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Monday, March 16, 2009

E-Prescribing Comes Around Again in Australia – Is This a Good Way Forward?

It is fair to say that there is an almost universal consensus that using a clinical computing system to formulate and then output a medication prescription can improve the quality, accuracy and frequently the efficiency of the prescribing process.

In Australia there has been a very substantial adoption of computerised prescription formulation and printing, especially in General Practice but increasingly in relevant specialist practice. What has not been widely undertaken to date has been the communication of the prescription to a pharmacist for dispensing.

A few days ago we had the following announcement.

e-Script roll out underway

Rollout of the first Australia-wide electronic prescription platform began yesterday in pharmacies in Victoria and New South Wales, in readiness for connecting GPs and medical specialists into the platform in April.

eRx Script Exchange will enable GPs and medical specialists to send prescriptions electronically through a secure, encrypted gateway, for later retrieval from a patient’s pharmacy of choice anywhere in Australia. The first pharmacies are successfully downloading prescription and external repeat data from eRx.

The rollout commenced in pharmacies using Fred Dispense, and will quickly expand to other pharmacy and prescribing vendors starting with medical prescribing software provider Best Practice.

Mr Kos Sclavos, National President, Pharmacy Guild of Australia, stated, “It is very exciting to see this vital project progressing so well.

Achieving an Australia-wide electronic prescription platform will be a real milestone for the Australian health system and for patient care.

eRx Script Exchange is an example of how innovations in e-health can lead to better coordination of care between GPs and pharmacists, generating the best health outcomes for all Australians.”

“The official launch at the Australian Pharmacy Professional Conference in April means the project is meeting key timelines and I am certain the pharmacy and medical professions are ready to embrace the change and explain the significant benefits to patients,” said Mr Sclavos.

Graham Cunningham, Chairman, eRx Script Exchange, says “Electronic prescribing is one of the fundamentals in improving medication accuracy and efficiency, leading to better patient care and safety. Importantly, for pharmacists, efficient accurate dispensing means that they can spend more time with their patients.”

Electronic prescriptions will enable better coordination of patient care across providers. In addition, key benefits of electronic prescribing include:

For pharmacists

* Reducing the likelihood of keying errors

* Strengthening dispensing accuracy

* Accurate retrieval of prescription data

* Faster retrieval of external repeats with scanning of one barcode

* Efficient and safe coordination of new scripts request and emergency supply of medications

For GPs and medical specialists

* Improving patient safety, as a result of reducing the risk of prescribing and administration errors

* Notification of dispenses can strengthen confidence that patients are receiving medication that they need

* Efficient management of new prescription requests and emergency medicine supply

Visit www.erx.com.au to register for updates about eRx Script Exchange.

To view demonstrations of the electronic prescription process, visit the eRx Script Exchange stand at APP on the Gold Coast from 2-5 April 2009

(stands 145,151)

The release can be found here:

http://www.erx.com.au/PDF/eRx_Media_Release_12_March_2009.pdf

More details – in the form of a Frequently Asked Questions (FAQ) document can be found here:

http://www.erx.com.au/PDF/eRx-FAQ.pdf

Note this document is current as of 12/03/2009.

Let me be quite clear here. As far as I am concerned an appropriate, open, private, secure e-prescribing messaging system would be a good thing for Australia for a range of the reasons outlined in the release above.

The evidence for this – or at least part of it – is summarised in this KPMG report on “Electronic Prescribing” done for the Department of Health.

See here:

http://www.health.gov.au/internet/main/publishing.nsf/Content/80B878329CD34C6ACA25715700229B28/$File/DOHA08-ePrescribing%20report-Final290708.pdf

There are however some implementation issues that I am very concerned about.

The first relates to the management and control of the core messaging hub on which the system is based. While I can see all sorts of arguments to permit the erx.com.au proposal to proceed as it is innovative and so on I do not believe this is appropriate infrastructure to be in private hands.

I do not see any problem with private providers being fully involved in provision of prescribing and dispensing clients, network communication and so on. The hub through which all the prescription data is to flow is different in my view and should be managed and controlled by a stakeholder representative driven Board – (with DoHA providing a secretariat). The actual operation of the hub can be undertaken by any competent entity – under the governance rules determined by the Board.

Let us be quite clear – the hub is a piece of core national e-health infrastructure and should be treated as such.

I believe the use of a secure store and forward hub is a reasonable architectural design approach for an e-prescribing network in Australia but I am not anywhere near as worried about direct transmission to pharmacies as the Pharmacy Guild – which is just horrified by the possibility. (It seems to work OK in the US). If we are to have such a hub, not only must it be open technically – but is must also be open from a managerial and privacy perspective.

A second key issue is around control of data that flows through any hub and the policies that are applied to its use. It needs to be appreciated that there are two parties with an interest in the prescription – the doctor and the patient – and that each of these has serious interests.

Ominously the FAQ says:

“The sale or supply of bulk de-identified patient data is restricted”

Note there is no comment I can see on sale or supply of doctor prescribing data and that the sentence does not rule out sale of patient data. There must be no sale or supply of any data from the hub in my view.

Third we have the comment in the FAQ:

“What messaging standards will eRx adopt?

eRx will adopt messaging standards when possible. eRx will however not let standards, or a lack of standards, further slow the implementation of this vital piece of the e-health infrastructure.”

This is a prescription for all sorts of issues down the track – and really is just not acceptable. Let’s do this once and do it right!

Overall I take the view that if eRx is planning to provide a piece of national e-health infrastructure it needs to be subject to the disciplines and review that befits that sort of plan. In my view there needs to be.

1. A review by NEHTA / DoHA of the appropriateness of and public interest in accepting further development of the planned initiative.

2. A full Privacy Impact Assessment of the eRx proposal

3. An assessment of any legislative / regulatory requirements to prevent any possible sale or leakage of patient or doctor information.

4. An assessment of the long term commercial viability and reliability of having infrastructure of this importance provided in this way. Once the service begins it will clearly, quite quickly, become hard to do without.

5. An assessment of the wisdom of having such a basic function in the hands of only one of the affected professions – and indeed one that does not seem to be operating all that professionally.

See:

Bitter pill for 'uncaring' pharmacists

  • Mark Metherell
  • March 6, 2009

SUBURBAN pharmacies sheltered from supermarket competition routinely failed to live up to their claims of being caring professionals, according to the consumer organisation, Choice.

The consumer group has seized on fresh research that says pharmacies are failing to give customers advice on drugs. It wants consumers to have a voice in the secretive negotiations between the Pharmacy Guild and the Government over the billions of taxpayer dollars paid to pharmacists to provide dispensing services.

University of South Australia researchers have found that nearly half the customers surveyed said they rarely got advice on drugs from pharmacists.

This was despite the $5.44 pharmacists receive from the Government each time they dispensed a prescription, in addition to their retail mark-up.

More here:

http://www.smh.com.au/national/bitter-pill-for-uncaring-pharmacists-20090305-8q1f.html

6. An assessment of where this proposal fits in the broader national e-Health Architecture and Strategy.

7. A clear set of published understandings about how any prescribing or dispensing system can seamlessly interact with the proposed infrastructure (standards, terminologies, protocols etc)

I am very aware of the fact that this proposal has come up largely as a result of profound Federal Government inaction on the e-prescribing space over many years – and understand their frustration etc – but I really believe we need to get this right. (I wrote my first report to DoHA about this in 1996!)

This should only go ahead if all these issues are satisfactorily – in the view of all stakeholders – properly addressed.

David.

11 comments:

Anonymous said...

but what happened to the work in the Northern territory on e- prescribing? Wasn't that funded by the Commonwealth - I thought it was going well?

Anonymous said...

Of course Mr Sclavos would be excited thinking of how much money will flow into the guild’s coffers if his cronies in the guild can turn their investment in the eRx Script Exchange into the gold bullion they have had their eyes on for so long.

In The Australian last week 10 March http://www.australianit.news.com.au/story/0,24897,25162620-15306,00.html Karen Dearne provided us with an extraordinary insight into the guild’s finances from information recorded in the guild’s 2007-08 confidential, members-only annual report!!

1. Political being kits distributed to all its members to help with ear-bashing their customers and the local politicians

2. The guild's national secretariat would have recorded a surplus of $2.4 million had Guild Group Holdings (the money machine extraordinaire) not been ‘LATE’ in declaring a $5million dividend on earned revenues totalling $30.3 million!!

3. The guild secured from the Howard government an extra 40c per script payment for every claim lodged using PBS on-line, in effect and $80 million pay rise based on the 160 million scripts dispensed annually in Australia.

Anonymous said...

I agree an amazing expose into the world behind the guild’s curtains. Of course you should not overlook the fact that the guild still holds $1.2million in the National Fighting Fund established some years ago to make sure politicians remain cognisant of the guild’s fighting power.
The guild wields enormous power capable of bringing the pollies down on their hands and knees whenever it feels inclined.

If you have any doubts about this read THE AMAZING POWER OF AUSTRALIA'S CHEMISTS published in the Australian Financial Review of 30 December by Ingrid Mansell, Nabila Ahmed and Emma Connors. http://i2p.com.au/downloads/AFRArticle.pdf It is clear the Guild is at war with all who stand in its way. Money, power and control rule their roost.

Anonymous said...

Despite enabling legislation and a consultants report into e-prescribing there has been no work done in creating a standard for this. As the FAQ implies, a lack of standards is slowing practical implementation in this area down.

IMHO it is the existence of nehta and its position as a de facto standards creator that has slowed all innovation in Health IT in Australia. This is one of very few recent examples of innovation coming out of Australia's Health IT vendors.

Anonymous said...

The NT project is not scalable and the architecture hasn't been designed for anything other than a project limited in scope to prove a point - that a script can be sent from one point to another; from a medical practice to a pharmacy with an aged care facility in the loop. Funded by DOHA? Yes, with the typical short sighted pilotitis mentality of "look at me Minister, look at me". Very very basic.

Anonymous said...

Government should regulate infrastructure but not run it. Does the government run the telco industry any more? The telco industry is a private, regulated marketplace that benefits from competition and innovation.

Aus HIT Man said...

"The actual operation of the hub can be undertaken by any competent entity – under the governance rules determined by the Board."

Just as I said!

David.

Anonymous said...

Could this be regarded as a monopoly and so contravene the Fair Trading Act?

Anonymous, of course

Anonymous said...

Is Graham Cunningham, Chairman, eRx Script Exchange a shareholder of the company?

I ask this because a search of ASIC’s records today, 17 March 2009, shows the shareholdings in ERX SCRIPT EXCHANGE PTY LTD have not changed since the company was registered on 22/08/2008, at which time the sole shareholder was PCA NU SYSTEMS PTY LTD with 12 Fully Paid Ord $1.0 shares.

Is Graham Cunningham a Director of the company?

I ask this because a search of ASIC’s records today, 17 March 2009, shows that Graham Cunningham ceased to be a Director of ERX SCRIPT EXCHANGE PTY LTD on 19 Sept 2008.

Anonymous said...

Pharmacy Guild has the business sewn up. Just look at PBS On line.

Medicare developed it and put it out there for the pharmacists to use, but there was very little uptake. Until, all of a sudden, one day the guild negotiated a ‘deal’ of 40 cents per script to incentivate the pharmacists. The suddenly, in a matter of months, the uptake of PBS Online rose to 90%! Amazing!

The guild said ‘boo’ and the flood gates opened and the money flowed all the way home. When will the politicians, the government and its bureaucrats learn to stand up to the guild’s bullyboy modus operandi?

Anonymous said...

Mr Sclavos got one thing right when he said, “Achieving an Australia-wide electronic prescription platform will be a real milestone for the Australian health system and for patient care.”

But at what cost?
The Guild applied for a worldwide Patent in 2002 to circumvent the government’s and the community’s intellectual property rights whilst at the same time signing Conflict of Interest Declarations at the beginning of every MediConnect planning meeting! Five years later DoHA 'helped' the guild to understand that it would be in the nation's interest and the guild’s best interest to sign over the rights to the patent to the government unconditionally!

Had it not been for a small group of health and IT specialists, who complained loud and long year after year about this blatant breach of trust, the Government and its bureaucrats would have let the guild’s patent slide through to the keeper. Are we now witnessing another attempt by the guild to grab control?