Catherine Dockrell:
Welcome everyone to today's webinar on electronic prescribing, supporting safe medication management. My name's Catherine and I'm a Project Officer from the RACGP’s practice technology and management team.
I'd like to kick things off by introducing you to our host for today, Dr. David Adam. David's based over in the eastern suburbs of Perth. He's a GP and hospice doctor, and is also a member of the RACGP’s practice technology and Management expert committee.
David was also on the electronic prescribing technical working group which was established by the Australian Digital Health Agency and the Department of Health.
Welcome, David.
Dr David Adam:
Thanks, thanks, Catherine. It's good to be here joining you from the cold and wet lands in
Welcome everybody. Today's activity is an accredited CPD activity, and it's being delivered by the RACGP in partnership with our colleagues from the Australian Digital Health Agency.
A couple of housekeeping type notes to start with. Firstly, this webinar is being recorded and we uploaded to the website for on demand viewing so if you've got a friend who missed it, or where you want to go back and, you know, listen to some of the points again, you're always welcome to do that.
We have placed all attendees on mute, just to ensure that you know your phone going off or the cat jumping on your lap doesn't cause too much trouble. But if you have any questions during the webinar you can add them using the Q&A box at the bottom of your screen. So you should see a thing down there saying Q&A. And there is a chat function as well, but we prefer to use the Q&A just for questions and so on. You can use the chat function as well to interact with the presenters and other attendees if you have any other comments or anything particular to ask.
It's lovely to see some familiar names on the participants list today, but from wherever you're joining, welcome. Before we can begin, I would like to acknowledge the traditional owners of country throughout Australia, and their continued connection to land, sea, and community. We pay our respects to them and their cultures, and to Elders, past and present.
So I’d like to introduce our presenter for the evening, whose name is Marwa Osman. She's a digital health educator from the Australian Digital Health Agency. She's got a background as a pharmacist, and is very passionate about utilising digital health tools to enhance patient outcomes.
And so Marwa welcome, and I’ll hand over to you to begin.
Marwa Osman:
Thank you. It's a pleasure to be here to speak to you all tonight about electronic prescribing, and how it can support safe medication management.
So some of the things that we're going to cover tonight are looking at, given that most of you are familiar with electronic prescribing now, what the potential benefits of utilising electronic prescribing as a technology in practice and how to implement this if you haven't already done so, looking more closely at the Active Script List, and then we're going to talk a little bit about which situations may be more beneficial for a patient to have an Active Script List and have their tokens in that, or whether they're just going to use the tokens or some other apps perhaps to manage their electronic prescriptions. And then we’re going to finish off with how to explain these options to patients and the different types of patients and their journeys, and why they might benefit from the different management tools available.
So, as I mentioned, most of you are familiar with electronic prescriptions. They don't replace paper prescriptions. They're an additional option. So a person can either have a paper script or an electronic script for the same item, because both are valid and both meet relevant commonwealth, state and territory legislations. It is entirely optional to use them. They are not mandatory, and so it's simply a matter of choice between the patient and the prescriber and what they're happy and comfortable to do.
And electronic scripts can pretty much be used for any type of prescription. The only exceptions are situations where the prescriber is not able to obtain the authority approval number at point of generating that script. So, for example, for some high priced or specialised items, the prescription needs to be printed and then sent off to Medicare to get that red stamp on it. Those ones you wouldn't be able to issue as an electronic script because you won't be able to finalise the details of that when you're generating the token. But for all other types of scripts or authority scripts where you can obtain that approval, either online through HPOS or via phone approval or streamline, those are all fine to be issued as electronic scripts, and that includes Schedule 8 medicines as well.
So most of you are familiar with what the token looks like. Usually, people present it on their mobile device with that QR code there. And these are very suitable for patients who are not on many scripts. It's fine to have 2 or 3 tokens on your phone for the items that you're getting dispensed. If a person's not on too many medicines, so don't have to worry about managing all the different tokens, and then the repeat tokens that get issued for those items.
Here’s just a quick example of what the patient sees on their end. So they arise basically as an SMS to a link, and the reason it's a live link is because the token is not actually the prescription. It's simply evidence that the prescription exists in the cloud or the prescription delivery service. So when we're using that live link to access it, if the script has been dispensed, you will then get a message that says token is not available. That QR code wouldn't appear at all because this item has been dispensed, or this item has been cancelled by the prescriber, whatever the reason will be will pop up and the person won't be able to view that QR code. Having said that, if somebody tried to outsmart the system by taking a screenshot of the QR code and presenting it to a pharmacy while it's already been dispensed, again, the system will actually detect that this has been dispensed, and the pharmacist would not supply the medicine.
In the case of repeat tokens really the only difference there is going from 2 supplies remaining, then there will be a new token issued that will say 1 supply remaining, versus the traditional method where paper prescriptions were used, we had the original PBS stationary script and you've got the yellow repeat form there.
There are now management options available for patients to manage their electronic prescription tokens. While some people are happy to receive these via SMS or email, I know that in some cases, some pharmacies choose to print off those tokens as well. But that kind of defeats the purpose of having it on the go, so we do encourage to have them stored as an SMS or sent via email, so that it's more accessible on the go.
The other option is a person may choose to pass it on to their carer or their family friend, or whoever they'd like to pick up the medicine on their behalf if they're not able to make it to the pharmacy. They can, of course, forward it to the pharmacy if the pharmacy has a delivery service, or they can choose to use a mobile app. And there are several available now. If you're interested in more information about what these apps are, there is an electronic prescriptions conformance register available on the Australian Digital Health Agency's website and you can see the full list of whether it's software in terms of whether it’s prescribing or dispensing software, but also applications that can be used to manage tokens. So basically, it's like having an electronic filing system where you can see these are the tokens you've got. Some of the apps can be used to order directly from your pharmacy that you frequently attend, and you can then select what you would like, and send that request through to the pharmacy and they can get that medicine ready so that you can drop past later and pick it up.
Now the final option is registering for an Active Script List. Essentially, the Active Script List is a list of a person's electronic prescription tokens, but there's also some other scripts that appear there. So any of the computer-generated prescriptions that have the Medisecure or ERX barcode on them - and I’ll just go back - so you can see here this is a paper prescription that's computer generated. But there's no barcode here or there's no QR code at the top. So this one is not something that would appear in the prescription delivery service. So it needs that ERX or any secure barcode on it. Essentially, it's about having that barcode at the bottom or the top, that will send the script to ERX, or Medisecure. Those scripts will also appear in a person's Active Script List, but they will not be able to be dispensed directly from the Active Script List unless that paper prescription is presented, because ultimately, when you're using a paper prescription, the legal entity is that piece of paper. Whereas in the case of electronic scripts, the script is stored safely in the cloud. You've got the evidence of prescription, that token there will be accessed through the Active Script List. So the Active Script List can be really useful if people are on multiple medicines and they're struggling to keep track of where the repeat tokens are, or which token is for the medicine that I’m picking up, particularly with active ingredient prescribing and then people having to recognise the different names.
And sometimes there are things that can be confusing or things that can be complicated by conditions that a person may have. You know, if there’s some cognitive issues or there's dementia, or perhaps even the complexity of their medical conditions, or the multiple specialists that they see or the pharmacy that's involved. So there's lots of things that can get in the way that can make it difficult for a person to keep track of which token they need to present to the pharmacist so that they can get that medicine dispensed.
Essentially, the Active Script List is a token management solution by listing all of the active prescriptions. When a person has a prescription that is an electronic script, or even a paper script that's got the ERX or Medisecure barcode on it and it appears in the Active Script List and it's expired, so it's older than a year, for example, it will continue to appear in the Active Script List until 28 days after it's expired. And the reason being is in the event that a person presents to the pharmacy, and they're trying to get it dispensed, it's good for the pharmacists to be able to say yes, I can see that that was there, but that one's no longer valid now because it expired a month ago. Most often people don't come looking for scripts that have been around for a year, but in the event that they do, it helps be able to retell the story of what's happened to that prescription, and that they need to visit their GP again.
Currently with the use of Active Script List, patients need to be registered at the pharmacy level. The plan for future state of Active Script List is that prescribers will also be able to register a patient for the Active Script List, and it's also hoped that there will be an interface where patients can actually view the items in the Active Script List. So currently, pharmacies are the only ones that can access the electronic prescriptions for a patient from the Active Script List once they've confirmed their identity. And a patient can request a printout of what's in the Active Script List, so the pharmacists can print out a list of what's in there for them. But both prescriber and patient can't see the Active Script List at the moment.
Now, in the context of patients who tend to keep their prescriptions at the pharmacy, and they sometimes just like to come with the box that they've run out of, the Active Script List is really useful. The pharmacist doesn't need to look for the right script. They simply need to select that from the Active Script List, and it eliminates that script on file, having to file those papers and things like that. So it makes the process more efficient. And this is useful for people taking multiple medicines, particularly when they have to manage the repeats as I've mentioned.
In the event that a person loses their tokens easily or gets confused with them, it can also be beneficial in that they don't need to worry about having a copy of the token. So when the GP is issuing an electronic prescription, they can still give the likes of an SMS copy of that token to the patient, or they can email a copy. But if the person doesn't really mind, then it can just be sent to the Active Script List. So the person doesn't even need to worry about presenting that token. They simply need to confirm their identity at the pharmacy and then say this is the item I’m after. And they don't need to worry about picking the right token to have dispensed.
So just to give you an idea of what the registration process looks like. There are several consents that a person or a patient would need to give to authorise the creation or the registration of an Active Script List for them. Basically, they need to provide this consent through their phone and their authorised representative can also, once they select a person to become the authorised representative during that process, they would also need to consent through their mobile device.
As you can see on the screen there, you get a request saying do you authorise pharmacy XYZ to see your prescriptions in my script list? And you can then have the option of replying 1 for yes, 2 for yes for one day only. And this is to differentiate between when a person is going to their regular pharmacy that they'd like to give ongoing access to. So they don't want to have to grant access every time they visit them, versus when you're visiting a pharmacy on the go. So if a patient is travelling through a town, or they’re caught out somewhere, and they don't really feel the need to give this pharmacy ongoing access to their prescriptions. It's just for one day only, and so they can select that option, or they may not grant them permission at all.
Now, at point of creating this Active Script List, a person also has the option to pre-load the Active Script List with any active electronic scripts that they have. So that's a choice that they can make at the point of generating that. So any active electronic prescription tokens that they have can then be incorporated in that Active Script List and the pharmacist needs to gain this consent before they're able to, or before they're granted access to the person's Active Script List.
Now, from the patient's perspective, they need to confirm their identity with the pharmacy, that's really important. Pharmacies will have policies and procedures in place in order to do that most often, particularly if a person is not known to the pharmacy, 100 points of ID will be required, and usually that involves some sort of photo identification. This also stands whenever Schedule 8 medicines are being dispensed, so they need to confirm photo ID when there's Schedule 8 medicines that are being dispensed.
So, after confirming their identity, they can then go through that consent process we explained, and the pharmacist can then access the tokens that they would like from the Active Script List, dispense them, and then any new tokens that are generated for repeats, if there are any, will also be uploaded to the patient's Active Script List, or they can be withheld if the patient chooses to withhold it. So the default is, once a person has created an Active Script List, whenever an electronic prescription, a new prescription, or a repeat prescription, token is generated, the default setting from either a prescribing or a dispensing software is that it will be uploaded to their Active Script List.
The exception is, if the clinician - so in this case we're talking about the dispensing of a repeat - so the pharmacists can intervene by unchecking the box in their dispenses software to ensure that that repeat is not uploaded to the Active Script List. They only need to do that if the patient requests it, the default is, once a person has consented to create an Active Script List as part of that consent process they’re actually consenting for their scripts to uploaded to the Active Script List.
And I’ll show you some examples later of what it can look like from the GP software side, and how you can withhold uploading. So a person may be happy to have all of their prescriptions uploaded to the Active Script List, but there may be something that they're sensitive about, that they don't really want in the Active Script List. And they would prefer to have it as a token on their phone, for example, and they only want to show that to the pharmacy that they're getting it dispensed at. So in that case they may say to the GP: yeah, I’d just like that sent as an electronic prescription token on my phone. Please don't upload it to the Active Script List.
So here I've got an example of what the Schedule 8 prescription token looks like. It’s just like any other token. And, as I mentioned, there's no limitation to that. If anything, using electronic prescriptions to prescribe Schedule 8 medicines simplifies the process in that you're not having to worry about having that handwriting in the process. There is that additional authentication step at point of prescribing, so the software that you're using will prompt you to reauthenticate your identity by re-entering your password, and that is in place of having that handwriting in your own handwriting on the prescription. There's that extra authentication step that's required to confirm that you are who you say you are, you haven't walked away from the computer and someone else has come to utilise the system to generate a Schedule 8 script. And that will then continue to be generated.
Any information requirements that need to appear on a Schedule 8 paper prescription still stands when we talk about electronic scripts. So if the quantity has to be in words and figures, that requirement still stands. The only exemption with the electronic prescription is that it doesn't need to be in the prescribers handwriting. So when we think of something like CNS stimulants, which we commonly see for children, for example, and we need to see that in the case of New South Wales, for example, because I’m from New South Wales, and so you need to be aware of the different requirements across all the jurisdictions. But in the case of New South Wales, each prescriber has that CNS or S28c approval number when they're prescribing these psychostimulants, and that needs to be annotated onto the prescription when it's a paper script. That still applies when we're talking electronic scripts, so it needs to be included, so that the pharmacist, when they're dispensing it, can access that. So again, pharmacists would dispense this in the same way. There is that extra requirement from the pharmacist perspective, though, to confirm identity by checking again because it is a high-risk item.
But in terms of forging scripts, I haven't heard of anyone being able to forge an electronic script. And this is the really good thing about electronic prescriptions, because even if 2 people tried to present the exact same token at the exact same time at 2 different pharmacies, because you can forward the SMS to as many people as you like, but remember, because the electronic prescription is not the script itself. It's simply a key that allows you to unlock where the actual legal prescription is stored, which is within the prescription delivery service. If 2 people use the same key to open a door, they're going to open the door and see the same thing, if one of them has already grabbed the script first, the other person won't be able to. Only one person will be able to dispense that. And there's actually a mechanism in place so once a pharmacy scans a QR code, even if they've just scanned it but they haven't actually gone through to dispense that script yet, by scanning it, it actually locks the script, and it kind of times out. I can't recall the exact number of minutes, but it times out, and no other pharmacy can actually access it during that time to allow that pharmacy to continue to dispense the item.
Sometimes it happens where a pharmacy dispenses the item and it's at the final stages that they actually go and grab it from the shelf and perform the final checks, and at that point they realise oh, we don't have this, and oh, well, I can't wait on my end, and I've got to go somewhere else, because I’m in pain now. That's okay, they simply cancel the prescription which reverses what's just happened. And actually that initial token becomes live again, and they can go to another pharmacy and have that dispensed. So it's fairly flexible and very safe in that it's very, very hard to be able to infiltrate the security requirements and the security in place from a cyber security perspective to you know, edit it. It's not about editing the screenshot of a token, or making it say something, because ultimately, it has to say the right thing when you scan it. So it’s a very, very secure way to prescribe Schedule 8 medicines.
Here's just a screenshot of what I just mentioned in that there is that legal requirement for the prescriber to re-authenticate with a password to generate an electronic prescription for an S8 medicine. And this is to just give that extra layer of security, that it's not a matter of somebody walking away and then some other staff member at the practice, or something like that, using the system to try and issue a Schedule 8 script.
There is a link at the bottom here to the electronic prescribing conformance register which I mentioned earlier this evening when I was talking about software that is conformant and apps that are conformant for electronic scripts, so if you’d like to have a closer look at what apps can be used or what software is conformant with electronic prescriptions, please do have a look at that link.
So we've already gone through the steps of registering for ASL, and unfortunately, as I mentioned, it's just at the pharmacy level at the moment. But we do expect this to change in future. At that point as well, what I’d like to mention is that if a person would like to set up a carer or agent to act on their behalf to access and dispense things from their Active Script List, they can definitely do that during this process.
Future ASL functionality will enable general practices to be able to register patients for that Active Script List, and also view their Active Script List and then from a patient perspective, they should also be able to view what's in their Active Script List, and then they can sort of decide whether they want to continue to allow a pharmacy to have access to their Active Script List. So if, for example, they've given a pharmacy ongoing access and they'd like to revoke their access, they simply need to log on to that platform that would be developed. To do that at this point in time, the only way that they can change which pharmacies, you know, if they're granted a pharmacy ongoing access to their Active Script List and they want to remove that, or if they've created an Active Script List and then they decide they don't want one, what they can do is reach out to the Active Script List operator, which at the moment is my script list. So the Active Script List concept is essentially agnostic. It's not brand specific, and you know, companies can then come onto the market and generate that script list product. At the moment, there is only 1 Active Script List which is known as mySL or my script list. So patients who have wanted to remove access to a specific pharmacy at this point in time. The only way they can do that is by reaching out to mySL and letting them know that they would like that pharmacy’s access to their script list removed.
So I mentioned that when you're generating an electronic prescription for a patient, it will automatically be uploaded to their Active Script List. And the person can choose whether they want to copy. So if they can have an SMS copy as well, or they may be happy to simply have it on their Active Script List. But you should be familiar with how to withdraw that consent to add an electronic script to the Active Script List, should the person choose to not upload a specific item. So you'll see here that the default setting is that this will be unchecked, and this is an example from Medical Director. It will probably be a little bit different with the other softwares. But here, you've got this Active Script List when you're at that point of generating the prescription, and you have the option to check this box, which would then exclude it. So the default setting due to the consent process of creating the Active Script List with the patient. That consent process, as I mentioned, a part of it, is that the patient actually consents to have their prescriptions or their future prescriptions uploaded to it, so the prescriber would only need to be concerned to exclude something from the Active Script List if the patient indicates that they would like it withheld. And the onus of responsibility here rests with the patient, so it's the patient's responsibility to inform their prescriber whether they want to withhold a script from the Active Script List.
We get a lot of questions about security. There's lots of security in place to ensure that the system is quite secure from a cyber security perspective. The software products have to undergo a conformance process that has technical requirements and legislative requirements, and I think Dr. David will probably be able to talk a little bit more about this if anybody is interested in that there was a whole, you know, technical framework, and there was a working group set up to work around what measures would be in place to protect the integrity of the system, what the minimum requirements would be. So you know, having things like password protected user accounts, re-authentication when we're issuing Schedule 8 medicines, having the information stored in the PBS that it's encrypted so even if a token were to fall into the wrong hands, the information available from that token itself is very minimal, so it's less than what's on a paper prescription. There's not much that you can tell about the patient. It's very minimal identifying information, so far less compromise of privacy data, and that ultimately protects patient information.
Now, the other thing is that when we’re dispensing electronic scripts, the pharmacist will always be able to see the prescription status. If a token, you know, the QR code doesn't appear, there'll always be a reason; this item has been dispensed, or this script has been cancelled by the prescriber, or this prescription has expired, and so there's always that follow through of this is what's happened. It's not like something's just disappeared, and you don't know what to tell the patient. You can tell that there's a story. This is what's happened. Perhaps this item has been cancelled because the GP has issued an alternative strength for the anti-hypertensive that the person is on, and they wanted to make sure that the person doesn't actually get both strengths dispensed, and we often see things like this happening where, when people are on multiple medicines, particularly, you know, when we're talking about older persons that you know, may be forgetful or who may drop some pieces of the key messages here and there along the way, they may unintentionally take the new strength and the old strengths together, and it's not until they start to experience side effects that we question well what's going on here that we realised that they didn't realise that this was the same as that, or the intention was that they would be stopping these and starting the lower strength or higher strength, or whatever it is that they may be experiencing. And this is the really good thing about electronic scripts because remember, once upon a time when we issued the paper scripts, you sent those out and you really couldn't say, give me back the script. Most often, people didn't have it with them when they came to see you, they've left it at the pharmacy, or they've left it at home.
So it's really useful and comforting for a prescriber to be able to be assured that when they cancel this anti-hypertensive and issue another one, the person is not going to take both together. If the person were then to try and get the one that's been ceased, dispensed, they won't be able to. And that provides that extra layer of safety in the process, and this is useful as well when a patient comes back and says I've lost the script. Can you issue another one? Well, to cancel that prescription in your system, the system will actually tell you if you can't cancel it because it's already been dispensed. So you'll be able to know. And I know this is not most of the cases, but we know that those tricky patients,
although they're not the bulk of the patients that we see often. It sometimes consumes a fair amount of our time trying to get through if they've actually had it dispensed, or if their story is genuine. And so this is just another tool that helps us decipher through that process, and be able to establish whether the person has indeed had it dispensed. Because if they tell you they've lost it and they didn't get it dispensed and you try and cancel it, and you see that no, it looks like it's been dispensed, well, something's going on here, and then that creates that opportunity to explore further with a little bit more insight into what's happening. And finally, there is an audit log as well of any changes and things that are dispensed. And so there's always the ability to track what's happening.
Again, this is just a link to that electronic prescriptions conformance register. And you're welcome to have a look at that to see the various options in terms of prescribing software as well as applications available to manage electronic scripts.
Here, I've just got a readiness checklist that you can use if you're looking at getting your organisation connected. If it hasn't been, I do think the majority of practices are connected, because really the main infrastructure that was built on to connect to electronic prescribing technology is very similar to that used for connecting to My Health Record, and because many GP practices were already connected to the My Health Record, it was just a simple configuration to be able to progress to that. But certainly, if you have any questions or require support with this, the Agency, so the Australian Digital Health Agency, is happy to help, or alternatively, you can reach out to your local Primary Health Network.
The only other thing that I think is worth mentioning is, when we talk about having policies and procedures in place, ensuring that you're keeping up to date with the state and territory legislation. You're aware of changes as they occur or any advice and educational content about this topic. Certainly, what we've seen, for example, with the use of electronic scripts is they've made it far more efficient to be able to get prescriptions to people, particularly when consultations are conducted remotely, or people require the delivery of medicines and they're at home. They can just forward it onto the pharmacy.
There have been some instances where, I've given lots of examples of how electronic scripts can enhance patient safety, but there's also been some instances where there are things that have happened where an electronic prescription token has ended up with the wrong patient. And most often when this happens, it has to do with things like not following the procedure at the practice for how we confirm a person's mobile number. So you might be in a rush, and taking their number just verbally on the go without checking. And then having that typo, and then the person says, oh, I haven't received it, and then they realise it's gone to another phone now. Fortunately, if you realise on the spot, and it's always good to check that the person has received the electronic prescription token during a consultation before ending it, whether it's a phone consult or an in-person consult, so that you can cancel that token and re-issue a new one because ultimately, even if it's gone to someone else, they won't be able to do much with it once it's cancelled.
Having said that, having the correct procedure in place that's suitable for your practice, so it may be in your practice that you have a procedure for checking phone numbers when a person checks in, just like they may check every once in a while or every few months have you have your address details changed? Have your phone details changed? To ensure that that phone number that's recorded on file is indeed correct. And that if you're entering the number at point of prescribing that you confirm the number, it's not just typing it in and then clicking enter, but you confirm it with the patient or the carer during the consult before finalising that. So if you've got the patient with you and they say, oh, but I’m not going to head off to the pharmacy, can you please send that to my son or my daughter. Here's their phone number. If you typing it in, then confirm that number once again before you click enter, that way you can make sure that it is going to the right person and that they're accessing that correct medicine there.
So I guess we’re coming to an end soon, and I can see that there's a few questions in the Q&A so I’ll try and hurry up so that I can give you an opportunity to ask away. Essentially the role of the prescriber is that they can make changes, annotate scripts as need be. The prescriber is able to use the technology within their software to cancel a script, and that would deactivate the token issued. They can do that if a person says they've lost a token, or if the person, for example, they've accidentally deleted the token. So if they've deleted the wrong SMS. Losing access to that token that doesn't actually delete the script. What it does is it deletes the evidence that the person has a script that's with the person, but you can actually resend that same token. So you don't have to issue a new script. You can simply resend that token to the patient. And if it's a repeat token that they've deleted, they can simply present to the pharmacy, or call the pharmacy that last dispensed it, and the pharmacy would be able to at the click of their mouse re-issue that token, because deleting the SMS does not delete the script. It simply deletes the copy of evidence that they have. So it does make some things like that a bit smoother.
And then the reference there to annotating electronic script with relevant information if needed, refers to the state or jurisdictional requirements, like, as I mentioned in New South Wales, having to include some certain things when psychostimulants are prescribed, and there may be other requirements in different state or territory locations.
And that just at the end there is confirming the receipt of the token, as I mentioned, that's the ultimate way to be sure that the token has gone to the person it was intended for. So I’ll leave you with some links to resources that are about electronic prescriptions. If you're interested in knowing more about the background to it, there some great resources from the Department of Health as well about the frameworks supporting electronic prescribing and the security of the system.
So with that, I'm going to hand back to David to go through any audience questions that we can go through.
Dr David Adam:
Lovely thanks Marwa. And yeah, we've got quite a few questions. So perhaps between the 2 of us we can tackle them. We'll start at the top. Kim's got a couple of questions, so the first is ‘what's involved when the pharmacist dispenses from a token but doesn't return the further supply tokens to the patient’. So I think that's referring to the scenario where you present to the pharmacy. But then, for whatever reason, the patient doesn't receive the repeat token. Do you have any comments on that? Or I’m happy to talk to that.
Marwa Osman:
So that's certainly not the intention of electronic prescribing. So the intention of electronic prescribing is patient choice. So patients should have the choice to get that token back, and they can take it to any pharmacy they'd like. And even with Schedule 8 prescriptions, in some states they need to be dispensed at the same pharmacy. In the case of New South Wales, for example, with electronic scripts that no longer applies. They can take that on with them. We do know that some pharmacies are retaining copies of that in some cases, and not forwarding it on. And this may be due to a few things like avoiding the cost of the SMS. So therefore, if the patient doesn't ask, then they won't forward that on or that they will just automatically print a paper prescription to avoid the SMS cost or the known SMS costs that will come in future. So what some pharmacies do is just print it on paper and then give it to them just like it's a paper prescription.
Certainly we're not encouraging that we talk a lot about using SMS and email because the whole point is to make it more convenient to make it paperless. Paperless was a big thing, you know. It's really avoiding the paperwork involved. But there's also some other workflow issues for pharmacies, so particularly in the case of pharmacies where patients kept scripts on file at the pharmacy. There's just routine for the staff to be able to have something that they can physically put in a filing system. And so sometimes it's a bit tricky to suddenly go from that to nothing. And so there's that in between, and they working towards, because ultimately it will actually save them time to not have to go through drawers and physically pull out these tokens. But there are a few hiccups along the way, and definitely we've seen that the registrations of Active Script List is not increasing at the rate we would have liked, we certainly would like to see more and more of that. But there's been so many changes in the industry and lots of things faced in the health sector as a whole, but within community pharmacy that I think, doing too many changes to workflow at once was a bit of a challenge. So it's a work in progress, but definitely the patient has a right I mean it's unfortunate that they at times have to ask for it, but they're well within their right to ask for it when they go to a pharmacy. I know that by default a lot of pharmacies will just print it out. When that happens to me, I just say do you mind if I get it back as an SMS, and they often will send it back. But yes, I agree with you more often than not where I've been anyway, I've had to ask for it as an SMS.
Dr David Adam:
Yeah, likewise I mean, it's certainly happened to me, and it certainly has happened to know my patients, and really just letting them know that yes, they should get it back. I mean, Kim, I see your follow up question here about is there a tick box that the pharmacy has to complete or something? Or why does it happen so often? I mean I think we've, without delving too much into what happens in the individual pharmacies, I think our action needs to be to to educate patients around the fact that yes, they have the right to hold their repeats, and that if they need to ask them, then they should do that.
Marwa Osman:
Sorry, Kim's next question. I'm so glad you raised this Kim, because it actually slipped my mind to mention this. But this is huge. This is a huge one.
So what happens when a prescription token is emailed to the pharmacy is they end up with an inundated list of emails that they can't actually tell who it's for, because the full name is not there. So you're often looking at something where you have to click on a hyperlink to then open it up and then even then you're not getting the full name, so often they won't go looking for a script because they don't realise it's there, or that this person wants it, or because it's kind of like if a pharmacy were to get a bunch of scripts in the post, usually what a pharmacy would do when they receive a bunch of scripts from a medical practice is that they go through and check if there's any owings that are outstanding, mark them off and file the repeats away in the draw. So it becomes tricky to do that with electronic scripts, and so often the prompting for the dispensing has to be from the patient, because when they go through their emails it's actually quite difficult to sort through what they've received because the full detail of the name is not there.
So it's like they'd have to actually go through the entire process to access the script from the delivery service. So click on the hyperlink. And as you can imagine when they're in a pharmacy they've got a busy dispensary. They've dispensing scripts. They've also got another pharmacist on doing vaccinations. They just don't have the capacity to be able to sort out who these scripts are coming for, and so often they'll be asking you questions like when was it sent? So that they can at least narrow down the day that they're looking for. But this is a really big thing from their perspective. If it's someone that you're sending it to the pharmacy for, I would encourage you to tell the patient to ask the pharmacy to register them for an Active Script List. Then you don't have to worry about sending it to them. It will simply be in the Active Script List, which is pretty much the intended purpose of, you know, forwarding the script. So the pharmacy doesn't need to worry about accessing it unless the person actually contacts the pharmacy or their carer contacts the pharmacy and asks for the script. So I hope that makes sense. If it doesn't, please ask away again, and I’m happy to have a crack at that.
Dr David Adam:
And my suggestion for those of you that haven't received an electronic prescription is to try and get one. I know, in some states and territories it's not legal to write yourself a prescription, but even in those where it is, perhaps if you write yourself to script for some Panadol, or something relatively, you know, the Medical Board has pretty firm views on anything stronger than that. But write yourself a script for Paracetamol and see how it comes through. When you've got an email that just says prescription for DA for Paracetamol, you'll see that finding those in a really busy inbox is very tricky. So patients really like the convenience of prescriptions going to their pharmacy. But it makes life significantly more difficult for the pharmacists. And then for you, when you're having to chase it up or re-issue it, or it's been lost. And so you can just see in that picture there.
Marwa Osman:
Yeah it’s tiny, but basically it says ePrescription tap the link to view AAB’s prescription for etanol tablet, 50 milligrams. And again, this is to protect the integrity of the person in case it gets emailed to the wrong email address. So imagine you did the wrong letter or something, and then it's gone to someone else, that person won't be able to get much further than that.
Dr David Adam:
Yep. And just to answer the next question. This is coming, yes, regulations on self-prescribing do vary from state to state, thanks to the wonderful Federation we live in. So please I’m not going to give you any advice on what the requirements are outside of Western Australia. Please check your State Poisons Act. And, in fact, if you even need a really thrilling piece of reading, the Poisons Act is well worth the read. I'm always astonished how often questions come up online, confusing National and State regulations and you know the State Poisons Act is a very important piece of legislation to be aware of.
Fiona's got the next question, which is ‘what to do If the script is lost in email cyberspace between the GP and the pharmacy, what are her options?’
Marwa Osman:
Sure. So if the pharmacy tells you they haven't got receipt of it and you're sure you've sent it, you can confirm the email address. If it appears that there's an error that's identified in that, then I would recommend that you actually cancel the initial script so that whoever's received it cannot access it, and then reissue a new one. If the details are correct, but it's actually lost because it might be in that entire pile of emails that we just spoke about, then resending it on the spot might be a good idea, or alternatively encouraging the patient, if the patient’s at the pharmacy at that point, they can create an Active Script List pretty much on the spot. It's instantaneous, and then, during that consent process one of the questions is, do you want to pre-populate the ASL with electronic prescription tokens that you have and immediately have access? So to give you an example, I was caught out once and I went to the pharmacy and I needed my son’s medication and I had the paper scripts with me, but I forgot the paper token that another pharmacy had given me, and I hadn't asked for that token to be sent to me electronically. So I was kind of stuck, and I said to them, actually, do you have Active Script Lists? Can you register me for the Active Script List? And so the pharmacist then yeah went yeah, click, click, yup, great, I can see that token, added it. We'll get it dispensed. Done.
Dr David Adam:
Yeah. And Fiona, the other thing I should say is that your software definitely will have a way to resend that token. So it's definitely worth checking. That's a key part of the conformance criteria. It's worth checking with your software provider to see how to resend tokens without having to cancel and recreate the prescription.
Look, in the interest of time, we might move on. We’ve got a question here about repeat scripts disappearing or becoming invalid, and I think Marwa sort of touched on some of the issues that can happen at the pharmacy. And sometimes we've run into problems with our software where when you create a repeat, it invalidates all the previous repeats for that that medication. That's a little bit of an unspecified area of the of the conformance profile in my view and different software does things differently. So if you're having trouble with repeats disappearing or becoming invalid, it's definitely worth checking with your software provider.
Fiona, you've got another question here about Active Script Lists for aged care residents. How can this work? And I’m not sure if Marwa you have some comments on that?
Marwa Osman:
Remember how I said earlier on that they can be a carer or a representative, so that representative doesn't actually have to be a person, it can be an organisation. So it then goes back to how that facility will incorporate that consent process in the onboarding, or when they're admitting a new resident, there are some consent forms that are signed in that process. But yes, the aged care facility can act as their representative officially, you know, with the pharmacy in their software.
Dr David Adam:
Yeah. And I mean for me, this is the biggest selling point of the Active Script List is, I look after a large number of people who are in care facilities of one kind or another, and dragging them in just to issue a repeat for their anti-hypertensive when I would normally be going to seeing them in 2 weeks anyway is a bit of waste of everyone's time and money. So the Active Script List for them is fantastic, I think there's a lot of scope there.
Kim's got a question about picking up prescriptions that are on the ASL by relatives, what sort of proof of identity is required?
Marwa Osman:
So if someone is not known to the pharmacy, the proof of ID should be 100 points. So there should be some sort of photo ID because, remember, if it's a relative that's actually authorised and documented as that in that ASL creation process, then their name would be there because the person can select a representative or an agent to act on their behalf.
And particularly when you're talking about things like Schedule 8 medicines. But if the person is known to the pharmacy then you know that then comes back to the pharmacy's policies and procedures, so the pharmacy should have policies in procedures in place as to how they will identify a person. The thing that's quite firm is I guess that the pharmacy can utilise whether it's a known person or an unknown person that they're identifying. But in all cases, when we're talking S8s, it's like everyone's unknown.
Dr David Adam:
Look, there is one question that I definitely want to tackle, which is about as a GP, do I have to register patients for the Active Script List? That person feels like it's a lot of work for something that they may not personally benefit from.
Marwa Osman:
You certainly don't have to. You can encourage. So eventually, when future functionality is available, so at the moment, you cannot register people for Active Script List because you don't have the functionality. In future, there'll be functionality to register patients. But there'll also be functionality for the patients to register themselves or to go to the pharmacy to get registered. So those options will still continue to be available.
Dr David Adam:
Yeah, and look, I think much like with My Health Record assisted registration, that will definitely not be something that they have as mandatory in the college, and I think it’s pretty inline on that one.
We’ve got a question here about patients who don't have Medicare. So they're visiting family, they need a prescription. What can we do for those patients?
Marwa Osman:
So a person to be able to have access to electronic scripts needs an Individual Health Identifier and that's linked to a person's Medicare or DVA card. Now I do know that people who do not have a Medicare or DVA card can apply for an Individual Health Identifier. However, unfortunately, there's no way to link that through the software to be able to issue them with an electronic script as far as I'm aware. So when they create that Individual Health Identifier through the application process, as happens with some overseas visitors or international students, for example, that's used to, it can be used to record their immunisations in the Australian Immunisation Register and so on. But it's at this point, I guess there's no connection between that and a prescription delivery service to be able to issue an electronics prescription, as far as I know.
Dr David Adam:
I think it might be software dependent, because it certainly has worked for me in the past. We’ve had a number of international visitors. So they have to register themselves for an Individual Health Identifier which is a form they've got to fill in, and then they've got to give you a 24 digit number whatever it is. And you have to write that into your software manually. But once that's been done, you know, that allows your, for example, organisation, registry you sign and electronic prescription to be provided.
Marwa Osman:
The key thing there exactly is as you've suggested. So if there is functionality to be able to enter the person's Individual Health Identifier in the system because some software only allows you to validate an Individual Health Identifier, which means that you put in the patient's key demographic data like their first name, last name, gender, date of birth, and you know Medicare or DVA card number. You can't input the IHI in some software so that Individual Health Identifier number. So if there is functionality in the software to be able to input that IHI then you're laughing. Great. But yeah, that's the limiting factor, and I’m not sure if there's anything in the technical framework that requires that. But it's certainly a question I could take on notice to see if anything has been built in, or if there have been any changes since, because this update I got was a little while ago, so I’m happy to take that question on notice and come back to you. But it relates to whether there is functionality to directly input an IHI into the software.
Dr David Adam:
All right. And look, I think we will take one more question. I know it's getting very close to 5.30. Bronwyn asks, can a person be registered for My Script List at multiple pharmacies?
Marwa Osman:
So when someone creates a my script list, it's only one list, but they can grant permission to lots of pharmacies to view that same script list. So it's not multiple lists that have different things. It's just the one list. When any GP issues an electronic script, it will go to that same list, and they can go to multiple pharmacies and give them all ongoing access, or give some one-day access. They can do what they like, really, they're in control.
Dr David Adam:
Yep, all right. Well look. It is 5.30 and we appreciate all your questions. I'm sorry we didn't get time to get to all of them. There is a significant amount of information available online, and you can get further information support either direct from the Australian Digital Health Agency, whose details are on this screen, or from the RACGP’s practice technology and management team and their details will be on the following slide.
Marwa Osman:
Sorry. I'll just add, look, I'm happy to take any questions that we didn't answer. And I’ll work with the RACGP to get some responses in, and then we can send those in an email to everybody along with the copy of the slides.
Dr David Adam:
Sure. Okay, well look. Thank you everyone for attending. We hope you've enjoyed this webinar, and we hope you've learned something. Thank you very much to Marwa for joining us today, and we will be sending out a resources pack, so that will include all the contact details and so on.
So thank you, everybody. Please enjoy the rest of your evening.