Electronic prescribing

MAHALA: You are joining us for another session from the RACGP’s Practice Essentials Webinar Series. This webinar is an “Introduction to electronic prescribing’. My name is Mahala and I am a Senior Project Officer from the RACGP’s Practice Technology and Management team. I will be with you for the presentation for today.

I'm joined by doctor David Adam, he'll be presenting the content to you.

David graduated from the University of Western Australia in 2010 and undertook general practice training in outer urban and rural Western Australia. He currently works part time in general practice in Lockridge, as well as being a hospice doctor with the home hospice service. He is particularly interested in children’s health and medical education. Dr David Adam is a member of the Practice Technology and Management RACGP Expert Committee and was on the Electronic Prescribing Technical Working Group established by the Australian Digital Health Agency and the Department of Health.

David, welcome to the webinar.

DAVID: Thanks Mahala, I'm looking forward to it.

MAHALA: Thanks, David, and thank you all for taking time out of your busy schedules to attend this session.

Before we begin our webinar, I would like to acknowledge the Traditional Owners of the respective lands on which we are meeting today, and pay my respects to Elders past, present and emerging. I would also like to acknowledge any Aboriginal and Torres Strait Islander people attending the session.

This webinar is presented in collaboration with the Australian Digital Health Agency.

DAVID: Thanks. And, as described, this is a RACGP Continuing Professional Development Credit activity, and these are the learning outcomes for the session today.

So, what we're going to talk about is an overview of what electronic prescribing is, and the various models that are being introduced in Australia currently. The various benefits and limitations, and then talk more practically about how to prepare our systems, how to prescribed electronically, and what the patient experience will be around electronic prescribing.

I think it's useful to look briefly at how we've gotten to where we are today. And in fact, many of you will be familiar with this diagram, which I think has been used for various forms of the last little while.

Back in the day, we started with paper prescriptions, which were of course done by hand. And then introduction of the Electronic Transfer Prescription information, or eTP, has led to a vast improvement in the safety, legibility, and accuracy of prescriptions. So, when we talk about eTP, what we mean is the sending of a copy of the information on the prescription to something called a Prescription Exchange sService or PES, and you might hear that term a bit later. And then the printing out of a barcode so that that information can be accessed by the pharmacist. And really, what that means is that the barcode on top of the prescription you print out can be scanned directly by the pharmacist and all that information which you put into your prescribing system is copied straight into their dispensing system, which reduces the issues around things like transcription errors.

However, that's not an electronic prescription as such - the legal instrument is still the piece of paper in the patient's hand that thing you've put your signature on. And so, electronic prescribing is a new initiative which we're going to look at in a little bit more detail.

Now, there has been some confusion around what's called prescriptions via telehealth, or image based prescribing - that was a temporary measure that was introduced not long after the telehealth item numbers were introduced. This was in response to the COVID-19 pandemic in Australia.

With many GPs delivering telehealth consultations, and particularly some of us having to do so quite suddenly, and particularly if we're doing it from home, it became very apparent that…and what those of us that have been doing lots of nursing home visits and so on have known for a long time, [is that] paper prescriptions can be very difficult to manage. So to address this, the Federal Department of Health and the State Departments have allowed healthcare providers to take an image of the patient's prescription and send it electronically. E-mail, for example, or fax to the patient's pharmacy.

The requirements around these vary a little bit, like all things between states, and the Federal guidelines are that the practice needs to hold onto the original [prescription] for two years, or they can send it to the pharmacy as well. That differs a little bit, depending on your jurisdiction, exactly what you're writing on it. Some scripts still need to be sent via post, so that the pharmacy holds the original. But I think what we want to be clear about is that this image based prescribing is not an electronic prescription, and it was always intended to be a temporary initiative, which we still expect to cease on the 30th September along with the new telehealth item numbers. And so, although that's available to us now, and particularly, if you're not able to start electronic prescribing, for whatever reason, I hope that you're all familiar with image based prescribing or prescriptions via telehealth as a stop gap.

So what is electronic prescribing? To give you some history, this is an initiative which was introduced in the 2018-19 Health Portfolio Budget. And that was to support change to legislation at the Federal level to recognise electronic prescriptions as a legal document which allows the supply of medicines. So, as we mentioned, prior to this only the paper prescription with a pen and signature was permitted, a wet signature. Electronic prescribing allows the prescribing and dispensing of medicines without the need for this piece of paper. And we hope that this will improve some efficiency, but it should not result in a huge change to the way that you're prescribing. It's certainly not compulsory. Paper prescriptions will still exist and the patient can make a choice about what form of prescription they receive. So, the aim of this initiative is to provide convenience and choice for patients, as well as improving compliance and as part of the medicines safety initiatives from the Federal government.

Electronic prescribing has been an initiative of the National Health Plan, it was due to be rolled out over the next year or two, but it has been fast tracked around supporting telehealth consultations, and to protect healthcare providers and patients from infectious disease. So, of course the COVID-19 pandemic is the thing that's on our minds at the moment. It removes the need to be seen in person to get a prescription easily and it removes the need to attend a pharmacy in person to get a prescription. So it's being introduced right now. And, in fact, I believe that the first prescribing systems have been certified, and are ready to start operation in the next month, or two.

Now, electronic prescribing has been a Federal government initiative, and as we all know, medicines and poisons are regulated, mostly at the state level, as well as through the Federal government PBS. So, some states and territories are still working through the various regulatory changes to allow for electronic prescribing. And that means that some states will start electronic prescribing before others do.

We will be communicating with our members about when electronic prescribing is available and your software vendor will be able to tell you when your software has the capability to do so. So, for example, having been to a webinar today from one of the big vendors, they're going to start in some states, but not in others. So, you will need to make sure that you're aware exactly what's allowed in your state, and we'll do our best to support that.

So, there's two models of electronic prescribing that are being introduced, and the first is what is referred to as the token model. And we're going to look at that now.

The idea behind the token is that there is minimal change to the current way of operating so that the prescribers still prescribe, patients still taking the prescriptions to a pharmacy, dispensers are still able to dispense more or less in the usual way but with support from the electronic prescribing model. So basically, what will happen is that when you write a prescription, the patient will be given a token. Now that is sent as a link to their phone via SMS or by e-mail or it can technically still be printed out if that's what they want. And that can be displayed as a scannable code for the pharmacist, or it can be loaded into a mobile app for managing prescriptions. This code isn't the prescription itself, but it acts as a key to unlock the prescription, so nobody can access the prescription without that code, it's fully encrypted. So the exchange services can't see what's in any prescription without being presented that code to retrieve it.

The prescription is kept in one of the script exchanges. Currently in Australia we have eRX script exchange and Medisecure, which are used for storing these prescriptions.

And it has fairly minimal personally information on it. And the reason for that is, that it is not a prescription. So, it doesn't contain all the details that you'd expect to see on a prescription, but it will contain some information about what the medicine is, the number of repeats, and some basic demographics. So, probably the patient's name, or perhaps initials.

So the pharmacist will be able to scan that code, or the patient's mobile app will be able to send it directly to the pharmacy. And the pharmacist will be able to dispense the medication.

Once it's been dispensed, if there's repeats for that prescription, the pharmacy software will send another token to the patient. So just like if you go to a pharmacy today and present your prescription, you can be handed some repeats, then the same thing will happen with electronic prescriptions. You will get another code to your phone, or e-mail, or similar, with the repeats, and that's what you will present next time you go to get your script filled. So these tokens really do need to be kept by the patient, in the same way that they would keep a paper prescription because if you lose the token, you lost that prescription. So although it can be forwarded to a friend or family member, caregiver, that kinda thing, to be taken to the pharmacy on your behalf, they can't be retrieved if you accidentally delete them, or you drop your phone to the loo, or something like that. 

There are ways around that, but the issues with that model is, and what's led to the development of the Active Script List model… And this is not currently available in Australia, although, work is being done towards rolling it out towards the end of the year. And the Active Script List is, as the name suggests, a list of all the patients active prescriptions, which includes their repeats. The patient will need to consent to a pharmacy having access to the Active Script List, but then the pharmacist no longer needs the patient's token and the patient doesn't have to keep on top of their tokens. They are able to look it up by the patient identity. 

Now, this is an opt-in system for reasons of patient privacy and consent, and although that access can be time limited, only access to the whole list can be shared or not shared. Now, this is something that doesn't affect the vast majority of patients, but there are some patients who are on medications but they don't necessarily want their regular pharmacist to know about. Speaking to our colleagues in the software industry, a common use case is HIV medication, where they attend the different pharmacy to pick up HIV medicines. And so that means that for those patients, they will want either some or all of the prescriptions given to them via a token.

So, patients don't automatically have script lists, they will need to register for this. There’s not currently a whole lot of detail about who will be providing that, which people will be in the market, but as soon as we know more, we will certainly try and let you know.

I want to just re-iterate, around the token model, that the token model also does support the use of mobile apps and similar programs to help people with managing their medications. That is kind of a middle ground between the two, when you receive a token, rather than showing the pharmacist the code you import it into the app and then you can send that directly to your dispensing pharmacist. There aren’t currently any apps approved for this purpose yet, they have to go through a compliance process. But, when some are, their names will be published on the Conformance Register, which I will mention a bit later on.

So, the benefits of electronic prescribing we've tried to summarise on this slide, and it’s really around providing convenience and choice to the patient. And also in improving, hopefully, prescribing and dispensing efficiency and accuracy, which hopefully will reduce the likelihood of errors.

We can remove the need for physical paper document, which people do tend to lose, or damage, or stuff in the bottom of the bag, And it's easier to send the token to another person to pick up medicines on your behalf.

The Active Script List has the added benefit of being an accurate and up to date list of the patient's current prescriptions and the patient no longer needing to keep track of things, so it's very hard to lose a prescription. And that's what we're going to be aiming for, for most people who are on many medicines.

There are some limitations to electronic prescribing and these are particularly around the token model and really the main thing that worries people is, well, what happens if I lose it? I think it probably is harder to delete an SMS that it is to lose a piece of paper, but I think that's very dependent on your demographics. So, the token model is really good for people who aren't taking lots of things regularly. You know, they've only got 1 or 2 things. But it can get a little bit difficult to manage without having a smartphone app, or something that, when you've got multiple tokens. And the repeats, again, can be a little bit confusing about which token replaces which token and so on.

On the other hand, the Active Script List, as we've mentioned, can only be shared in its entirety, not in part, and so if they have some prescriptions of a sensitive nature that they're only comfortable taking them to certain pharmacies, they need to be on top of whether they are using a token or a script list. My experience has been that the patients who are concerned about these things are very switched on to the potential risks. And so, they will probably be quite good at communicating with you around which medications they want transmitted in which ways. But it's important for you to be aware of that distinction so that if somebody brings it up, you’re able to explore with them.

Now, one thing that was a real issue during the development of electronic prescribing is the concept of, you can either have an electronic prescription, or you can have a paper prescription.

So, if you have both of those things, then you have two prescription. so you can't, write one script print it out and then send that electronically. There must only be one legal instrument, one legal prescription. And so you can't use the paper as a backup, for example.

This limitation also extends to electronic prescribing with repeats, so, for example, if you present an electronic prescription to your pharmacist, the pharmacist cannot then issue with paper repeats as they would for normal paper PBS prescriptions.

So once the prescription is written, then you're sticking to either electronic or paper for the course of that medication.

It is possible to print the tokens out. The paper token does seem a little bit counter-productive because then you've got somebody with electronic prescription, but it might as well just be on paper. The printed token is not the same as what you'd see as a PBS paper prescription, and in particular, will be missing some of the key elements that make it a full prescription if signed.

So, what this means is that when the Active Script List functionality is available, they can take that paper token to a pharmacy and have their prescriptions uploaded to their Active Script List through that method. And, finally, I know that many of our patients don't have smartphones, are not as literate digitally as some of our other patients or lose their smartphones, so that is definitely a limitation of electronic prescribing. I mean, certainly, some patients might have family members, or carers who they can forward their token to, or you can ask for tokens be sent to that person. Otherwise, of course, as, as mentioned earlier, there's absolutely no requirement to take part of electronic prescribing. They can still have a paper prescription like normal.

So just to review some of those scenarios where there are issues. If they can't receive a token, they can either get a paper prescription, or they can have it sent to a carer. 

If they don't get it, look, this is a real issue. And I think something that we will get very good at is confirming that the token has been received by the patient. So, for example, sending to the wrong number will mean that it needs to be cancelled and re-issued. And I think the step of your reception staff when checking the patient in, of confirming the patient's mobile number or confirming the e-mail will become even more important now.

I think most people would like to know that when they leave the consultation, that they've got what they came for. So, I'm sure if you're not giving them a piece of paper, they will definitely want to be checking their phone. And that's important for you as well to confirm the right person has received a token.

And accessing repeats, as discussed with the token model, so as it happens at the moment, you'll hand your prescription over, or your electronic prescription will be dispensed. And then you will either be issued with your paper repeats if you started with a paper script or you'll be issued with a new token for the repeats.

So I realise that's a quite complex series of ideas. And having been working on this for probably the best part of the last year and a half, I know that there are times that I get confused as well. There is a lot of reference information out there about electronic prescribing, and so on. Don't hesitate to ask questions or to look further or to speak to the college or to your colleagues because it will take a little while for us all to get ahead of these ideas.

So, what do you need to do to make sure that your practice is ready to start electronic prescribing? The first thing is you need to be connected to the Health Identifiers Service and have what's called an HPI-O. Now, the good news is if your practice is already connected to the My Health Record then you are done, this step is sorted. If you need some more help with that, the college has lots of information and the ADHA has lots of information about getting connected to the HI service, and you can always ask your software vendor as well. The second thing you'll need to do is make sure you connect to an open prescription delivery service, so that’s eRX or Medisecure. And again, most of you will find that this is already ready if you've got a barcode at the top of your prescriptions, you're done with this step as well. If not, contact one of those providers, or contact your software developer and work out which one is right for you.

It's very important that everyone's patient contact details are kept up to date. And so it might be a good time to review your practice procedures for confirming things, like people's mobile numbers. You will need the latest version of your software as well. So depending on what you're using, it would be worth contacting your software developer to find out when they're ready to start supporting electronic prescribing. You can also check out the Australian Digital Health Agencies Conformance Register. They publish a list of all the software which is approved for electronic prescribing in Australia.

At the moment, last time I checked it, the two packages that are on that list are Best Practice and Medical Director, I beg your pardon, Best Practice and ZedMed, but you can always check that list out to find out if your software has been approved yet.

You might like to start talking to your practice team, so that's the other doctors and your practice management staff about electronic prescribing and how it might impact what you're doing on a day-to-day basis. And we encourage you to stay up to date with the information coming from your provider and from groups like the RACGP, and the Australian Digital Health Agency. We will do our best to keep you up to date through our website and through other communication channels.

Right, what we're going to do now is look at a bit of a mock-up of generating the actual electronic prescription. I want to be clear that this is not a live system, so every software vendor can incorporate this into their system slightly differently. I know that, for example, Best Practice are running some tutorials on how to access it through their particular software. So we'll talk through the mock up now. But just keep in mind that this is generic.

So, what's been suggested is that when you go to write a prescription, you'll get a pop up asking if you would like to generate a standard paper prescription, like what you're used to, or an electronic prescription. You will create the script as normal. You know, drug directions, quantity, and so on. And then when you're ready to send the prescription, you will be asked how you would like to send it to the patient. So, if you want to print out the token, well you can. It's not the same as a script, so it needs to come out on plain paper and if you sign it it's not a full prescription, so you won't be able to just use that.

But most people will probably choose to send it either by SMS or by e-mail, so that's why it's really important that the number that you have for your patient is up to date in your system.

So, here's one example. So, we’re writing a prescription for our test patient, and then we're going to choose to send it electronically, or by paper - we're going to click electronic.

We’ve written our prescription up. And then we're presented with a list of options, in terms of how to send that to the patients. So I’d say to Mr Test “Are you happy for me to SMS this to your phone?” And then, hopefully, on their phone, they will receive something like this, that they will get a text message with a link to the prescription, and you can see a mock up there of what an electronic prescription token looks like. And you can see there's the code that can be scanned. There's the medicine and the quantity and there’s the patients initials as well. So, we're hopeful that if this is sent to the wrong person, that not too much personal information is disclosed by that token. And that if the patient doesn't receive it, then it can of course be cancelled and re-issued.

So, from a patient point of view, hopefully they receive the SMS, or the e-mail, if not instantly, then pretty quickly. And, that links them to that token, which they can then take to the pharmacy which can either be presented directly to the pharmacy for scanning, or it can be imported into one of these mobile apps that will be hopefully available soon for managing electronic prescriptions. 

So, that is a whirlwind look through electronic prescribing.

You will want to be aware that the Australian Digital Health Agency is launching a new awareness campaign around various digital health initiatives, one of them is electronic prescribing. So, there will be a whole bunch more awareness sessions for providers dispensers and prescribers. There'll be a new toolkit that's available, which you can use in the practice, and you may find that patients are going to start asking about these things as well.

So, the next steps are to ensure that your practice has the technical capability to start electronic prescribing, and that was those steps that I mentioned earlier. Discuss with your CIS provider (with your software provider) to see when it will be available and what updates you'll need to make, and to discuss with your both practice staff, and this is probably the most important thing, the pharmacies around you about their awareness and their readiness for electronic prescribing.

I have to say that electronic prescribing for doctors is, is pretty much optional. You know, we can take part as when we want to. But for pharmacists, I think they have a lot more pressure on them to become electronic prescribing ready, because patients who have e-prescription that can't be filled at a pharmacy will have to go elsewhere. And so if you're interested in electronic prescribing, I really encourage you to speak to your usual pharmacists about whether they are ready and what they're doing around electronic prescribing.

Alright, so before we go into the Q and A section, we have our usual brief notices from the RACGP’s Practice, Technology and Management section on some of the resources that we've made available to you.

These include, the Emergency Planning and Response in General Practice factsheets. That includes a particular list and that's been developed to support GPS and practice teams in response to an increased number of measles cases presenting after international outbreaks. Of course, we're all very aware of other major infectious disease outbreaks that are impacting us all at the moment. But this one looks particularly about preparation, response, and recovery around measles, which remains a highly contagious illness. We’ve produced a fact sheet on responding to requests for drugs or dependence, which it can be useful for people managing people with behaviours that might be problematic or risky use of drugs of dependence, includes things like prescription monitoring services, and practice-wide approaches which can help you to manage these requests appropriately.

We've got a good guide to telephone and video consultations in GP land. And this was developed to help you and your practice to provide safe and effective telephone video consultation. So the clinical, administrative and technical considerations for your practices, I think a lot of us have pivoted to telehealth recently. And I think although the telephone has been pretty easy, getting video consultation going, has certainly been more of a challenge. And this actually can assist you, to some degree in that regard.

And finally, the fourth thing I'd like to mention is our managing requests for the secondary use of deidentified general practice data. This is a guiding document to help you evaluate requests from other parties, for the information that your practice holds about your patients. Helps you to minimise the risk, comply with the relevant legislation. And there's some useful checklists and principles about the provision of that information to third parties.

The RACGP has been working on a number of resources to support GP during the current COVID-19 pandemic. I think, you'll all have been getting daily bulletins which feature what we hope is the latest information relevant for GP’s. And the COVID webpage is kept up to date regularly, or almost every day, so you might, if you haven't already be interested in looking at the website of your screen.

MAHALA: So, that almost brings us to the end of this webinar but first we’ll go through some questions that we have been getting about electronic prescribing. So, David, can I prescribe S8 medicines electronically. 

DAVID: So, look, the intention around electronic prescribing at a federal level is that, you know, it will be available for all medications. However, Schedule 8 medications are particularly tightly restricted, as you know. And so, some states may have different requirements around Schedule 8 or other restricted medicine, so, there's no federal or legislative, there's no federal legislative barriers to Schedule 8 prescribing, but that may be dependent on your state.

MAHALA: And if a patient is receiving multiple tokens, how can they differentiate between them?

DAVID: Yeah, look, and I think even just looking at that mock up there, you can see how it might be easy to get them confused. If they click through the link, that's in the token SMS, or the e-mail, then they'll be able to see the name of the medicine, the quantity, and so on. Or alternatively one of the apps that will hopefully be available for managing these medication prescriptions, it will be able to manage those automatically for you.

MAHALA: And how do you cancel an electronic prescription?

DAVID: So, electronic prescriptions can definitely be cancelled after the fact. Of course, if they've been dispensed then they can't be cancelled. But if your patient loses it or, you know, there was a problem you can cancel, and the either re-issue, or re-prescribe, that will vary a little bit depending on your software. So, some software, in some of the mock ups I’ve seen you can right click and then click cancel. But that's something that you'll need to check with your software vendor it should be a central part of their training.

MAHALA: And can you send a token as an e-mail and an SMS? Does this mean the patient potentially will have the medicine dispensed twice?

DAVID: That's a good question. Look, as I understand it you can send the token to a mobile phone and an e-mail, I think that’s to be dependent on software product. But I don't think there's anything that technically does not allow it. But the token is only valid or the prescription is only valid once. So if you if you dispense it from the SMS, then you won't be able to dispense it from the e-mail and you can only send it to, I think one of those endpoints per prescription, so you can't send it to two mobile numbers.

There's quite a lot of work being done around the interlock to prevent that double dispensing. So, you know, if you copy the SMS and forward it to someone else, you can still only dispense it once. You know the other copy will be will be useless once it's been dispensed.

MAHALA: And with image based prescribing, or prescriptions via telehealth as it's now called, we send the image of the prescription straight to the pharmacy. Why can't we send tokens right to the pharmacy?

DAVID: OK, so, the various stake holders in the groups involved in the development of electronic prescribing, are very keen to preserve pharmacy choice for our patients. So, that means that, any patients should be able to take any prescription to any pharmacy. And with electronic prescribing, it's just one of the measures that help to preserve people's choice of pharmacy. That is why the electronic prescribing systems don't support delivering direct to pharmacy, although there are some provisions made around emergency supply or what are sometimes called owing scripts where you ring the pharmacy and ask them to dispense something without having the physical prescription. So prescriptions via telehealth or image based prescribing is temporary. We've got no indication at this stage that will continue in the long term after the 30^th of September this year. And I guess that's the reason for always delivering the token to the patient or to their carer.

MAHALA: And David, last question for you here, how do I manage electronic prescriptions for minors.

DAVID: Yeah, so I think it's pretty similar to how you handle prescribing for minors at present. For young children, you're going to discuss that with the parent, but presumably we'll go to their mobile or their email. For a mature minor, you know, someone who's old enough to come and see you alone, just like you'd handle the paper prescription. Now, I think you would send it to their device, but I think that requires professional judgement. Hopefully, there won't be too many issues of that being sent to the wrong person.

MAHALA: So I think that brings us to the end of the webinar. David, thank you for a great presentation today.

DAVID: Thanks very much. But I guess the other thing that I did mean to bring up earlier that I know some people have had concerns about, is the cost.

As you know at the moment, your PBS prescription paper is supplied free of charge, but you have to provide the printer, the pen and the toner. The cost of sending an e-mail or an SMS token is something that your practice might have to pay for.

That will be determined by your software developer, and that's something that you can have a discussion with them about. I think for me every day that I don't spend wrestling with a printer is a good day and unfortunately with PBS prescriptions that are printed out as they are, those days are few and far between. But, of course, you know, every practice has different considerations.

MAHALA: Thanks, David. That is great to keep in mind. Thanks, David, and we hope you enjoyed the presentation. Thank you, everyone, and goodbye.