“Doctors and pharmacists have backed calls from a Victorian coroner for the introduction of a real-time prescription monitoring system in an effort to stamp out doctor-shopping.
Coroner John Olle called for the introduction of live prescription monitoring within the year and asked for written submissions from relevant experts before he makes final recommendations in relation to the death of a Melbourne man, 24, who overdosed on prescription morphine and diazepam two years ago.”
Medical Observer reported these Victorian Coroner findings on 9 August 2011. A tragic case of a young man caught up in a deadly addiction to prescription medicines and no safety net in place to prevent this abuse of the national medicines system.
How is this possible? With all the sophisticated IT systems in the banking world that track customer behaviour, with all the IT systems deployed in social media and the ability of advertisers to know what any user is looking at and how they behave, how can the medicines system, a fundamental plank of the world‑class Australian health system, get it so wrong?
At the root of this young man’s problem was the process of prescribing and dispensing of medicines; in particular, the Schedule 8 (S8) or Drugs of Addiction process. The management of S8 medicines is a state responsibility and each state has their own version of ‘best practice’. As a general rule, the use of paper and manual notifications is part of the S8 management process.
Doctors have long been concerned about the ‘doctor shopper’ and have for decades sought an answer to the “how do I know?” question. The process of prescribing and dispensing S8 medicines is used every day by doctors and pharmacists across the country. Opioid medications have a legitimate and necessary role in treatment of pain in the community. But the process of managing these drugs of addiction and the patients who use them appears to be deficient, particularly for timely feedback to both prescribers and dispensers on the activity of an individual patient.
Medical Forum WA recently addressed S8 management and “compare[d] some results with our 2009 survey around narcotic prescribing. Since 2009, the profession has lost the Medicine Information Line for doctor shopping on PBS scripts, a service that 17% of our surveyed GPs found ‘very helpful’ and 31% found ‘sometimes helpful’ ...”
In Western Australia, “there are approximately 200‑300 scripts of concern each month” in the defined high-risk groups. Letters are sent to the prescribers after the event. Further, “over 200 letters are sent each month to prescribers who have prescribed for a [registered drug addict] without prior authorisation. In addition, ‘doctor shoppers’ ... (are) identified when they present at one or more pharmacies with prescriptions from more than one doctor ... One proposal ... is to write to identified patients, informing them that their behaviour has been noted ...”
Is this a deficient process? Or is it just technically not possible to gather data and act promptly? The Western Australia S8 management process, like most other states, relies on paper collection of data, manual processing and manual follow up. Staff and resources issues magnify the S8 problem.
According to Medical Forum WA: “The ... Education and Health Standing Committee report on Changing Patterns in Illicit Drug Use in Western Australia ... echoed the idea of addiction to dangerous prescription drugs coming from long wait times to see a specialist and it said there was deficient tracking of opiate scripts due to a three-month delay before they appeared on the WA Health database.”
Quite clearly, the S8 management system is a dinosaur.
Capacity to manage doctor-shoppers with timely and focused intervention is severely limited when the management process involves procedures like those in Western Australia. Note that the primary data collection point in most state systems is at the pharmacy end of the process, that is, at the point of dispensing.
The Victorian Coroner called for a more effective system, based on the prescribing end. Did he have in mind a system that would identify the problem patient when they were sitting in front of a doctor, and where positive intervention action could occur?
There is a simple and effective answer for S8 management as outlined by the Victorian Coroner. Based on an existing e-health system that works and is deployed in many medical practices across all states and territories, the system has been developed, deployed and is operated by the private sector under clear privacy, security and standards requirements. Commonwealth and State Governments have not spent taxpayers funds to deploy it, but they are the major beneficiary of the efficiencies, savings and benefits generated by this e-health system.
The existing Electronic Transfer of Prescriptions (ETP) system is in place and adding value for prescribing clinicians. It is delivering economic advantage to participating pharmacies and can carry a secure e-version for every computer‑written prescription. By using ETP, management of S8 prescriptions and doctor shopping can be addressed.
Very simply, if every prescription for S8 medicines was transmitted to an AS4700.3 compliant Prescription Exchange Service (PES) — such as the MediSecure Script Vault — from the medical practitioners’ clinical software, then the Coroner’s recommendation for an (almost) real-time prescription monitoring system would be in place. Monitoring of prescriptions would not take place within the PES, but in a third party service as defined by NEHTA in the ETP Release 1.1 specifications.
MediSecure's MDSv2.0 software meets the NEHTA Release 1.1 specifications at an operational level. This includes a patient Individual Healthcare Identifier field (IHI) in the e-prescription meta-data on the outside of the secure prescription message. The IHI allows for individual medicines management, a key service for patients. With a medicines or S8 code in the meta-data, S8 and doctor shopping management can commence.
Any prescribing clinician could elect to receive a pop-up after they print the S8 prescription but before handing it to the patient to inform them of how many S8 scripts that patient had collected in the past 90 days. The clinician could then make an informed judgement: intervention; hand over the S8 prescription; or refuse service.
When all doctors send all their prescriptions to AS4700.3 compliant Prescription Exchange Services, this simple, effective, no-cost-for-clinicians service can manage S8 patients. The necessary infrastructure is in place. The frustration of doctor-shoppers and the danger of the current S8 management system can be relieved.
At the pharmacy end, manual reporting of all S8 dispensing remains a continuing cost. Utilisation of an AS4700.3 compliant PES can automate the entire S8 process with more timely reporting to state authorities, immediate flagging of patients with multiple S8s and other non‑standard S8 events.
It is acknowledged that there are two PES services, but unfortunately no interoperability at present. MediSecure is committed to full interoperability. When this operates a doctor can choose to send the S8 e-prescription to any approved PES provider.
With a small change in thinking, the Victorian Coroner’s call for S8 management can be implemented. Community harm from S8s will be diminished; individual patient and doctor benefits will accrue with no additional work, and pharmacy data reporting will be more accurate, timely and automated.
Phillip Shepherd is CEO of MediSecure Pty Ltd. With over 30 years experience in manufacturing, technology and information strategy, Phillip previously worked with community pharmacies in e-commerce and supply chain and with general practice in practice management software, e-commerce supply chain and e-health programs. Phillip has a detailed understanding of the business drivers that are essential for success in e-health adoption in primary care.
- O’Brien M. Wide support for real‑time prescription monitoring call. http://www.medicalobserver.com.au/news/wide-support-for-realtime-prescription-monitoring-call
- McEvoy R. Stolen Scripts Just a Symptom? http://www.medicalhub.com.au/wa-news/guest-opinion-editorial/3680-stolen-scripts-just-a-symptom
- Bangor‑Jones R, Keen N. Opiate monitoring: pharmacists, patients and prescribers. Medical Forum WA October 2011.