Key questions on the electronic prescribing service, and its second roll-out
Dr Tony Kaye answers key questions on new prescribing IT.
Have you been wondering what has happened to Release 2 of the Electronic Prescription Service? Did you think it was one of those massive NHS IT projects that was doomed to failure? Were you hoping it would ‘go away' if you ignored it long enough? In fact EPS R2 is now on the way to a pharmacy near you.
I've been involved with the development of EPS R2 for about 5 years now, and remain as passionate about it now as I did when I first was invited to become a member of the GP Advisory Group to Connecting for Health for programme development. It made total sense to me then, just as it does now, that in this world of electronic communications, our NHS should be able to send prescriptions without bits of green paper floating around, sometimes illegible, often getting damaged or lost, not to mention the possibility of errors in re-keying entries at the pharmacy or PPD.
How has EPS changed?
The interoperability between all the GP clinical systems and all the pharmacy systems is the key to the success of this project, and of course, clinical safety is paramount. These are the two key reasons why development has taken so long. And in fact most of the delay has not been due to CFH, moreso to the system suppliers, and the variability of the resource they have thrown behind the development.
Once the suppliers had completed their development, a lot of work took place, testing the electronic transmission of the messages, to ensure that what goes in at one end, must come out exactly the same at the other end. The prescription message, including drug, dose & quantity needs to be 100% correct every time, and the messages transmitted alongside the prescriptions, on the ‘right hand side' of the prescription, also have to be available for the patient.
InPS Vision has had approval to roll out EPS since last year, and has started to do so, in various parts of the country, including the entire Isle of Wight (where every practice uses Vision). EMIS has decided to provide the EPS functionality only through EMISWeb, which is currently being rolled out, and practices are currently migrating to it before being able to use EPS. Other GP systems are now coming up to ‘full roll out approval' as we speak. PCTs have to be granted secretary of state approval before their GP practices can go live.
Almost all the pharmacy EPS systems now have ‘full roll out approval' and once a pharmacy has an ‘EPS enabled' software system, it can be switched on to go live. The national pharmacy chains are at various stages of readiness, some are already live across their entire estate and others just about to do so. Independent pharmacies are at no disadvantage since their systems are also rolling out at the same rate.
So, in essence, we are now on the brink of a massive roll out of EPS 2, and the GPs need to move quickly to embrace this and to gain the potential benefits.
How does EPS now work?
Firstly, a patient needs to ‘nominate' their chosen pharmacy ie., where they would like their prescriptions sent, once their pharmacy is EPS2 live. Nomination can be done either at the pharmacy or at the GP practice, and can be changed or cancelled at any time, quickly and simply. Nomination is not ideal for everyone, but since most prescriptions are repeat prescriptions, and the majority of these tend to go to the same pharmacy each time, this is very suitable for the majority.
The prescription is then signed electronically, by the GP, and sent via the NHS Spine from where it is downloaded by the pharmacy into their system and dispensed. The pharmacist can then make electronic claims for reimbursement from the PPD and the evidence to date is that the reimbursement accuracy is excellent, probably better than in the paper world.
What are the key benefits?
The prescriptions when processed in the GP practice, do not get printed, and are sent to a GP's prescription ‘mailbox'. With the NHS smartcard in place, all the prescriptions waiting there can be signed electronically with a single electronic signature. Bulk signing of prescriptions in this way is a key potential time saver for GPs.
The ‘holy grail', in my opinion, is electronic repeat dispensing (eRD). My practice did not use paper based repeat dispensing much, finding it difficult particularly when there were amendments to the medication regimen. But in the electronic world this is the other key benefit for workload reduction for GPs.
Let's assume a patient is stable on their repeat medication regimen; has had their annual clinical and medication review, and is now authorised to have their prescriptions for 12 months, at monthly intervals. It's very quick, (straightforward and slick) to process the entire 12 prescriptions with a single electronic signature, and the prescription will appear at the pharmacy every month, 7 days before it's due, thus allowing the pharmacy time to ensure the medication is in stock, and have it prepared ready for the patient to collect. Thus one piece of work at the practice instead of 12! (and of course if the patient is on several items, and tends to order them at different times, the potential time savings are even greater).
If the patient requires the medication sooner, perhaps due to a holiday – no problem for the pharmacy to download it sooner if clinically safe to do so, which of course in the majority of cases it would be. Should there be a change to the medication regimen, it is easy to cancel all outstanding issues, the amendments made, and a new series of issues released, without the patient having to be involved at all.
Electronic Repeat Dispensing passes the responsibility for the ongoing management of the patients' medication to the pharmacist so I would not recommend setting this up if you felt this was inappropriate, but this would be for a minority of patients. With eRD the pharmacist becomes more involved in the patient's compliance with their medications. It can even be used as a mechanism for weekly dosette prescriptions if you wish.
The other key benefit is the ability to electronically cancel prescriptions – either single items or the entire prescription. The prescriber then receives an electronic notification that the cancellation has been successful, or not, perhaps if the pharmacy has already downloaded it. In this case you would be notified which pharmacy has the prescription, with contact details – a big improvement on the paper based prescription system –currently you would be unlikely to know where a patient has taken it.
Other benefits to GPs include no lost prescriptions – so far, there have been no lost EPS prescriptions nationally. If they have been signed, and sent, then they have never gone missing! Also, a significant saving in laser toner costs.
What are the key benefits to prescribers?
Over time a considerable workload reduction due to nomination, bulk signing, electronic repeat dispensing, and electronic cancellation.
Nomination may potentially bring considerable commercial benefits having patients signed up (less so if they already have a prescription collection service in place). They will receive the prescriptions electronically direct into their IT system, with no need for re-entry of the information, reducing errors, and workload, and they will be able, with repeat prescribing or repeat dispensing to order the medication and prepare the medication in advance of the patient arriving – so less owings to the patient, and possibly improved stock control.
What are the key benefits to patients?
All of the above bring about efficiency, time saving, less waiting in the pharmacy, less owings and return visits, and the possibility perhaps to nominate a pharmacy near their home or office rather than one near the GP practice.
Practices around the country are already starting to use the system now, and once pharmacies are live on the ‘spine' they can receive electronic prescriptions from ANY live GP practice. Over the next 6 – 12 months I would imagine a significant majority of pharmacies will be live – both chains and independent pharmacies.
What should I do now?
GPs need to approach their PCT to find out what is happening locally – the Medicines Management and RA (registration authority- smartcard) teams at the PCT need to be involved. Smartcards need to be updated with the appropriate roles and activities for EPS – you would not want your receptionists to sign scripts, but would want them to be able to view and issue. You might wish your medicines management team or trained prescription clerk to have the rights to re-authorise or cancel.
Of course only clinicians can sign. Role Based Access Control (RBAC) is the terminology for the activities on the smartcards, and PCTs need to understand what the requirements are, both for pharmacists and GP practices. There is much information about this on the CFH website, in the EPS section.
The drug dictionaries in your clinical systems need to be updated to the national dm+d dictionary (dictionary of medicines and devices) which has been chosen for EPS. Obviously you can only have one drug dictionary across all systems otherwise it would be chaos. Some systems are moving to dm+d, and some ‘map' their existing drug dictionary to dm+d, with the decision support software as part of it.
Finally, your repeat medication masters for patients need to be updated to the new drug dictionary once the above steps are in place....then you are ‘ready to go'.
You will of course require training from your system supplier and PCT and need to ensure everyone understands the business process changes brought about by this new service to patients.
Dr Tony Kaye is a a GP in Trafford and a former national clinical lead for EPS