2003, and she’d never seen a paper prescription before she came to Australia,” says Logan.
“She said [in Sweden] effectively they use what’s their Medicare card, and they just present it at any pharmacy and it dispenses one box of their medicine out of the ‘cloud’—out of however many boxes the doctor prescribed into the cloud.”
It’s about time for Australia to introduce similar measures of digitisation across the healthcare industry, says Logan, who adds that pharmacists are frequently underestimated when it comes to their ability to embrace it.
“I’m standing here in my dispensary looking at the piles of paper and thinking, ‘boy it’d be great, imagine if you didn’t have to print repeats’.
“I don’t think pharmacists have considered what it would be like not having to print repeats.
“I can assure you that all pharmacists are sick of the amount of paper that we generate. There’s a lot of office work involved with a huge amount of paper that is generated.
“People routinely criticise pharmacists for being resistant to change but we got computerised in 1985, that’s like 15 years before every other industry,” argues Logan.
“We’re actually good at change and I think technology is one of those things we’re really good at. I’d be very surprised if pharmacists don’t get aboard e-health and e-prescribing super fast,” he says.
Biggest change in decades
Change is coming—the Department of Health has partnered with the Australian Digital Health Agency to deliver the technical framework for e-prescribing by the end of 2019, if all goes according to schedule.
This work is being bolstered through the Federal Government’s commitment in the 2017–18 Budget of $28.2 million over five years towards implementation of the system.
The Department says it is leading work to enable the prescribing, dispensing and claiming of PBS and RPBS medicines in a seamless electronic manner.
“Electronic prescriptions … will provide an option for prescribers and their patients to have a fully electronic PBS prescription as an alternative to a paper PBS prescription,” a spokesperson for the Department of Health told the AJP.
“The development of the required legislative and technical frameworks is well underway, which will enable modifications to existing systems and software to allow the safe and secure use of an electronic prescription as a legal alternative to a paper prescription.”
Recent changes to legislative rules related to PBS/RPBS claims are now paving the way for the use of electronic-only prescriptions across the country.
An amendment enacted by the Department of Health on 29 October 2019 provides the legislative framework for the use of an electronic prescription as an alternative to a paper-based prescription.
The amendment sets the rules for how electronic prescription should be differentiated from paper scripts, including additional information that would be required from approved suppliers in relation to the supply of pharmaceutical benefits upon electronic prescription.
There are other rules in place, for example, that, following initial prescription, any subsequent change to a different format (from paper to electronic or vice versa) would require cancellation of the existing prescription and preparation of a new script, in order to avoid duplication.
A new PBS/RPBS item receipt flag will also be provided with electronic prescription—this flag is an indication that the person acknowledged receiving the pharmaceutical benefit.
This replaces the existing mechanism whereby a patient signs a paper prescription to acknowledge receipt of the benefit, in accordance with regulations.
Changes will also allow claims for both paper and electronic prescriptions for residents in aged care facilities.
The introduction of paperless electronic scripts will be the largest process change in medication supply since the introduction of computers in pharmacy and general practices since the 1980s, says Paul Naismith, CEO of Fred IT Group which runs the eRx Script Exchange.
“It’s the largest change in [over] 20 years, as far as how we process prescriptions,” he says. “I believe patients are looking to pharmacy to modernise and move into the new digital age.”
While the e-prescription network already exists, the legislative changes mean that a paper script is no longer legally required, so the patient can choose to get the script either in paper or go totally digital, says Naismith.
“For 10 years there’s been e-prescribing in Australia. In the last two Community Pharmacy Agreements there’s been funding for e-prescribing and today there’s about 30,000 doctors and pharmacists connected to e-prescribing systems,” he explains.
“The difference is that while the e-prescription network is there, eRx is the one we have and the other is called MediSecure, those exchanges are there but the legal document is still the paper.”
He explains that the infrastructure provided by eRx Script Exchange together with MediSecure will be used as the backbone for the national e-prescribing network.
Following changes to the legislation, “the main difference is that you can choose to get your script in paper or, if you want, you can go totally digital. You don’t need any paper in the process,” he says.
“The requirements of the new system are quite different but they build on that infrastructure that’s already in place, and the government via the Australian Digital Health Agency has come up with new guidelines and requirements for both the exchanges.
“Additionally the doctors’ and pharmacists’ software needs to be upgraded to be able to operate without paper.”
Benefits across the board
A national e-prescribing system offers several significant benefits for patients and healthcare practitioners, say experts.
Doctors will no longer need to print and sign scripts if the patient chooses to get it electronically, Naismith said.
“The exciting news is that pharmacists’ paper-driven clerical roles will reduce dramatically. No longer will we spend our time looking for paper prescriptions on file, sorting wads of scripts for the next supply, sticking claim and duplicate stickers on scripts and chasing patients to sign-off supply,” he says.
“That gives [pharmacists] more time for patients, so spending less administrative time and more time providing professional services and advice.”
He says, additionally, that reduced transcription and retyping will make script processing safer because there is less chance of errors.
“It will be more efficient and less frustrating,” says Naismith.
Meanwhile the patient also has significant benefits.
“There is a lot of consumer benefit, the patients no longer need to carry around bits of paper so it makes it definitely more convenient.
“At the moment if you lose a prescription you have to go to the doctor. The patient may choose to use the system in a way that means they will never lose a prescription.”
Patients will be able to view and access scripts electronically if they choose to do so.
Apps such as MedAdvisor and GuildLink currently provide consumer views of patient scripts and information held by eRx and MediSecure, however under the old system paper scripts are still required.
MedAdvisor is ready to embrace the changes that will come with national e-prescribing.
The company has already enabled digitisation of health for pharmacies in its network since 2013, explains MedAdvisor executive director and CEO Robert Read.
“We have over 1.2 million patients who have ordered more than 25 million scripts through the MedAdvisor network, so patients of MedAdvisor have been experiencing some of the benefits of e-prescribing already in terms of digitisation of scripts—but paper had to follow those orders,” says Read.
Typically pharmacies maintain these paper scripts on file, he says.
Patients can currently request a script from their GP and, if that GP is connected to the MedAdvisor system, the script can be sent by mail and electronically to their preferred pharmacy through the platform.
“That has been an experience our patients have started to get used to and have become acclimatised to,” says Read.
He says the further changes with e-prescribing will provide even further convenience for patients.
“Having the convenience of scripts on your phone is a major benefit for users, it gives you an element of control, and it also gives you an increased opportunity to boost their health literacy and engage with the health system,” says Read.
“We’re obviously very keen for e-prescribing to help our 60% of pharmacies in Australia. Many of those pharmacies are now technically enabled for e-prescribing in the first iterations of that platform.”
However, he warns that e-prescribing may change the pharmacy landscape by making it easier for online pharmacies to flourish.
“Up until now it’s been a hard environment for online pharmacies, because not only do you have to order online but you’ve then had to send your script in physically to that pharmacy before it’s dispensed,” says Read.
“But if you can simply SMS or email you script to an online pharmacy, you’ve got rid of that barrier to usage.
“There will be online pharmacies that come out in Australia and they will market aggressively for patients.”
Robert Read encourages community pharmacists to make sure they are offering their patients the convenience of an online solution in addition to the support of a physical pharmacist.
“That is something online pharmacies can’t do. Community pharmacy should leverage their strength as trusted health practitioners … and also provide the convenience of ordering, paying in advance and delivering to your home at the times you need it.”
Addressing privacy & security concerns
There are various privacy and security models that the government is considering, Read explains.
“One of the things we were very focused on, and I think the Department of Health is focused on, is making sure the privacy is no worse than what you’d see with paper scripts,” he says.
“There are considerations that the government will work hard to ensure that people are educated on,” he adds, referring to privacy and consent issues.
Paul Naismith said there will need to be appropriate protections in place to ensure cyber security.
“There’s continuing risk with cyber issues and pharmacists and doctors. Whether this be e-scripts or My Health Record—those general risks are there, they’re real and rising in some extent.
“There’s a requirement that we continue to get better at that,” he says.
More certification and information will be required for each claim, so the government is comfortable that the person or system writing the e-script is approved, Naismith explains.
Software used to prepare prescriptions will generate unique PBS electronic prescription numbers, according to the relevant legislation.
Intermediary systems that sit between the prescribing software and dispensing software hold e-scripts securely in an encrypted format, according to the Department of Health.
These intermediary systems, eRx and MediSecure, are not permitted to view prescription information without the consent of the patient and must adhere to the Australian Digital Health Agency technical framework to gain valid identifiers.
Claims upon electronic prescription must contain identifiers to ensure “adherence to privacy and security principles”, except in some settings such a hospitals, where a single system is used for prescribing and dispensing.
There will be different models that will require varying levels of consent, depending on what the patient wants.
However, Naismith emphasises that patients will be able to choose between paper and electronic prescriptions.
“If they’re not comfortable with their information being used this way, they can choose to keep going with paper,” he said.
“The consumer can choose whether to use the system of not”.