Rolling out electronic prescriptions

mr_fegelien

When will the HPRA along with the ICPhA introduce electronic prescriptions in Ireland?

The goal of this of course is to prevent prescription forgery. Ireland has a huge issue with legitimately prescribed benzodiazepines being sold on the blackmarket by patients.

I know relatives who live in the US and though they get addictive meds (the opiate, oxycodone and benzo, diazepam), they have a sophisticated system that keeps track in each state that tracks what doctor a person visited, what they were prescribed, how much, and at what pharmacy they filled it in. This has largely got ridden of a practice known as 'doctor' shopping, where people go to various doctors, get a bunch of scripts for addictive meds and go to various pharmacies to fill them in. People are also much more careful about selling medication because of the hefty penalties.

AFAIK, this is still legal in Ireland and probably contributes to the drugs crisis. Even Australia has cracked down on benzo problem through this. If you do this, you get a letter from the Health Minister that you appear to have a pattern of doctor shopping.

Would this be expensive to implement? A few billion euro.

locum-motion

The HPRA is the Health Products Regulatory Authority.
The ICPhA is the Irish Community Pharmacy Association. *

Neither one will have anything whatsoever to do with the introduction of electronic prescriptions in Ireland.

The bodies involved are/will be;
The Department of Health
The HSE (particularly a department called the PCRS)
The PSI (Pharmacy Regulator)
The IMC (Medical Regulator)
The IPU (Pharmacy Union)
The IMO (Medical Union)
And finally the various software companies that provide the software that’s used in doctors’ practices and in pharmacies.

*: a body of which (despite having worked in Community Pharmacy for well over 30 years) I have ever heard until now.

locum-motion

There’s been a project under way (involving the bodies I’ve mentioned) for a few years to introduce electronic prescribing.

The biggest problem it has encountered has been the fact that the Irish population does not have a single identifying number. People might have a GMS card number, a LTI number, a DPS number, ir a couple of others, or they might have more than one of those. Of course, they also have PPS numbers. However, for some reason of which I’m not fully aware, the PPS number can’t be used. For a system that integrates all the services and records to work, each person has to have a single unique identifying number that follows them from birth to death. And apparently, introducing such a number system will cost a huge number of millions. I don’t know why.

locum-motion

The Covid pandemic, of course, suddenly meant that something had to be rolled out quickly, and so there is a system called Healthmail now which means that a doctor can transmit a prescription electronically to a pharmacy. It’s effectively a secure email, but it doesn’t include any features like tracking where and when those prescriptions are dispensed. Another major drawback is that it is a so-called ‘push’ system - the Dr sends the prescription to one particular pharmacy. Ideally it should be a ‘pull’ system, where the Dr uploads the prescription to some sort of central server from which the pharmacy (chosen by the patient) pulls or downloads the prescription.

A system like you’re asking about will come, but will take a long time. And now that Healthmail is in place, the DOH & HSE are going to be even less in a hurry about it.

Mrs OBumble

Pharmacy shopping, ie patients being able to get quotes from different pharmacies for filling a prescription before presenting it, would be a very desirable outcome, too. It's crazy that it's impossible to know the price prior to the pills (etc) being packaged.

locum-motion

Mrs OBumble wrote: »

Pharmacy shopping, ie patients being able to get quotes from different pharmacies for filling a prescription before presenting it, would be a very desirable outcome, too. It's crazy that it's impossible to know the price prior to the pills (etc) being packaged.

It’s not impossible. Just ask.

kerry cow

I am sure they will tell you if you ask ,
I must ask at the till in lidl the price of my groceries and compare it to the price I asked the supervalu assistant , must get onto it first thing tomorrow .

L1011

The software firms have been pushing for this for two decades; primarily as it would mean the last few percent of prescribers that aren't computerised would have to be computerised and everyone would need up to date and in support software, = more money for them.

In the last few months I'd suspect that a very significant % of scripts are being sent via Healthmail; either just as scanned attachments or specifically from the prescribers software but

1: there is still a transcription phase where errors can occur*
2: the paper prescription is still legally required.


* a transcription error proof paper based system, using cryptographically hashed barcodes, was trialled in ~2008 but with the obvious potential for an electronic system instead, died a death. Would have got rid of dot matrix for GMS scripts at the very least!

The main software provider for GPs *is* the main software provider for pharmacies also (albeit less dominant in that market with vastly stronger competitors); and has implemented both sides of the UKs electronic transmission system for various customers too so they have plenty of experience.

Grab All Association

Benzodiazepines should be limited to a maximum 5-7 days supply by a GP/out of hours/hospitals. Any further prescriptions should be obtained from mental health services upon referral which would be more likely to prescribe antidepressants for anxiety/depression. It’s just that simple to implement. This would remove the majority of prescribed benzodiazepines from getting into the hands of those not prescribed these medications.

mr_fegelien

Grab All Association wrote: »

Benzodiazepines should be limited to a maximum 5-7 days supply by a GP/out of hours/hospitals. Any further prescriptions should be obtained from mental health services upon referral which would be more likely to prescribe antidepressants for anxiety/depression. It’s just that simple to implement. This would remove the majority of prescribed benzodiazepines from getting into the hands of those not prescribed these medications.

Well I do know that many doctors are still prescribing a monthly supply of benzos (one friend I know in Wicklow gets 0.5mg of alprazolam/Xanax and fluoextine/Prozac)

But I would have thought the medical council brought in an announcement last year that they will sanction doctors that overprescribe benzos and Z-drugs. Even my psychiatrist only gives me 10 tablets a month of zolpidem/Stilnoct due to worries about being reported.

However I don't think that would change much. Illicit prescription drugs manufactured in China and sold in the West is big business so I imagine those already addicted to benzos are unlikely to just stop taking them. They'll most likely turn to the black market.

But I'd like to see electronic prescriptions rolled out as I think Ireland is relatively behind in this.

locum-motion

L1011 wrote: »

...
2: the paper prescription is still legally required...

No, it’s not.

RobAMerc

locum-motion wrote: »

However, for some reason of which I’m not fully aware, the PPS number can’t be used. .

because there is the possibility to work out what ailments you have based on your PPS Number - and folks dont want that.
Also PPSN isnt as unique as you think - married women used to just assume theor husbands PPSN ( Back in the good auld days ! )

locum-motion wrote: »

For a system that integrates all the services and records to work, each person has to have a single unique identifying number that follows them from birth to death. And apparently, introducing such a number system will cost a huge number of millions. I don’t know why.

The HSE have created a new unique health identifier called IHI through their HIDs program - but they have made such an unholy mess of the implementation of it, it could take years to fix

There is a need for a single health identifier, but because all of the health systems in Ireland would need to be retrofitted with the ability to store and use it, and because all of the companies who sold the HSE software over the last number of years took advantage that no one in the HSE was qualified to understand software - contracts signed by them means it will cost millions to fix - there therefore needs to be a different system employed.

HSE are still scratching their heads - they dont want to implement any other solutions now as its an admission of their fook ups previously.

Pasteur.

Grab All Association wrote: »

Benzodiazepines should be limited to a maximum 5-7 days supply by a GP/out of hours/hospitals. Any further prescriptions should be obtained from mental health services upon referral which would be more likely to prescribe antidepressants for anxiety/depression. It’s just that simple to implement. This would remove the majority of prescribed benzodiazepines from getting into the hands of those not prescribed these medications.

I thought hospitals and GPs were limiting it to a week

By the time you get to pharmacy hopping it's too late

Users are in full blown addiction and can switch to street drugs or online easily now.

Breezer

Grab All Association wrote: »

Benzodiazepines should be limited to a maximum 5-7 days supply by a GP/out of hours/hospitals. Any further prescriptions should be obtained from mental health services upon referral which would be more likely to prescribe antidepressants for anxiety/depression. It’s just that simple to implement.

I’m an GP with an interest in addiction medicine. This has not been my/my colleagues’ experience. It depends on the GP and the psychiatrist, in all honesty. A common complaint among GPs is that they work for a long time on reducing and rationalising a patient’s benzodiazepines, only for a psychiatrist (whether a consultant or, more likely, a registrar working the graveyard shift in the emergency department) to come along and start them again.

Also, my local psychiatric service (with whom I’ve a good working relationship) currently has an 8 month waiting list. They won’t keep drug addicts on their books for long, because their problem is addiction and not mental illness. So under your system, what precisely am I supposed to do with my benzo addicts in the intervening 8 months, and then after their single mental health clinic visit?

GPs are well placed to prescribe benzodiazepines appropriately. There is excellent training available to them. The lack of addiction counselling services and support workers in many areas is what leads to excessive benzodiazepine prescriptions.

Anyway, back on topic. Healthmail e-prescribing is a vast improvement on what was there before. The “pull” system sounds interesting, alright, but I’d see that more as a nice to have. “Lost” prescriptions have more or less ceased to exist since Healthmailed prescriptions were legalised. And I used to get a lot of those.

Breezer

Pasteur. wrote: »

I thought hospitals and GPs were limiting it to a week

Guidelines suggest that they are dispensed weekly and that lower dose tablets with a lower street value are used.

mr_fegelien

Breezer wrote: »

Guidelines suggest that they are dispensed weekly and that lower dose tablets with a lower street value are used.

From my experience, quite a few are still prescribing diazepam at 2, 5, or 10mg.

Diazepam has a much longer half life than Alprazolam and less potent which means tolerance and withdrawal is much less likely albeit still a possibility.

Pasteur.

mr_fegelien wrote: »

Diazepam has a much longer half life than Alprazolam and less potent which means tolerance and withdrawal is much less likely albeit still a possibility.

Wrong it's highly likely

locum-motion

Pasteur. wrote: »

Wrong it's highly likely

He said less likely than with Alprazolam.
Not that it wasn’t likely.

He wasn’t wrong.

Breezer

mr_fegelien wrote: »

From my experience, quite a few are still prescribing diazepam at 2, 5, or 10mg.

Diazepam has a much longer half life than Alprazolam and less potent which means tolerance and withdrawal is much less likely albeit still a possibility.

2 and 5 would be generally seen as acceptable. I agree 2s all the time would be better, but it gets a bit impractical, and you’re sometimes up against a big belief in the healing powers of “Roche 5”, “yellows” etc. 10 is not encouraged, though of course it does get prescribed. Is there scope for pharmacists to dispense this as 5s, actually, under the new controlled drugs legislation? Or does having to specify the number of tablets put paid to that?

Pasteur.

locum-motion wrote: »

He said less likely than with Alprazolam.
Not that it wasn’t likely.

He wasn’t wrong.

It's clear he's saying it's not likely

L1011

locum-motion wrote: »

No, it’s not.

When was that changed? Or was it just a massive misinterpretation on behalf of the HSE for decades?

During any trials in the past, the signed paper scripts were delivered to the pharmacies after the fact to keep the HSE happy.

Breezer

L1011 wrote: »

When was that changed? Or was it just a massive misinterpretation on behalf of the HSE for decades?

During any trials in the past, the signed paper scripts were delivered to the pharmacies after the fact to keep the HSE happy.

That was with the e-script system built into Socrates (and possibly some other GP software packages). The Healthmail system was brought in on a legal footing since March, and was subsequently built into the GP software.

locum-motion

Pasteur. wrote: »

It's clear he's saying it's not likely

Oh, FFS!

He was comparing the likelihood of addiction between two different drugs. It is more likely with one of the drugs. Therefore it is less likely with the other.

Saying something is less likely is NOT the same as saying it’s not likely.

Graces7

L1011 wrote: »

When was that changed? Or was it just a massive misinterpretation on behalf of the HSE for decades?

During any trials in the past, the signed paper scripts were delivered to the pharmacies after the fact to keep the HSE happy.

Out here they email the prescriptions to the pharmacy. Not sure after that.. Probably send on the paperwork.

leanin2019

locum-motion wrote: »

Oh, FFS!

He was comparing the likelihood of addiction between two different drugs. It is more likely with one of the drugs. Therefore it is less likely with the other.

Saying something is less likely is NOT the same as saying it’s not likely.

You could argue that saying something is much less likely is inferring that it is not likely. And much less likely is what was said. They said it was still a possibility. Still a possibility does not infer that it is highly likely.

Dingle_berry

L1011 wrote: »

When was that changed? Or was it just a massive misinterpretation on behalf of the HSE for decades?

During any trials in the past, the signed paper scripts were delivered to the pharmacies after the fact to keep the HSE happy.

The MN-CMS system has been live for 3 or 4 years with electronic perscriptions included.