Pharmacy IT: Welcome to the future

Despite its poor track record in IT, the Government is determined that its NHS digital projects will bring healthcare in the UK into the 21st century.

The Government is keen to bring healthcare in this country up to speed in terms of the digital revolution that is transforming many other sectors. England’s chief pharmacist Keith Ridge made this clear when he said recently that, “the future is digital, underpinned with efficient use of technology”.

The Government believes that both ‘click and collect’ and ‘hub and spoke’ models should be used more widely in pharmacy to cut costs, while health secretary Jeremy Hunt wants a quarter of smartphone users – 15 per cent of all NHS patients – routinely accessing NHS advice, services and medical records through apps by next April.

Although the track record for NHS digital projects is poor, with technology such as the electronic prescription service beset with issues and delays, persistence may finally be paying off and pharmacist access to the Summary Care Record (SCR) appears to be a rare success.

Following a successful proof of concept across 140 sites, last June saw NHS England commission the Health and Social Care Information Centre to support all community pharmacies in England to implement access to the SCR. The Government promised to invest up to £7.5 million to give pharmacists the training and tools they need.

A report on the proof of concept found that SCR access in community pharmacy delivered benefits to patients, pharmacy and general practice, including:

  • Pharmacists avoiding the need to signpost patients to other NHS care settings in 92 per cent of encounters where the SCR was accessed
  • 85 per cent of pharmacists surveyed agreeing or strongly agreeing that SCRs reduced the need to contact a patient’s GP
  • The risk of a prescribing error was avoided in 18 per cent of encounters.

In November, pharmacies in Sheffield and branches of Day Lewis were the first to begin a nationwide roll-out of the SCR. By the beginning of February this year, over 380 community pharmacies were ready to view SCRs.

Different delivery organisations and partners across the country are at different stages of the roll-out, according to HSCIC. Some are still formulating their plans and approach, but others have started to deliver briefing sessions direct to pharmacies.

Full details of the areas and organisations which have agreed firm timescales are published on the HSCIC website. The roll-out is expected to be complete by spring 2017, although the process of upgrading smartcards has apparently been slowing down the initial stages.

“HSCIC would like to thank Day Lewis for actively working to be the first organisation to complete the SCR implementation process, and for helping us to identify areas for improvement,” says a HSCIC spokesperson.

“We are working with NHS Registration Authorities (RAs) to support pharmacies with the roll-out, which we appreciate is a significant project for the many organisations involved. We know RAs are working hard to make the necessary updates to users’ smartcards to enable SCR access as quickly as possible and we thank pharmacies for their patience.”

HSCIC has regional implementation managers available to help with any queries. To contact them, pharmacists should email scrpharmacy@hscic.gov.uk.

Code4Health and pharmacy

Code4Health is a programme managed by NHS England “to enable the best use to be made of digital tools and technology to deliver safe, high quality, efficient and compassionate care. It aims to educate and inform all participants in the health and care community … about the possibilities digital technologies open up in health and care and equip them with the tools, knowledge and skills to work together to develop and implement high quality digital solutions.”

It enables individuals to join with like-minded people in its communities, learn to code (write software), explore the resources in the emerging open health and care ecosystem, build apps and test their ideas. It contains learning resources such as the ‘App in a day’ module, which is an introduction to the tools that can be used to develop apps in a test environment using LiveCode and the NHS Code4Health platform.

Based on the learning from these communities and the projects delivered to date, Code4Health is now establishing a pharmacy Code4Health community. The first pharmacy Code4Health event was due to take place in February, with a range of pharmacy professionals and interested technology stakeholders across the industry taking part. This event aimed to introduce participants to coding for health, the role pharmacy can play in influencing innovation and help to shape the work of this new emerging community.

Liability concerns

A concern for some community pharmacists has been the increased liability that comes with SCR access, but both the NPA and Numark have committed to insuring pharmacists and technicians for this role.

The General Pharmaceutical Council has also issued the following statement: “Pharmacy professionals who can access patient medical records must ensure that they apply the principles and requirements of conduct, ethics and performance to any additional information that they can access as result of these changes.”

GPhC inspectors will explore pharmacy teams’ use of the SCR as one evidence source when assessing a pharmacy’s performance against its standards for premises.

Pharmacists are not contractually required to take part in SCR access and can opt out. HSCIC says that it is aware of only one independent contractor deciding to opt out.

Tackling EPS issues

Although the proportion of prescriptions transmitted electronically continues to increase – currently standing at 42 per cent – a number of problems with the system remain. Pharmacy Voice has collated a list of 63 unresolved related issues (some of the most serious are listed in the panel above).

Ways pharmacy teams can improve EPS management include using the prescription tracker system to help find a prescription, says John Palmer, national IT lead at Pharmacy Voice. Filtering or ordering script lists by patient in the PMR can help find all scripts for that patient, he says, although some can be delayed at the prescriber’s end.

Although GP systems of choice (GPSoC) suppliers have been asked to relax the demographic match criteria, asking local prescribers to look out for mismatch warnings could reduce the number of prescriptions appearing on paper. Asking prescribers to add a note for split scripts (e.g. ‘script one of two’ or ‘expect CD script on paper’) can also save dispensary time.

Unresolved EPS issues

  • Split prescriptions (i.e. where one or more electronic or paper scripts may not have arrived) cause logistical problems and can cause patients to not get all the items they need. CDs still having to be prescribed on paper increases the number of split scripts
  • Having to press a key to download new scripts
  • Claiming correctly is still a “huge” problem in terms of exemptions, and ensuring the claim is sent before prescription expiry. Partials and owings do not help
  • Editing dosage instructions. It would be preferable if the prescriber system sent usable dose instructions, and editing them in pharmacy was a rare event
  • No facility to send an electronic note back to the prescriber
  • Smartcard issuing, updating and unlocking – especially where a trip to a remote registration authority is needed
  • Trying to reconcile EPS claims with what the BSA actually paid.

 

As part of Release 2 enhancements that HSCIC expects by the end of the year, prescriptions will download automatically at intervals, without having to be manually triggered. NHSmail 2 includes instant messaging, which might prove useful for communicating between pharmacy and prescriber while chasing a script. Other suggestions for improving IT systems include:

  • Reports can be run on most systems to ensure all prescriptions have been claimed, while others use pop-up warnings or email alerts
  • Ensuring exemptions are entered correctly needs good processes and workflow within the pharmacy. Ensure exemption warnings from the PMR system are configured to match dispensary processes
  • Claim amend is possible in EPS, but EMIS PMR systems are the only dispensary software that currently supports this function
  • Try the Care Identity Service (CIS) portal for smartcard management. Ask your RA if they will delegate some responsibilities (e.g. sponsorship/document checking) to the pharmacy
  • Item level payment information is now available via the BSA portal and can be reviewed to check your pharmacy is receiving what is expected
  • Send all members of the pharmacy team on a local EPS masterclass training event (planned to run until the end of June) and complete the CPPE module on repeat dispensing.

Poor GP engagement is slowing down uptake of electronic repeat dispensing

The inability to transmit prescriptions for controlled drugs is another issue hindering smooth adoption, with HSCIC blaming system suppliers. “Based on the latest plans from suppliers, it is looking like controlled drugs will not be available in all dispensing sites until 2018,” says HSCIC.

“We cannot implement controlled drugs until this point as we cannot risk a controlled drug going to a site that does not have the capability. The legislation is in place and central systems are ready. Progress is now reliant on system suppliers providing the capability. We are now exploring a range of options to minimise the impact on overall EPS delivery timescales and at this stage, no decisions have been made.”

Pharmacy access to an electronic database of patients’ prescription charge exemptions is something else that might speed up the dispensing process. Back in 2014 the DH announced that all pharmacies would have this access by 2018. The new system is still on schedule, a DH spokesperson said last month.

“We remain committed to the programme of work to combat fraud, which could save the NHS £150 million a year. This includes a new electronic system that will allow pharmacists, for the first time, to see with a click of a button who is entitled to a free prescription and who is not.

“We are still planning to have the new system in place in 2018, and will consult with pharmacists and a range of stakeholders as we develop it.”

Assessment and development

Meanwhile, PricewaterhouseCoopers is conducting an independent assessment of the costs, systems and usage of the EPS. The work is being undertaken on behalf of HSCIC, PSNC, NHSE and NHS Employers. Pharmacy teams were able to contribute via PwC’s online survey, which closed on February 19.

PSNC describes the work as vital to ensure that “any additional costs associated with the use of EPS can be assessed and then considered in future funding negotiations”. The survey is part of a larger piece of work that was agreed with NHSE as part of the 2015/16 contractual framework funding settlement. This study, which began in January, is assessing the costs and benefits of the system, involving 200 randomly selected pharmacies. It will particularly examine:

  • The time taken to manage the receipt, preparation, dispensing and claiming of prescriptions using EPS compared to paper scripts
  • The frequency, severity and additional costs and/or time pressures relating to system issues with EPS.

Top of PSNC’s recent set of service development proposals made to the DH was a large-scale transfer from repeat prescribing to electronic repeat dispensing (e-RD). And that e-RD should become the default prescribing option where the prescriber wishes to prescribe on a long-term basis.

The biggest factor slowing down the uptake of e-RD has been the lack of GP engagement with the service, says Alastair Buxton, PSNC’s director of NHS services. GP practices need to go live with an EPS Release 2 compliant system to be able to use the e-RD facility. Only 77 per cent of practices are currently live, but HSCIC is working to make sure the rest are live by the end of the year.

“Technical barriers are not an issue for the majority of GP practices, but use of the e-RD service requires initial investment of time by GP practices and a behaviour change by prescribers. Greater use of e-RD has been a key target for NHS England for some time due to the benefits it brings to patients and GP practices. We do, however, believe that engagement of GP practices with the service will realistically require some direction or incentive from NHS England,” Buxton says.

The SCR roll-out is expected to be complete by spring 2017.

Tackling counterfeits

The EU Falsified Medicines Directive (FMD) will apply across Europe from February 2019, requiring measures in place to prevent counterfeit medicines entering the supply chain. These include a 2D barcode on medicines that can be used to verify the product in the pharmacy before dispensing.

The directive requires verification to take place at the time the medicine is supplied to the patient, and this will also inform the pharmacist if the product is out-of-date, recalled or withdrawn from the supply chain. Wholesalers must also have a system in place to check medicines using a risk-based approach.

The scale of the challenge is considerable. Over 6,000 pharmaceutical manufacturers must serialise and add tamperproofing to roughly 10 billion packs of prescription medicines that are dispensed every year across Europe. Costs for community pharmacy are likely to be significant, mainly in terms of staff time involved in scanning and checking tamper evident seals.

The NPA has worked with AIMp and the CCA to establish a community pharmacy working group on FMD implementation. This group aims to limit the bureaucratic demands and enhance any opportunities for pharmacy that exist within this legislation. It will consider how costs can be managed and seek to put in place measures to prevent inappropriate use of commercially sensitive data extracted from the verification process.

The group is engaged with the DH and MHRA, liaises closely with Pharmacy Voice and the PMR suppliers, and is seeking to work with PSNC, Community Pharmacy Scotland, Community Pharmacy Wales and Community Pharmacy Northern Ireland.

A huge amount of work is required to ensure that community pharmacy will be ready to meet its legal obligations by 2019, says NPA public affairs manager, Gareth Jones. Realistically, the sector probably only has a year to determine how this system should work in community pharmacy to allow time for the IT development and training that will be required, he says.

The NPA wants community pharmacy to be granted flexibility over where the authentication process takes place, helping to ensure that it does not slow down dispensing, and hopefully reducing the overall costs. It could, for example, be decided to authenticate medicines at the point where the stock is received in the pharmacy – something that has already been offered to the hospital pharmacy sector.

Tech facts and figures

  • In the UK, 84 per cent of the population use the internet, 59 per cent use a smartphone, but only 2 per cent have had any digital interaction with the health service
  • More than 96 per cent of the population have a SCR
  • 74 per cent of adults made an online purchase in 2014, but less than 10 per cent ordered their medicines online
  • £4.2bn of the Government’s investment in the NHS until 2020 will be ringfenced for IT projects
  • More than 97 per cent of the population now have access to GP services, such as ordering their repeat medicines, online

 

Key facts

  • The inability to transmit prescriptions for controlled drugs via EPS is unlikely to be resolved until 2018
  • Code4Health is now establishing a digital pharmacy community
  • A huge amount of work is required to ensure that community pharmacy can meet the EU Falsified Medicines Directive requirements by 2019.

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