Sunday, May 19, 2013

I Have A Feeling This Aspect Of The NEHRS Seems A Bit Incoherent And Ill Thought Out. Confusing Even!

As mentioned a week or so ago there has been an update to the viewable NEHRS / PCEHR.
See here for the blog.
A few days ago the professional FAQ for the PCEHR was updated.
This is found here:
This section I found interesting among others. It explains what the intent of the new Medication View of the PCEHR is and it now becomes clear it is a broader implementation of the MedView Wave Site program conducted by the Pharmacy Computing Company FRED IT I believe.
MedView has been renamed the NPDR.
Here is what we learn.

What is the National Prescription and Dispense Repository (NPDR)?

New functionality has been added to Australia’s eHealth record system to make, over time, the prescribing and dispensing of medication a safer, more effective part of health care.
The National Prescription and Dispense Repository provides for the creation of an online medication history (not retrospective) for patients with an eHealth record based on information collected at the point of prescription and the point of dispense.
A new Prescription and Dispense View has been added to the eHealth record system that displays information entered by participating healthcare providers relating to the medications prescribed and dispensed to patients with an eHealth record.
The new Prescription and Dispense View displays the name and date a medication has been prescribed (both the brand and generic name), the strength or dose of the medication (e.g. 2mg, 20mg, etc), the direction for consumption (e.g. take one capsule daily) and the form of the medication prescribed (e.g. capsule, tablet, inhaler, etc). Similar information is also displayed as medications are dispensed.
For healthcare professionals participating in the eHealth record system, this gives a better view of the medications that has been prescribed and dispensed to a patient, which, over time, will help support better clinical decisions.
While the new prescribe and dispense function is now available, benefits will only be realised over time as more people – consumers and healthcare provider organisations alike – register and participate in Australia’s eHealth record system. The new Prescription and Dispense View should not be wholly relied upon to be complete record of prescribed and dispensed medicines.
Very useful information is also found from the FRED IT website. The discussion shows how the PCEHR can be accessed and viewed from the Dispensing System.
See here:
Very interestingly it seems the Pharmacist can access the Shared Health Summary and most other documents, including Advanced Care Directives , presumably with the default security settings in place. (I would have thought such access might have been made ‘opt-in’ - but there you go).
Another wrinkle in all this was raised a month or two back:

MediSecure announces RACGP Protocol Implementation for e-Prescriptions

Published on: 7th March, 2013
Earlier this week, MediSecure met with RACGP to discuss potentially significant issues in relation to the dispense notifications provided to general practitioners through the electronic transfer of prescriptions (eTP). These RACGP concerns impact both prescription exchange services.
Under current privacy legislation, GPs are required to obtain patient consent to receive and read Dispense Notifications in their clinical system. The RACGP advises that receiving Dispense Notifications may also impact on the GP’s duty of care.
The RACGP has requested that MediSecure provide an option to both not install, and remove the dispense notification function from the practice’s clinical information system and the practitioner’s view.
MediSecure has agreed to this. Accordingly we have disabled all Dispense Notifications in the MediSecure eTP system, effective from 8 March 2013.
Any new MediSecure® installation or an existing installation will not be able to access the Dispense Notification service from this time. Over the coming weeks MediSecure will develop and deploy a new client adaptor to remove the Dispense Notification menu option from your desktop.

In summary:

The immediate fix to this patient consent and doctor medico-legal risk issue is to disable Dispense Notifications. No MediSecure® user can access Dispense Notifications from 8 March 2013.  Over the next two months, MediSecure will contact your practice to update your existing MediSecure client to remove Dispense Notifications as a menu option.
You are referred to Friday Facts for the RACGP advice in relation to dispense notifications.

Future New Dispense Notification Service

For those practices and clinicians that wish to access the Dispense Notification data after 8 March, we advise that MediSecure will release a new ehealth service as a specific opt-in Dispense Notification service with a separate Licence. Details of how to enrol for this service will be released around 15 March 2013.
For any GP or practice that decides to adopt the new Dispense Notification service after 15 March 2013, MediSecure and RACGP recommend that GPs obtain and record consent from the patient to receive dispense notifications.
More information on an appropriate Consent Protocol will be released at the time of announcement of the new service.
See here:
The eRx Script Exchange responded similarly.
The way the RACGP saw things is here:

Electronic transfer of prescriptions – update to Medisecure and eRX users

The RACGP supports electronic transfer of prescriptions (eTP) as a prescribing process to reduce transcription errors and increase medicine safety for the community. However, the College has become aware of potentially significant issues in relation to the dispense notifications provided to general practitioners by the two proprietary eTP vendors (Medisecure and eRX). The receiving of dispense notifications is a departure from current clinical practice whereby GPs are generally unaware as to whether or not a prescription has been dispensed, unless advised by the patient at a subsequent visit. Whilst GPs may find it useful to know whether their prescriptions have been dispensed, it requires patient consent to receive or read such notification; this may impact on a GPs duty of care.
This week, the RACGP met with both vendors to request that they review the current consent and product installation processes and terms of use. The College has requested advice from both vendors about the feasibility of modifying their system to not install, and remove the dispense notification function (where already installed) from the practice’s clinical information system and the practitioner’s view. In response to our request, Medisecure has advised that dispense notification functionality will be disabled effective Friday 8 March 2013. Medisecure will provide more detailed information directly to its users. When information is available from eRX, GPs will be advised in a future edition of Fridayfacts.
See here:
In my view what we have happening here is a total failure of the observance of basic system design and implementation approaches.
First we have introduction of functionality into the PCEHR and e-prescribing systems which the GPs are not at all happy with to say nothing of the whole thing being obvious scope crepe - like the planned ACD addition and the Child Care Section.
Second we have the nonsense of there now being two sources of information regarding medications in the same patient’s PCEHR which are neither synchronised or obviously related. What ever happened to the single source of information for this sort of data. Multiple differing sources are just a joke.
Why this happened was all due to the haste with which the program has been conducted and the nonsense of multiple Wave sites conducting non-integrated pilots and development and a rather obvious effort to get as much stuff as possible out there before the looming Federal Election.
It is really amazing a single patient record can have 3 different sources of medication information (Shared Summary, Medicare and the NPDR) each of which has a different delay and almost certainly different information.
What is more is that you still can't have your prescription sent to the pharmacy of your choice and the functionality overseas experience shows is liked by patients in a PHR are still not  present.
What we have now looks pretty amateurish and really confusing for the average patient.


Anonymous said...

David, while I often agree with your views, I don't this time. The NPDR is driven by ETP, it would not exist without it so the data is from 'one' source. Also, clinically the NPDR data will be up to date and include private prescriptions, the PBS data feed does not.

As for the RACGPs issues with the dispense notification, thses can be understood as it is a very grey area at this point in time, however the PCEHR is opt in and a doctor or pharmacist can choose to not to request access to a patients record if they are that concerned.

Dr David More MB PhD FACHI said...

Sorry, this is all stuck together with sticky tape in my view. One patient record and 3 sources of drug information which are different is just silly. (Medicare, NPDR and Shared Summary)

Also it is by no means clear to me whether every time a pharmacist dispenses a script just how consent is obtained to expose that to a person's record.

From any perspective this is a gown up like Topsy mess to me!


Anonymous said...

David I am very confused. How does the prescription data get to the NPDR?

Does the prescription software send it from the doctor’s system or does the prescription exchange vendor first receive it then send it to the NPDR or does it get there from both sources?

And what happens at the pharmacist’s end? Does the pharmacist’s dispensing software update the NPDR directly or is that left to the prescription exchange vendor after receiving notification from the pharmacist’s dispensing software or do they both update the NPDR?

And how is it all synchronized?

Also if the NPDR is being updated by some of the aforementioned why on earth does the PBS system need to send anything at all to the NPDR – surely that would just create total confusion.

Anonymous said...

Who updates the NPDR? Is it done by the PBS or by the Prescription Exchange Services or by the prescribing and dispensing software in the doctor's practice and the dispensing pharmacy?

Surely to avoid over complicating the whole process and guard against duplication and data corruption one party only should be designated to update the NPDR.

Anonymous said...

David, I think its very very dangerous for the PBS to be involved in any form of update of the NPDR.

It makes most sense to have the PESs update the NPDR as it is the PES which receives the eScript from the prescribing doctor and makes it available to the dispensing pharmacist who then updates the PES after the script has been dispensed.

Tell me if I am wrong BUT surely for carriage of the NPDR updating process to be consistent and as error free as possible we should be demanding that the NPDR be updated by the PES which received the eScript and dispatched it to the pharmacist. That seems like a very clean procedure does it not?

Anonymous said...

The NPDR is updated by the PES.

Anonymous said...

Would 5/20/2013 05:50:00 PM please explain why the PBS is sending information to the PCEHR if the PES is responsible for updating the NPDR which is used to create the online medication history (not retrospective) for patients with an eHealth record.

Anonymous said...

You would have to ask that question of DOHA & NEHTA. I don't work for them but have asked them the question previously without getting a decent response. The response I received from them about 12 months ago was 'we thought we better have some medications data in the PCEHR rather than nothing at all'. The same NEHTA person was the one that told me that the PBS data is based on the prescription being claimed and reconciled so it could be weeks out of date!

Anonymous said...

.... the PBS data is based on the prescription being claimed and reconciled so it could be weeks out of date!

Being weeks out of date is not the issue. What we have here is a ludicrous situation which is medico legally indefensible.

Errors will occur and people will die when the information being sent by the PBS is muddled and not reconciled with other more reliable information received from the PESs.

The Doctor, the pharmacists and the script exchange vendors will not be liable.

Liability will lie precisely with those responsible for sending the PBS data - namely DOHA and its agency the PBS and NEHTA and the operator of the PCEHR for allowing the PBS data to contaminate the PCEHR in this way.

The safest and only legally defensible solution is for the PBS to immediately terminate dumping PBS data into the PCEHR which is the target record for receiving clinically reliable medicines data from the NPDR.

Anonymous said...

The response I received from them about 12 months ago was 'we thought we better have some medications data in the PCEHR rather than nothing at all'.

Well .... now that they are getting data fed into the PCEHR from the NPDR it would be very smart to stop feeding in the PBS data as well. Bureaucrats have an amazing capacity to sabotage their own work without knowing they are doing so.

Patto said...

Interestingly, the court case that caused the
concerns about duty of care - that had translated
in switching off the dispense feeds - was
quickly and successfully appealed.

Patto said...

The PBS data feed to the PCEHR has never
been anything other than

- incomplete (i.e no private scripts)
- second hand (rekeyed by the pharmacist)
- out of date (months later)
- billing/audit data (i.e. not actually recorded
for clinical use)

The fact the data is crap is a surprise to anyone??

It was put in because otherwise there would have
been no other data in the PCEHR on its July 1 launch.

I am sure it will be switched off (or
marginalized/quarantined) once a proper feed of prescription/dispense
events start coming into the PCEHR.

I don't think anyone is going to die/be harmed
because of it though.

I think doctors have a little bit
more sense than to base prescribing decisions
solely (or even partly) on this data without
verifying it. Surely doctors verify any
third party information source?? Surely doctors
verify that any drug that is potentially harmful is
suitable for the patient in question? That's why
they went to medical school right?

Dr David More MB PhD FACHI said...

Patto said:

"Interestingly, the court case that caused the concerns about duty of care - that had translated in switching off the dispense feeds - was quickly and successfully appealed."

Sadly I believe this may now been appealed some higher court.

Medical Observer in April.

"Dr Varipatis told of the strain the case had caused him, having been branded negligent.

“I’ve been infamous,” he said.

“To have notoriety for the wrong reason is not nice and especially when most of the patients seem to know about it.

“This will certainly make me feel better about it.”

Mr Almario’s solicitor, Sally Gleeson, said the decision was “disappointing” but “we will not stop fighting for Mr Almario [and] we are currently considering his further rights”.

She indicated this could involve a High Court challenge.

Allan Tattersall, head of NSW claims for Avant, Dr Varipatis’ indemnifier, said the “three-nil” Court of Appeal ruling suggested the matter was unlikely to reach a different result in a higher court."

We can only hope!


Keith said...

It seems to me that the notion of a national prescription and dispense repository, linked to the electronic prescription exchanges is an excellent one. What I don't understand is why such a potentially valuable service should be linked to the dreadful PCEHR/NEHRS fiasco, or limited only to patients and doctors who have signed up to that system. I'm sure that when FRED IT developed MedView it was not intended to be shackled to the PCEHR.