Rewriting the script: the NHS and electronic transmission of prescriptions

New Southmead superhospital under construction

A version of this article appeared in Health Service Journal, 9 December 2004

Of the three main applications within the English NHS’s National Programme for IT, electronic transmission of prescriptions (ETP) looks the least controversial. The Care Records Service’s online database of patient records causes concerns over privacy and security, while attitudes towards the Choose and Book electronic booking system are coloured by views on patient choice.

By contrast, ETP does not create new flows of data: prescription details already move from GPs to pharmacists, then on to the Prescription Pricing Authority (PPA), allowing it to reimburse pharmacies for the difference between real cost and charged price. Under ETP, this data will move electronically rather than on paper, hopefully cutting errors, saving money and time.

Sending prescriptions electronically will also allow remote pharmacies to work effectively, so prescription medicines can be sent by post. It will also help pharmacists take the greater role in patient care and in management of repeat prescriptions promised under the new contract for community pharmacy.

Yet ETP’s progress has not been smooth. In June 2003, the Department of Health shut down three pilot schemes, despite expectations from the participants that these would be made permanent (see box 1 for details). The National Programme’s ETP plan has taken elements from all three trials (see box 2 for details). But don’t expect to see these quite yet. According to the information on the National Programme’s web-site, ETP will be ‘progressively available from early 2005’. However, the initial version, known as ‘ETP Core’, will see the electronic system just shadowing GP-signed paper prescriptions, as abandoning the latter requires a change in the law.

‘We are adopting a staged and incremental approach to the roll out, both in terms of functionality and in terms of the number of deployments,’ said a National Programme spokesperson. ‘We will initially do a small scale implementation of core functionality. This will enable us to get feedback and make any necessary refinements and to ensure that lessons learned in the initial implementation will be used to ensure the success of the wider national roll out.’

The legal change allowing ETP to replace paper prescriptions is due to be enacted alongside the new contractual framework for pharmacists due in April. But this will start a second ‘Transitional ETP’ phase, with patient nomination of pharmacists not coming until the full version. ‘It is currently expected that the technical functionality [for nomination] will be available during summer 2005,’ said the Programme spokesperson. ‘However, details as to how this will work in practice and will be implemented have still to be finalised.’

For some, ETP will mean little until patient nomination is in place. ‘The nominating opens doors to the opportunity for pharmacies to move into medicines management,’ said Dr Andrew Willis, a partner of King Edward Road Surgery in Northampton, as it allows a pharmacist to take a long-term interest in a patient’s care and gives them steady, repeat trade.

King Edward Road Surgery took part in the ETP trial run by mail-order firm Pharmacy2U, and continues to work with this company, although to comply with the law it has to send signed paper prescriptions to confirm electronic orders. ‘It was an excellent pilot, which worked and was of benefit to the pharmacist, to the patient, to the practice and to the PPA,’ said Dr Willis. ‘It was superb, but it was stopped because the National Programme wanted to start with a clean sheet of paper.’

Around 650 patients from King Edward Road Surgery use the system, which involves Pharmacy2U calling them when their repeat prescriptions are due. If they confirm, the medicines are delivered the next day. ‘There are exceptions, but the vast majority think it’s absolutely wonderful.

A few people don’t like the fact that it’s remote, a few don’t like that the deliveries come early in the morning, but this is very much the minority. I hope that pharmacies would take leaf out of of Pharmacy2U’s book, and Kaiser Permanente in America, in delivering prescriptions,’ said Dr Willis. ‘I think people have put up for far too long with the ridiculous situation where they have to order their repeat prescriptions each month.’

He is concerned about the possibility of ETP being phased in slowly. ‘I very much hope that the National Programme will come up with something better that it’s replacing, which is what they said they would,’ he said.

Julian Harrison, commercial director of Pharmacy2U, is naturally keen to see ETP introduced in full. ‘Those [pharmacists] that get nominated are those who can build a point of difference,’ he said. This will include mail-order firms such as his, but also: ‘I think that independent pharmacies will do well. They often have a good relationship with their patients.’ But some which rely on location rather than service may suffer. ‘There are still people within the pharmacy establishment who are trying to delay ETP,’ he said.

Lindsay McClure, head of information systems for the Pharmaceutical Service Negotiating Committee, said that rather than being a threat, the majority of shop-based pharmacists offer prescription collection services, which nomination will simply automate.

‘If you look at repeat dispensing in the new contract, where the pharmacist can issue repeat prescriptions for a year, there is a “State of the Ark” system with paper,’ she said. By contrast, repeat dispensing run through ETP will hopefully be state of the art. But there is still work to be done, such as adjusting about 10 rival pharmacy system software packages to work with ETP.

Patrick Leppard, a community pharmacist in Bedhampton in Hampshire, was involved in the TransScript ETP pilot, and is enthusiastic about patient nomination. His pharmacy, part of a chain of six, is located at the site of an old GP surgery that was moved to a new health centre, about a mile away in Havant, around 20 years ago. The pharmacy started providing a prescription collection service then. ‘It keeps me in business, I suppose,’ said Mr Leppard. ‘For elderly patients, it’s a fair old journey [to the health centre].’ ETP would cut the need for him to travel to and from the health centre, and should stop prescriptions going astray. ‘If the new ETP is as good as what we had before [in the trial], bring it on,’ he said.

Sarah Davis, professional process manager of 1,350-branch firm Lloydspharmacy, said that ETP should also improve the efficiency of pharmacists. ‘The main saving will be around data entry,’ she said. ‘At the moment, we spend time entering data into pharmacy systems.’ That time can be better spent advising patients.

There are prescribers other than GPs. Aintree Hospitals trust won the Guild of Healthcare Pharmacists’ information technology award this year for a system which partly automates its discharge prescriptions. Previously these were posted to GPs, so they could alter patients’ repeat prescriptions, but this was slow and unreliable.

Instead, at a cost of £1,500 on a fast personal computer, a scanner with a feeder mechanism and some software, the trust scans its discharge prescriptions, uses the barcodes on them to find the GP from the patient management system, then emails the scripts as image files using addresses from a database. Having started in 2003, the scanner is now used for about half of discharge prescriptions. ‘It takes five minutes to scan and email 150 prescriptions,’ said Brian Smith, deputy chief pharmacist. ‘The time is takes up is someone watching the feed chute of the scanner, to make sure it’s not blocked.’

Although the scripts need to be retyped by the GP concerned, they do arrive quickly – ‘the GP often has the information before the patient has left the trust,’ said Mr Smith – and as they are stored by the trust and often by the GP too, they can be checked easily.

Mr Smith says it is only intended to be a stop-gap before the National Programme’s ETP system takes over. But he believes that will take some time. ‘There’s still a lot of clarification to do,’ he said. ‘With the logistical nightmare it will involve, and no-one’s really started on this, it will take at least two years to get anything sorted out, I would imagine.’

The experience of Systems Solutions, an Irish-based firm with around two-thirds of that country’s market for pharmaceutical systems, also provides a cautionary note. In 1997, the Irish equivalent to the PPA wanted to cut the 60 days taken to process payments. It did so by getting Systems Solutions and its competitors to adjust their systems to send in prescription details electronically; pharmacists now receive their money in 14 days.

The firm has also installed a patient management system in Boots’ 900 UK branches, which holds all transactions with patients, so it has experience of what the National Programme is planning. ‘I can tell you that the National Programme will have a lot of problems in terms of making sure it’s scalable. The volume of data is enormous,’ said David Raethorne, technical director and founder of the firm. He has seen estimates that 80% of the data flowing over the National Programme’s N3 data network will be from ETP. ‘If I’m diagnosed with asthma once, I’m given medicine for the rest of my life,’ he said: in this case, one diagnosis transaction leads to hundreds of prescription transactions.

Mr Raethorne also believes that the external costs of ETP will be great, pointing out that Boots’ 4,200 terminals for its patient management system meant training 14,000 staff, and the chain represents about 10% of the UK market. ‘It’s one thing to accept a payment for a piece of software, but they need to take into account training, disruption to their business, what happens when locums come in, installation costs, putting in new equipment, moving to broadband,’ he said.

It may be relatively uncontroversial, with some worthwhile benefits for all involved, but ETP may yet suffer the problems of high cost and slow progress that hold back so many government IT projects.

Box 1: the three ETP pilots of 2002/3

– Pharmacy2U: GPs sent prescriptions to a remote pharmacist, which then delivered them by registered post anywhere in the UK. The pharmacy called patients to ask if they wanted to reorder shortly before they were due to run out of a medicine.
– SchlumerbergerSema/Flexiscript: GPs sent prescriptions to a central server. These were pulled off the server by a pharmacist when a patient claimed their prescription (a ‘pull’, or ‘relay-based’, system). It preserved freedom of choice of pharmacist, but did not allow prescriptions to be ordered if out of stock, or made up in advance.
– TransScript: GPs sent prescriptions directly to a nominated pharmacist (a ‘push’ system). Patients had to use that pharmacy, but the prescription could be ordered and made up in advance.

Box 2: how will it work?

ETP will employ a relay-based model: GP’s prescriptions will go to the National Programme for IT’s Care Records Service database, signed with their digital signature, a secure electronic code. The patient will receive a piece of paper which they can take to any pharmacy, but this will just be a token of the legal prescription. It will carry a barcode which can be used to retrieve the record, as well as a code number which can be given over the phone or the internet. If patients choose to nominate a favourite pharmacy – and most are expected to – that pharmacy will be able to retrieve the prescription from the Care Records Service the next time it checks for new orders, allowing preparation of prescriptions before the patient arrives (making it similar to a ‘push’ system). The nominated pharmacy could be a remote one. Pharmacists will need to obtain a connection to the Care Records Service, either through the National Programme’s secure N3 broadband network, a corporate network or a secure ‘virtual private network’ running over a commercial broadband internet connection. They will have limited access to patients’ individual care records.

Copyright SA Mathieson 2004