Wednesday, January 12, 2011

NEHTA and Electronic Transfer of Prescriptions - A Very Tiny Step on A Long Journey. The Pace Needs to Pick Up!

Very late last year we had the release of NEHTA’s most recent document on Electronic Transfer of Prescriptions (ETP)

The key document is titled as follows:

Concept of Operations

Electronic Transfer of Prescription 1.1

Version 1.1 — 17 December 2010 -Final

It can be downloaded from here:

What is important here is really to come to grips just what is here and what is missing.

What is discussed in this document is neither electronic prescribing or electronic Medication Management - except to point out where ETP actually fits.

NEHTA sees the big picture thus:

1.3 Requirements

“NEHTA has identified six capabilities required for comprehensive eMM, listed below. Only the first capability is delivered by ETP. The remaining capabilities are the subject of proposed future initiatives and may not necessarily be delivered in sequential order.

Exchange of electronic prescribing and dispensing messages The generation and exchange of standardised, secure electronic documents that represent prescriptions and their associated dispensing records.

Adherence monitoring Supports the timely notification of authorised healthcare providers and individuals when deviations from the expected sequence of dispensing events are detected. Adherence monitoring requires records of an individual’s prescribed and dispensed (and/or supplied) medications, and will make use of the electronic prescribing and dispensing records described above. The full medico-legal effects of this capability need to be understood by participants and agreement secured prior to implementation.

Electronic Medication Profile Supports the storage of medication reviews that are performed by healthcare providers. The documents produced by these medication reviews are referred to as Electronic Medication Profiles (eMP) and reflect existing paper-based current medication lists. These could be stored in Personally Controlled Electronic Health Record (PCEHR) repositories and/or sent directly between healthcare providers, or form part of electronic discharge summaries and referrals.

Medication History Lists Supports the storage of a chronological record of an individual’s prescribed and dispensed medications. Such records comprise a Medication History List (MHL) for each individual. These are either stored in dedicated MHL repositories or are stored with other types of individual electronic healthcare records in general purpose PCEHR repositories. In either case the repositories make MHLs available to the individual, their authorised representatives, and to the healthcare providers who require this information to service the individual and who are authorised to do so by the individual.

Clinical Decision Support

Many of the proposed benefits of eMM have been based on expectations that clinical decision support will improve safety and quality, with considerable savings estimated. It is intended that eMM will be supported by decision support to guide health professionals and consumers to make the best decisions about medicines use.

This capability will identify and prioritise new opportunities for decision support arising from the eMM processes and ensure specifications developed as part of the EMM program support future clinical decision support development.

Future Permissible Secondary Uses

This capability supports the access and use of de-identified data related to eMM processes for monitoring the safety, effectiveness and cost-effectiveness of medicines use. It includes:

1. Determination of permissible secondary uses and governance of the data;

2. Processes for collection, storage and analysis of more complete and more detailed consumer medications data than is currently possible

3. Use of this data to identify quality improvement opportunities.

These six capabilities reflect various stages in the evolution of eMM and are not to be interpreted as a roadmap for national implementation across all healthcare communities. Different communities will likely vary in their support of these capabilities depending on the rate at which they can implement changes to existing policies and practices and how rapidly the required e-health foundation services become available to them.”

The issue with all this in my mind is that the ETP component has already been implemented, at least partially, by both eRx and Medisecure quite a while ago, and this is by far the simplest part of the whole eMM story. NEHTA is happy to claim all sorts of benefits from eMM without bothering to point out you need an integrated eMM environment that covers all the bases mentioned above for these benefits to actually be delivered (DoHA is also famous for making similar benefit claims for the PCEHR!).

What is really breathtaking about this and all the associated documents is the lack of clarity regarding implementation of this and the environment in which it will be implemented, and where the resources to provide the proposed ‘Prescription Exchanges’ will come from. Is this another place where the private sector is to fill the gap - presumably by using the 5th Pharmacy Agreement per prescription incentive funds - and if that is the case just why would they adopt an unproven approach rather than one that seems to be already working.

Of course the NEHTA approach is dependent on the National Authentication System for Health for which we have still to hear about the winning tenderer, let alone availability timetables etc. Just how this can NEHTA can offer a Technical Specification for Trial Implementation is a little confusing when key dependencies appear to be as yet not available or defined. Also we need the HI Service operational at a large scale level!

Interestingly very late last year the IHE Program also released what looks to be a much fuller and more developed, and more international, approach for eMM.

These documents can be reviewed here:

The documents contain trial implementation approaches and specifications covering a fair bit:

· CMPD - Community Medication Prescription and Dispense

· HWM - Hospital Medication Workflow

· PRE - Content Profile for Prescription

· PADV - Content Profile for Pharmaceutical Advice

· DIS - Content Profile for Dispense

The IHE Technical Frameworks already have well developed secure messaging and other basic infrastructure service specifications - which have been thoroughly tested at many recent Connectathons.

Of course we also have the e-prescribing SIG of Standards Australia’s IT-14 also working to come up with an agreed Standard.

It should be noted this group take a broader view than NEHTA.

See here:

Prescription Messaging

E.scripts will touch more Australians, more often, than any other clinical application

Replacing the simple printing of prescriptions with E.scripts involves the formulation of a prescription, supported by a relevant Clinical Decision Support System (CDS), and secure transmission of the prescription to the pharmacist, who then dispenses to the patient using associated software for data collection and reporting mechanisms.

The IT-014-06-4 Working Group, Prescription Messaging is focused on the development of standards for communication between prescribers, dispensers, agencies and healthcare trading partners involving technical document exchange and the clinical terminology content operating under a national business and governance model.

Globally, a universal standard for a prescription platform is a priority for most advanced countries. Many issues faced by expert working groups vary between countries or regional jurisdictions. However, three common elements are:

  • the technology platform;
  • the clinical terminology content; and
  • the governance structure.

Of the three, the first two are relatively common across national boundaries and jurisdictions, while the third, governance and legislation, is dependent on national and regional jurisdictional control. While the terminology is fairly common across borders, it is also complex due to the requirement to be consistent with other overlapping, patient-centric, clinical applications and services. As such, different names are used in different countries, which will require a naming framework and rules to be collaboratively developed.

Internationally, the harmonisation of prescription messaging standards involves substantial committee work in HL7 organisations and ISO/TC-215, Working Group 6 (Pharmacy Terminology). The IT-014-06-04 working group is linked into this international effort and is determined to deliver appropriate standards to the Australian health sector. Standards that will underpin the collaborative process between the doctor, patient and pharmacist in adapting to electronic representation of a prescription.

Of all the health sector clinical documents, prescriptions are the most prevalent. In Australia, patients experience the prescription process in greater numbers than for any other clinical application. This process is federally regulated and highly subsidized and crosses all points of clinical care.

Prescriptions link three broad levels of data interoperability:

  • the supply chain for unique, aligned and synchronized product identification;
  • the clinical functionality of diagnosis, prescribing and dispensing; and culminating in
  • the record of the transaction and the content of the transaction being seamlessly archived in a patient’s Electronic

The page is found here:

So we seem to have, at least four sets of actors here:

1. The Private Prescription Exchanges.


3. Standards Australia

4. Integrating the Healthcare Enterprise (IHE).

To that we need to add Governments, Consumers, DoHA, Software Providers, Academe, Clinicians (prescribers, pharmacists) and so it goes on.

If ever there was a reason to have a proper National Summit to sort out a future direction, set up governance and get clarity about what the rules of the road are, who will pay whom etc. this is the topic! As the title of the blog says what NEHTA has done so far is a tiny step and we need to open the process of specification and trial implementation to a broader audience

There are so many stakeholders, and the issues are so central to patient outcomes and safety to not take a holistic approach is just plain stupid.

I don’t know all the answers, but none of the other actors, on their own, do either!


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