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Thursday, May 22, 2008

E-Prescribing – Do the Current Initiatives Make any Sense?

In recent times there has been a lot of discussion about electronic prescribing (or e-prescribing). In this blog I want to run through just what I believe would constitute a satisfactory e-prescribing system for Australia. The criteria I would apply are as follows.

Criterion 1.

The E-prescribing should be fully compliant with all aspects of AS 4700.3(Int)-2007 : Implementation of Health Level Seven (HL7) Version 2.5, Part 3: Electronic messages for exchange of information on drug prescription.

This would include electronic messaging of standardised content between prescriber and dispenser as well as support of the other medication management functions the Standard envisages.

Criterion 2.

The terminology used is the current version of the Australian Medicines Terminology (AMT) which in SNOMED CT compliant. This is a minor problem at present as I understand this is still a work in progress with a completion date somewhere in 2009.

Criterion 3.

The act of prescribing should be supported by Level 4 clinical decision support based on approved knowledge databases of established quality and consistency.

Criterion 4.

There be effective communication between dispensing and prescribing systems to enable assessment of issues such as compliance and medication abuse, while avoiding any leakage of such information to any third party without the agreement of the patient.

Criterion 5.

There be absolutely no access to prescription data by any commercial interests – most especially any pharmaceutical companies.

Criterion 6.

If any centralised ‘store and forward’ hub networking technology is to be used (as I would prefer) for allowing a prescription to be held until requested by a dispensing computer system then the hub should be controlled as a key piece of national e-health infrastructure by the Commonwealth Government (or a Government owned agency with appropriate governance in place to totally protect the public interest and patient privacy).

Criterion 7.

All access to the National e-Prescribing network should be fully protected by appropriate security, encryption and privacy mechanisms.

Criterion 8.

Access to the National e-Prescribing network should be via a fully open and standardised mechanism with an entity like Australian Health Messaging Laboratory (AHML) certifying compliance before access is permitted.

Criterion 9.

Of course, there should be only one national network with competition being encouraged based on the quality of the prescribing and dispensing systems offered by those who connect to the network.

At present there are three potential offerings in trial or in development on the table.

First we have the NT e-Prescribing Initiative.

Details of the approach being adopted can be found here:


(at page 11)

Or here:


Second we have the commercial ScriptX initiative.

Details of this can be found here:


(at page 17)

Or here:


Lastly I am assured that Medicare Australia has been considering how it might get into this space to augment their on-line presence and leverage the data they already hold.

I will leave it as an exercise for the reader to see how close each of these might be to what I believe is desirable.

Essentially I believe we should have a National E-Prescribing infrastructure that is open, fully standardised, fully SNOMED CT based system with hub controlled ultimately by Government.

Competition should be at the prescribing and dispensing client level. Trials of half-baked systems have their place – but they will not lead to the national infrastructure we need.

This is a project Government should support soon so we don’t wind up with a mess of incompatible and non-standardised systems.



Anonymous said...

Is the ‘hub’, which you refer to as a centralised ‘store and forward’ facility, the same piece of architecture which holds a record of past and present, prescribed and dispensed, medications?

Think on this. Is there a justifiable case for building a centralised national database of every individual’s medication record, albeit as a segmented part of a national shared electronic health record? No.

Should the consumer have control of their Personal Health Record? Yes.

Should an individual’s Personal Health Record be the place where the individual’s complete medication record is ultimately be stored and, with the appropriate permission, accessible by prescribing and dispensing health service providers? Yes.

That being so the ‘hub’, to which you refer, should simply be, as you have rightly described, a ‘store and forward’ hub networking technology which is not tied to any centralised national repository.

Anonymous said...

Details of the approach being adopted can be found here:


(at page 11)

The link you refer to above takes forever to load. They lost me.

Anonymous said...

The store and forward - or rather store and retrieve (approach (as choice of pharmaicist has to be assured) will certainly be reccommended as phase 1 of eprescribe strategy by KMPG to avoid the mire of records repositories and getting caught up with the PHR, EHR EMR or IEHR whatever they want to call the electronic health record.

By the way where in the hell did the term IEHR suddenly arrive from in the NEHTA lexicon? The yanks spent months trying to standardise the terminology and IEHR is not one that is recognised.See the 28 April 2008 paper on Defining Key Health Information Technology Terms from the National Alliance for Health Information Technology.

Anonymous said...

Criterion 5.

There be absolutely no access to prescription data by any commercial interests – most especially any pharmaceutical companies.

Pharmaceutical companies seem to be keen to have this data as evidenced by agreements with MD etc. How / what are they going to do to misuse this information ? If you kept them appraised/involved you might be able to get them to foot the bill since they'd be getting data that's of value to them.

You linked to/talked about examining who benefits most from some of these systems and it seems like the pharmaceutical companies would have a vested interest in this initiative.

Dr David G More MB PhD said...

Big Pharma are keen to get prescription data to use for marketing to doctors - especially data relating to individual prescribers. I happen to think they should not have access to that data as it is between the doctor and the patient.


Anonymous said...

Criterion 6

Medicare Australia has been considering “how it might get into this space” for a very long time, ever since its failed attempt to develop MediConnect.

There is no way the ‘hub’ or any hub will be controlled as a “key piece of national e-health infrastructure by the Commonwealth Government (or a Government owned agency)”.

The Guild would never agree to let that happen now that it has found a clever way (through its association with ScriptX) to not only get control over ePrescribing but also to outwit Medicare Australia and the Doctors both at the same time.

If perchance it did permit Government to become involved in control of the ‘hub’ the Guild would want a very high price indeed. But then it’s the ScriptX investors, not the Guild, who would have the final say and they would want a truly hefty ROI, very hefty indeed.

Stalemate it is not. Is it Checkmate or are there more moves yet to come?

Anonymous said...

I agree - the Guild would never agree to let that happen. In Pharmacy News (10 April) the Guild’s President was reported as saying “Electronic prescribing poses many threats to our profession. We have only one chance to influence the way this new phenomenon is established - and that chance is now.”

Anonymous said...

Controlling ePrescribing is the Guild's best defence against the Supermarket chains.

Dr David G More MB PhD said...

I am not sure the Guild is as powerful as you seem to imply. I suspect the AMA will sooner or later notice the way they are being blindsided at present and we will see some real fun!

Also in a tussle between the Government or Medicare Australia and the Guild I think I know who I would back.


Anonymous said...

1. Can Anonymous (Friday, May 23, 2008 10:25:00 AM) clarify the supposed link between controlling ePrescribing and keeping Pharmacy out of Supermarkets.

2. Anonymous (Friday, May 23, 2008 10:07:00 AM) - don't rule out the possibility of ScriptX participants having their software made "non-ScriptX-ePrescribing" compatible by third-party vendors.

3. It would be cheaper for Govt to build and run its own hub than subsidise the Guild/pharmacists for the outrageous prices the ScriptX gang are going to attempt to levy on pharmacists. Therefore, the question isn't whether Govt will build it (they will), or whether ScriptX will succeed (it won't) - the question is, What other hub based secure messaging services will Govt allow their ePrescribing infrastructure to be used for?

Anonymous said...

Is there a link between controlling ePrescribing and keeping Pharmacy out of Supermarkets?

Some of our colleagues think so. We are all only too well aware that the two major retail chains are fighting tooth and nail for the right to provide pharmacy services. They claim they can do it cheaper, maybe they can, who would know. They want the pharmacy business because it will increase their foot traffic. Increased foot traffic equates to increased sales. We all know the formula it underpins so much of our business. That’s why apart from dispensing pharmaceuticals we sell cups and saucers, snow domes, statues, trinkets and bling, it brings in the traffic. Although as Norman Swann said back in February on the ABC's Health Minutes “you do have to wonder about the quality of pharmacists' advice when you see some of the garbage they have in their shops and the potential conflict of interest they have in flogging you something." We really do ourselves a great disservice.

ePrescribing will increase the traffic in a supermarket pharmacy enooooormously.

Look at what a con the 4c / litre petrol discount coupons have been. Yet people were seduced by them, flocking to service stations and increasing the revenues for Coles and Woollies big time, eventually putting many of the independents out of business. Substitute 4c / litre for >4 c/ prescription and service station for supermarket pharmacy and read that again. It shouldn't be too hard to understand.

Now a Supermarket with a pharmacy will be at a great disadvantage if it cannot avail itself of the power and convenience of ePrescribing. So if we can control the ePrescribing process we can influence the software suppliers and if we can do that we can defend our patch with the Guild’s help against the enemy.

Anonymous said...

You make the ScriptX gang sound like Highway Men or Bush Rangers. If the prices they want to levy on pharmacists are too high they will quite happily lower them, they’ve left plenty of fat in there for that purpose. 25 cents was the opening gambit. It wouldn’t make sense for government to develop an alternative once ScriptX is up and running. It would be more economic and politically palatable for Government to pay some kind of subsidy, then the 25 cents could be lowered. You can be confident the Guild knows how to negotiate those kind of deals with Government.

Anonymous said...

"So if we can control the ePrescribing process we can influence the software suppliers"

That's a great Friday funny!

Anonymous said...

Could Anon (Friday, May 23, 2008 1:33:00 PM) explain please what is meant by …. a “ScriptX participant have their software made "non-ScriptX-ePrescribing" compatible by third-party vendors. Could you give us an example and what the ramifications might be? Thanks

Anonymous said...

Once the Govt gets a hub based secure messaging service in place around ePrescribing infrastructure surely you would not be agin it being used for anything that is useful and in the communities interest provided such use respects all the normal accepted governance issues relating to privacy, confidentiality, ethics, probity, etc.

Of course it goes without saying that regardless of whether it is Govt or private sector involved there must be severe penalties in place which will overcome the temptation for anyone to bend the rules or step over the line.

Anonymous said...

It looks like the three systems to which you refer are aligned as follows 1. NT - the doctors, 2. ScriptX - the pharmacists, 3. Medicare Australia - the Government.

Isn't this a sign of healthy competition, let the market prevail and all that stuff.