Opinion: ePrescriptions still in a state of lockdown

Congratulations Australia. In 2020 in the year of COVID-19, widespread lockdowns, quarantine and MBS-funded telehealth, legalised ePrescriptions have finally arrived. It is a major achievement that should not be underestimated, but there are lingering issues with workflow, safety and privacy that still need to be resolved.

The road to legal ePrescriptions has been long and winding but it has not been a technical or software journey alone. It has required persistent lobbying from the healthcare sector with changes required in legislation at both a federal and jurisdictional level, including changes to the PBS dispensing rules. Governments of all ilks have been risk averse and have consequently been slow to embrace the available solutions.

ePrescribing in Australia has gone through an evolution. Initial trials commenced in the Northern Territory in 2008. Newspaper reports at the time stated: “Darwin doctors are trialling what could become a new Australia-wide system for issuing electronic prescriptions to combat fraud and dodgy handwriting. Doctors using the system will give patients a printed prescription with a digitally encrypted signature and barcode.” This was the start of electronic transfer of prescription (ETP).

At the beginning of the last decade ETP was implemented nationally, with the appearance of a printed barcode on a software-generated prescription. Prescription information was then available to be forwarded digitally to pharmacies via either of the two newly established prescription exchange services (PES), eRx or MediSecure, with no interoperability between the two PES. This was negotiated and agreed upon about a year later. The core objective of ETP was to enhance clinical safety by reducing transcription errors. It has also been assumed by the prescriber community and many other healthcare industry participants that ETP would rapidly morph into legalised electronic prescriptions.

It took, however, another decade until the emergence of the COVID-19 pandemic for this to become a reality. The community lockdowns brought about an urgent operational and critical safety imperative for prescribers to be able to transfer prescriptions to consumers without the need for physical attendance in the practice. In April 2020, after significant lobbying from the RACGP and AMA, image-based dispensing was approved by the governments of Australia, albeit on a limited based for the duration of the pandemic. Image-based dispensing has been widely embraced by prescribers and consumers.

The timeline for the electronic prescribing program which was due to be implemented in early 2021 was also rapidly accelerated and in May 2020 Australia’s first electronic prescription was transmitted in Anglesea, Victoria. This involved generation of the electronic prescription by a general practitioner, provision of its associated token digitally to a consumer, supply of medicines via a pharmacy and subsequent PBS claim. This has now been expanded to rollouts in communities of interest around the country including the whole of Melbourne and in October to Sydney. There is now significant momentum with increasing adoption and script volumes.

The current ePrescription implementation is ideal for single scripts that do not contain routine monthly repeats. Single issue, single dispense, done and dusted. When a QR code is sent to a consumer via an SMS and that mobile phone is scanned at the pharmacy and the medicine is dispensed, the original QR token is cancelled and replaced with another token sent by SMS. Single issue, single dispense, done and dusted.

However, many patients take more than one prescription medicine daily, with persons over 65 on average taking five prescriptions per day. At a routine medical appointment it is common practice for a patient to have repeat prescriptions issued for all their current medicines. In the new ePrescribing world this will result in the issuance of five separate SMS for five separate QR tokens each containing up to five repeats.

This is a recipe for confusion. Repeat scripts require the patient to be able to store and manage the initial prescriptions and also the repeat return SMSs. This is highly challenging as mobile phone software is not designed to support the storing of SMSs in folders. Consequently the token SMSs are highly likely to get lost amongst all the other SMSs a person sends and receives in the course of other routine conversations. Try to find a specific QR code a month later. Not easy. A solution is being developed in terms of the active script list and app wallets which may resolve this problem. In the interim clear advice needs to be provided about how to mange this challenge.

The next concern is that the last mile hasn’t been well considered. Patients or their carers are in the majority still having to physically turn up to the pharmacy to have the medicines dispensed as most pharmacies (including the major chains) do not have an ability to have the SMS QR token forwarded to them by the patient. In effect, the current ePrescription implementation is electronic prescribing with physical in person dispensing. This needs to be urgently addressed as it is inconvenient and furthermore creates unnecessary human-to-human contact with consequent COVID-19 risk. From personal observation, pharmacies are as crowded as ever, at the pharmacy counter, at the dispensing counter and at the cash register. So much for social distancing.

There is also a new privacy concern. There are now numerous reports from patients (and I’ve also had a personal experience) where the only method to electronically forward the SMS token to the pharmacy is to call the pharmacy and obtain the pharmacist’s mobile phone number, then SMS the QR token to the pharmacist. This is not a sustainable solution and also exposes the pharmacist's personal phone number. This could easily be resolved by pharmacies establishing inbound SMS gateways – the modern version of the fax gateway so to speak. It is unclear whether this is under consideration.

In the rush to implementation, the end-to-end workflow hasn’t been properly considered. To dispense a script, the QR code needs to be scanned and many pharmacies do not have easily accessible consumer scanners (think supermarket with their front-facing reward card scanners). Consequently patients are being asked to hand their phone to the pharmacy assistant over the counter in order to scan the QR code. Another unnecessary COVID-19 risk. So whilst the technology certainly works from a prescribing perspective, the workflow and integration processes require further assessment.

Finally, there is the unresolved question of the transmission cost. Prescribers should not have to bear the ongoing SMS cost once the Commonwealth’s support funding ceases at the end of Q1 2021. If this is not addressed there is a risk that this will impact on compete adoption. It will cost a typical general practice thousands of dollars a year in SMS charges to issue SMS prescriptions. It should be noted that there is an email option available but this can’t be set as a default option and at the present time hasn’t been widely promoted. Furthermore a pen and paper prescription has always and still costs nothing to issue.

So it’s wonderful that in 2020, in the year of COVID-19, that electronic prescribing and dispensing has finally arrived. Never waste a good crisis. What is required now is broader stakeholder engagement with prescribers, dispensers and consumers. This is not a technical or software program alone. The end-to-end workflow and change and adoption issues need to be properly evaluated and supported. As a core principle of quality improvement, lessons learned – and to date, there are many – should be openly shared with the community of interest. Ultimately, and somewhat cliched, aren’t we all in this together?

Dr Nathan Pinskier is a Melbourne GP and former chair of the RACGP's eHealth and practice systems expert committee.

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