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Published on 23 September 2009

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ePrescribing and medication management

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The introduction of electronic transfer of prescriptions (ETP) in ambulatory healthcare has been suggested to have a positive impact on the prescribing and dispensing processes

Emelie
Montelius
MSc Pharm

Åstrand Bengt
MSc Pharm, PhD

eHealth Institute
University of Kalmar
Kalmar, Sweden

ETP technology was first deployed in 1983 in an outpatient setting with electronic communication being set up between the computer systems at a doctor’s office at the medical clinic and those at a nearby pharmacy in Jonkoping, Sweden. The collaboration resulted in the world’s first electronically transferred prescription in an outpatient setting. In 1984, Swedish authorities regulated the ETP for the first time. In short, the new regulation made it legal for pharmacists to dispense an electronically transferred prescription with local agreements regulating the responsibility for the sending and the receiving professionals. By making their computer systems available for ePrescriptions, the dispensing pharmacists were
made responsible for the quality and safety of ePrescriptions. Since then, prescription software, including both systems integrated with electronic health care records (EHR) and web-based stand-alone systems, has been developed, marketed and implemented and is currently being introduced on a broad scale within health care. In recent years, in countries such as Sweden, Denmark and the US, considerable efforts have been made towards the wide scale implementation of ePrescribing.

The development of ePrescriptions in Sweden has accelerated rapidly since a new strategy with collaborative national and regional implementation teams was introduced at the end of the 1990s. The new strategy prioritised the implementation of ePrescriptions among all stakeholders in a coordinated way to reach a penetration rate of at least 80%. By the end of 2007, the actual penetration rate of ETP was as high as 68% of all new prescriptions. A national ePrescription communication exchange hub with a virtual repository, called the national mail box for prescriptions, allows the patient to access their prescriptions at any pharmacy on presentation of valid identification. However, the introduction of new technologies such as ePrescribing may create new errors, both systematic and non-systematic, in the prescribing and dispensing processes. Stored ePrescription information may be used not only for filling the actual prescription but also for future clinical decision making and epidemiological research. Thus, it is vital to systematically monitor the quality of the electronic prescribing process.[1]

An increased use of drugs
The sale of drugs has increased successively during the last decades. The increase depends, among other things, on the introduction of new medications and on new medical recommendations to treat morbidity in higher ages. Moreover, drugs are also used to prevent health-related disorders among healthy individuals. On a national level, the vast majority of all medications aredispensed drugs, but over-the-counter drugs (OTC), vitamins, herbal, alternative remedies, and in-hospital medications do all contribute to the total drug consumption. The individuals’ use of several different drugs, the so-called multiple medications, has also increased. The use of many drugs may be rational for many individuals. However, multiple medications is also commonly associated with an irrational, excessive use of drugs, and are, concomitantly taken, a well-known risk factor in terms of patient’s health. Furthermore, the risk of drug-drug interactions (DDIs) and adverse drug reactions (ADRs) is expected to increase exponentially with the number of drugs.[2]

From epidemiological data it is estimated that roughly 5-20% of serious adverse drug reactions needing hospital care are caused by DDIs. Taking the frequency of serious ADRs into account, approximately 1 in 200 hospitalised patients has a serious ADR caused by DDIs; expanding this data to fatal adverse drug events, 1 in 10,000 hospital deaths may be attributed to DDIs.[3]

Electronic storing of prescribing information
One approach to improving the situation for prescribers has been to store information on the prescribed therapy in databases at institutions or within larger regional organisations, mostly as part of an electronic health record. When prescribing, the physician will be able to check the patient history for polypharmacy, interactions, and different kinds of contraindications. Automated systems for DDI alerts may also be integrated in these systems. Results of the alerts may be to refrain from prescribing, adjusting the dose, or monitoring the
plasma concentration of the drug. Discontinuation of previous prescriptions may also be relevant. However, automated medical alerts are often being overridden by prescribers, which may be due to too low thresholds and an experienced alert overload. With an increasedspecificity of the alerts, the acceptance rate may be considerably improved. By designing a selective set of drug alerts, only critical alerts are interruptive to clinician workflow.

Another approach to providing prescribers with medication history has been the new legislations in Denmark (Medication Profile) and Sweden (National Pharmacy Register) allowing nationwide databases with information on dispensed prescriptions at the pharmacies. Information is accessible to the patients and with the patients’ conditioned consent, to prescribers and dispensing pharmacists for a limited period (Denmark 24 months and Sweden 15 months), and also permits the patient full transparency as to who has accessed the information. These databases comprise a large proportion of the national population and are subject to strict security regulations to ensure individual confidentiality. According to national laws, unauthorised access might be subject to a lawsuit.

The information systems should be suitable for decision and process support at the point of care, for follow-up of individual patient care, and of healthcare activities, as well as for statistics and research. The National Pharmacy Register is individual-based and contains data from all dispensed outpatient prescriptions at all Swedish pharmacies from July 1, 2005, including multidose dispensed prescriptions and legal Internet sales, but does not cover drugs dispensed in hospitals and OTC sales.

The use of prescribing information
The recorded information is available for the registered individual at the pharmacy counter, with valid identification, and on the internet, with a secure digital signature. After conditioned consent from the registered individual, the register is accessible online to prescribers and dispensing pharmacists. The registration is mandatory and includes the name and the personal identification number (social security number) of the registered individual along with the day of dispensing, drug name, prescribed amount and dosage. The information is stored in the register for a period of 15 months and thereafter cleared. Use of the medication history in this register is, by a special law, restricted to clinical use and documentation.

Prescribers who used the National Pharmacy Register on a pilot basis were in an evaluation study generally positive, and 69% reported that they could provide their patients a safer care and drug treatment. However, relevant information has to be more readily available on a broad basis in healthcare, functionality being incorporated in different EHRs, with a strong authentication, to protect the personal integrity.

Individuals are increasingly becoming more engaged in their healthcare and are interested in reading their medical records, and also find it valuable to access their medical records via the internet. Individuals are expected to be important users of their own electronic health information. To become better informed about their medications, current and past medication information is one type of information requested by patients.

An evaluation of individuals’ attitudes towards access the National Pharmacy Register, revealed that they were generally positive and appreciated the access to their medication record on the Internet. They mainly accessed their medication record to get an overview and to get control of their medications. Their willingness to share their medication record with physicians and pharmacists increased with age. Individuals may by online services detect their own potential DDIs, hence increasingly forward questions about risks to healthcare personnel.

A first group of users appreciated having their medication record on the Web, and they had a generally positive attitude towards the Web-based service. The users found the information valuable and easy to understand. They primarily visited the Website to get control and see an overview of their drugs.[4]

If feasible, it would be beneficial to include all drugs in the register, eg, over-the-counter sales and drugs used for inpatients in hospitals. Also, to increase the clinical usability of the information in the register, information on the actual prescriber of each prescription should be included.[5]

Need for quality improvement
With the majority of prescriptions transferred as ePrescriptions, there is an obvious need for improved evaluation and certification of the information and communication technology (ICT) systems which produce drug prescriptions. ICT systems for ePrescribing must also be evaluated intermittently with compulsory certification to assure patients of high quality health care. ETP technology should be developed towards a twoway communication between the prescriber and the pharmacist with automated checks for missing, inaccurate, or ambiguous information. Such a process would increase safety and quality for the patient and improve efficiency and cost-effectiveness within the health care system.[1] To avoid DDIs, reliable information on all drugs used by each single individual needs to be available at the point of care. Knowledge databases about clinically relevant DDIs must be updated and accurate.

References
1. Astrand B, et al. Assessment of ePrescription quality: an observational study at three mail-order pharmacies. BMC Med Inform Decis Mak 2009;Jan26;9:8.
2. Hovstadius B, et al. Dispensed drugs and multiple medications in the Swedish population: an individual based register study. BMC Clin Pharmacol 2009;May 27;9:11.
3. Astrand B. Avoiding drug-drug interactions. Chemotherapy 2009;55(4):215-20.
4. Montelius E, et al. Individuals appreciate having their medication record on the web: a survey of attitudes to a national pharmacy register. J Med Internet Res 2008;Nov 11;10(4):e35.
5. Astrand B, et al. Swedish National Pharmacy Register. Stud Health Technol Inform 2007;129(Pt 1):345-9.



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