Clinical Records Assignment

The impact of the NHS National Programme for IT in England on the development of community Pharmacy patient medication record systems

Hossein Hooman Ghalamkari

Abstract Community pharmacists keep records of patient medication records (PMRs) that allows them to retrieve details of previously supplied medicines to patients against NHS prescriptions issued by doctors. This paper investigates the impact of the NHS National Programme for IT in England, in particular the Electronic Prescription Service on the development of pharmacy patient medication records. A search strategy was developed and a literature search was carried out using several sources. The elements that enable the Electronic Prescription Service were analysed in relation to the development of PMR systems and the role of the pharmacist. It is concluded that the NHS National Programme for IT has greatly influenced the development of PMR systems by setting standards. The standards include those for reliability of software and hardware through a compliancy testing procedure; for interoperability with the use of the dictionary of medicines and devices; connectivity with standards for N3; and standards for confidentiality and security of patient information with the requirements for registration of users and the issue of smart cards. The paper indicates that the next developments in PMR systems is in the direction of clinical functionality which together with two way access to patient information will maximise pharmacists contribution to patient care.

What is the impact of The National Programme for IT on the development of Community Pharmacy Patient Medication Record Systems in England? Introduction Community Pharmacies in the UK that are contracted with the NHS to provide dispensing services hold records of medicines supplied to patients against prescriptions issued by doctors. They refer to these computerised records as patient medication records (PMRs). This document investigates the impact of the NHS National Programme for IT in England, in particular the Electronic Prescription Service, on the development of PMRs. Methodology A literature search was carried out on the subject according to the strategy below. 1. Databases containing pharmacy related journals were selected a. The library of the Royal Pharmaceutical Society Library was contacted and access to the societys e-library was obtained. b. This provided access four databases: Medline, CINAHL, Biomedical Reference Index, and International Pharmaceutical Abstracts 2. Key words were selected: a. National Programme for IT, Electronic Prescription Service, Evaluation, Research, Pharmacy Medication Records, UK, England, Great Britain 3. The Pharmaceutical Journal, the main professional journal for pharmacists in the UK, was searched using the on-line facilities. The same key words as above were used to search the journal. 4. Google search carried out on evaluation of Electronic Prescription Services. Results There were no published articles found with the search terms electronic prescription service AND evaluation. It was decided to simplify the search strategy and search for terms such as Electronic Prescription Services. The results of the literature search using the different sources are presented in the table 1 in the Appendix. The low number of academic articles found may be as a result of two issues, firstly the terms Electronic Prescription Service and NHS national programme for IT are specific to the UK, whereas the databases draw mainly from American journals. This theory was tested by using the term Electronic transmission of prescriptions, primary care, dispensing errors, prescribing errors, economic evaluation which found over 7000 articles, the vast majority of which were not specific to the UK. Secondly the programmes are relatively new and the evaluations may not have been completed and published. The Google search on Evaluation of Electronic Prescription Service pointed to collaboration between the School of Pharmacy in London, Nottingham University 1 . EPS is certainly a topic of much debate in the pharmacy profession in the UK as indicated by the large number of articles and news stories reported in the Pharmaceutical Journal. The NHS National Programme for IT website2 as well as the Pharmaceutical Services Negotiation Committee website 3 also provided much of the information and insight presented in this document.

History of development of Pharmacy Medication Records To make an assessment of the developments in PMR systems, it will be useful to understand the history of their development. The act of dispensing of medication when presented with a prescription requires the pharmacist to ensure that the directions by which the medicine is to be taken by the patient is attached to the medicines that are supplied 4. Historically pharmacists would hand write the direction details required on labels which would then be stuck on the packages of medicines supplied. Typed direction labels became the norm with the use of type writers in dispensaries. This was followed by the use of electric type writers which both had short cut keys for commonly used text such as one tablet to be taken twice a day and also allowed the pharmacist to review the label and make amendments before being produced. The next development was the use of the early computers which stored previously dispensed medicines and their directions and thus enabled retrieval of the details of medication supplied for individual patients. Since the majority of the dispensing workload is for repeated transactions this produced great efficiencies and enabled pharmacists to produce labels more quickly. The introduction of the use of modems to transfer information over the telephone network facilitated another aspect of a pharmacists requirement; the transfer of orders to suppliers. Suppliers of pharmacies saw this development as an opportunity for investment in pharmacy medication record systems. These suppliers offered free software in return for the major proportion of the business generated by that pharmacy. Now the pharmacists could label efficiently and place orders efficiently. This development also led to the introduction of a database of medication used by these software systems each containing reference to the suppliers codes and prices. Thus several supplier catalogues were developed which transferred order codes through a modem from the pharmacy PMR to the suppliers. There were also changes in the community pharmacy market which influenced the development of patient medication records. Companies with multiple pharmacy outlets became the major owners of the pharmacy market. These companies had requirements for reporting and stock control. These requirements saw the development of stock control facilities and the pooling of data from many pharmacies. Professional development of the role of the pharmacist brought about the need for the first clinical decision support 4. The new role required pharmacists to check that there were no drug-drug interactions and that there were no risks of an allergic reaction with the medicines supplied. In addition each dispensed medicine had to have advisory or cautionary instructions attached to it. Traditionally pharmacists would manually look up details of each medicine in the British National Formulary and in the case of cautionary instructions stick pre-printed labels on to the dispensed medication. There was also a process of manually checking drug drug interactions in the British National Formulary and in the case of allergies asking patients if they were allergic to any medicines. However this was time consuming and often not carried out effectively. Thus decision support software was developed as an integral part of the PMR system that the pharmacists were already using for labelling and ordering of medicines. The requirement of cautionary instructions, interaction and allergy checking required the medicines databases (or catalogues) to be linked to specific clinical information. This was the start of Clinical Decision Support in pharmacy patient medication records 5. These systems interrogated medicines supplied to patients and checked for drug- drug

interactions and also allergy-drug interactions (The early systems actually did not check an allergy status by drug. In fact they recorded a specific product that the patient was allergic to and if a similar product was being supplied then the pharmacist would be alerted. In effect this was a type of drugdrug alert). This professional role and the need for clinical decision support was further endorsed by its link to the NHS Pharmacy Contract where payment was provided for having an electronic medication record and accredited training for maintaining these records 6. The next development in decision support in the pharmacy medication records was the need for a system of endorsing prescriptions which is a requirement for re-imbursement. Traditionally pharmacists would handwrite an endorsement according to rules defined in the Drug Tariff for claiming re-imbursement 6. Decision support software enabled automatic endorsing of prescriptions thus producing greater efficiencies in the submission of prescriptions for re-imbursement. Once again the medicines databases had to be linked to codes that enabled rules for re-imbursement to be applied. At this stage there were no standards for pharmacy patient medication record systems. There were many systems on the market and each would have developed their own medicines databases, each with different codes for directions, each with different systems for reporting drug interactions and different systems for recording allergies. Pharmacy companies generally chose patient medication record systems based on the affordability of the systems and requirements of their businesses rather than clinical functionalities. The costs of the systems were partly or fully covered with agreements for purchasing from particular medicines suppliers whose primary goal was the efficient transfer of orders from pharmacies 7. There were relatively few developments in the pharmacy patient medication record systems throughout the 1990s. Notable exception was the need for providing services to care homes who required printed medication administration charts along side dispensed medicines 7. The announcement of the National Program for IT in England acted as the next major catalyst for the development of PMRs. The National Program for IT has as one of its main corner stones the Electronic Prescription Service which would obviously impact on pharmacy and thus their PMR systems 2. The aim of the National Program for IT is to develop a national infrastructure of national services and national applications that will allow the sharing of information between different health professionals including community pharmacists. The national services include the following: Spine; this is where an electronic summary care record will be stored and accessed by anyone within the NHS. The spine is part of the NHS Care Record Service (NHS CRS). The electronic Summary Care Record holds limited patient information but includes patients current medications, allergies, and adverse drug reactions (It is thought that additional information would be added to the Summary Care Record). All these items of information would be very useful to the care of patients provided by pharmacists 8 . N3. This is a fast broadband service that connects all NHS organisations thus producing a national network. This service replaced the NHSnet. The implication for pharmacy medication records is that to receive information and data from the NHS, the PMR systems need to be connected to the NHS via the N3 service which ensures a secure connection. The

majority of pharmacy PMR suppliers are currently offering a package that also includes connection to N3 9. NHSmail; is a secure email service that allows the transfer of patient identifiable and clinical data by email. For community pharmacists this will facilitate greater and more secure communication with other healthcare professionals about patients.

The national applications include the following: Choose and Book. This is a national referral application which gives people choice about the location and time of their first outpatient appointment at a hospital or clinic. This service has not impacted on community pharmacy medication record systems at the present time. However it has potential future applications as the role of the pharmacist develops. For example patients could be referred to pharmacists with special interests or community pharmacists may in the future refer patients to GPs or other clinics. Electronic Prescription Service (EPS). This is a national application which will allow electronic prescriptions to be sent from the GP surgery to the pharmacy and once dispensed to the NHS Prescription Service for payment. EPS is discussed in more detail below. Secondary Uses Service (SUS). This application aims to provide a store for comprehensive health data and enable detailed report and analysis for performance monitoring and payment. Currently this application has had little impact on pharmacy but it has potential for reporting on future pharmacy related activities7. Summary Care Records (SCR). This application was discussed above as part of the NHS CRS. It holds limited information on patients and includes current medication, allergies and adverse drug reactions. GP2GP. This is an application that allows the secure transfer of Electronic Health Records between GP practices when for example patients change GP surgeries. This application has had little impact on pharmacy. QMAS. This application is the Quality Management Analysis System which provides GPs and PCTs evidence and feedback based on the Quality of Outcome Framework which is used to pay for GP services. Currently this has had little impact on pharmacy, but as an application it could potentially be used for administering the quality elements of a future pharmacy contracts.

Electronic Prescription Service (EPS) EPS allows electronic prescriptions to be sent from the GP surgery to the pharmacy and once dispensed and collected to the NHS Prescription Service for payment. The application is intended to provide accessibility, convenience, and choice for patients in obtaining their prescribed medication. The service also aims to provide efficiencies for submission of prescriptions for pricing and

reimbursement. The application could also reduce dispensing errors associated with the traditional transcription of information from a paper prescription to a medicine label 10. The national model is made up of a series of stations holding prescription details 11. This series is linked to the NHS Care Record Service. Pharmacies are then able to pull down prescription message tokens on receipt of a bar-coded prescription. Eventually it is envisaged that patients will be able to nominate pharmacies that can receive their electronic prescription in advance of the patient coming in to the pharmacy. The implementation of EPS is very challenging and is organised in terms of Phases of implementation and Release of software, see Table 2 and figure 1 in the Appendix. In terms of software both GP and Pharmacy PMR systems need to be upgraded and connected to the service 12. In terms of phases of implementation, pharmacists and GPs need to be registered and issued with smart cards (Phase 1), the new service has to run along the old service (Phase 2), the old service has to be phased out (Phase 3) and then the new service has to be the sole provider (Phase 4). In addition patients need to be made aware of the service. The implementation of EPS, particularly nomination with Release 2, on pharmacy businesses is immense 13 14. As mentioned above the vast majority of dispensing workload is for repeat prescriptions. Over the past 10 20 years pharmacy companies have tried very hard to capture repeat prescription businesses. They have offered free delivery of dispensed medicines as well as services that makes it convenient for the patient to re-order their prescriptions. These companies see the implementation of the Electronic Prescription Service as an opportunity to capture more repeat prescription business as well as an improvement in their business efficiency 15. The implementation of EPS in pharmacy medication record systems was further boosted by the provision of payments to pharmacists to purchase EPS compliant systems and an ongoing allowance to maintain N3 connection 16. In addition the NHS contract for community pharmacies was amended to specifically include participation in EPS as part of the Essential services offered by community pharmacies 5. Dictionary of Medicines and Devices (dm+d) An essential feature of EPS is the use of a standard database of medicines and devices. As explained in the sections above PMR systems did not have a standard database of medicines. Instead these databases were either supplier catalogues or a database of medicines developed in house. Given that there are many medicines databases used by GP and Pharmacy systems then EPS would be dangerous without a standardised database of medicines 10. For this reason a requirement of EPS is the use of a standard database of medicines called the Dictionary of Medicines and Devices (dm+d). The adoption of dm+d with its unique code for each medicine and device, by both GP and Pharmacy systems has enabled interoperability between the two clinical systems 17 . The dm+d has gone a long way to improve interoperability however there are some issues to be pointed out: 1. Coverage of drugs prescribed in primary care is over 99% but there are drugs that are used in secondary care which may not be contained within the dm+d. Medicines not in the dm+d can not be prescribed electronically.

2. Data is provided by the NHSPrx service and relates mainly to reimbursement as opposed to clinical data such as drug interactions 3. GP and Pharmacy System suppliers need to map their own medicines databases to the dm+d. If items are not mapped to the dm+d then they can not be prescribed electronically and can not be clinically checked automatically. 4. There is currently no standardised coding for directions of how to take the prescribed medicines. The directions are therefore communicated as text which does not remove the possibility of misinterpretation. Work is currently being undertaken by the NHS information authority and HL7 to develop standardised dosage syntax. Smart Cards All details contained on a prescription have to be treated as confidential and security of this information is paramount 4 . For EPS this is a sensitive aspect 18 especially in Release 2 where pharmacists will be accessing the Personal Demographic Service of the NHS CRSs. EPS requires pharmacists to be registered and issued with Smart cards. With Release 1 pharmacists are issued with an EPS01 card. They are required to be registered to government standard e-GIF Level 3 with the PCT as the registration authority. In Release 2 of EPS pharmacy personnel are required to register for an NHS CRS smartcard. This is a process where staff has to sign to say that they are bound by the NHS Confidentiality code of practice 19 and the Care Record Guarantee 20. The smartcard is issued based on the role of the staff and the site of where they work. The registration of pharmacy staff, the issuing of smartcards and the role based control further ensures security and confidentiality of patient information.

Discussion In 2008 it was reported that 80% of pharmacies had compliant Release 1 pharmacy PMR systems 21 . This Phase of EPS did have some problems but the problems were not attributed to the national structure but rather the local systems in place 22. July 2009 saw the first patients to benefit from Release 2 of EPS 23. By February 2011 there will be 24 PCTs who will be able to authorise their prescribers to operate Release 2 of EPS 24. By the first quarter in 2011 it is also expected that 7 pharmacy systems will be compliant for Release 2 25. The vast majority of pharmacist will have already registered and have smart cards for Release 1. Registration and issue of smart cards for Release 2 started in December 2010 in 17 PCT areas 26 . Access to Summary Care Records by pharmacists is currently being piloted in one PCT. It is notable that in this pilot, access is not via the pharmacy PMR system but separate and it is read only access to the record 27 which does not allow pharmacy data to be added . NHSmail via pharmacy PMRs is currently being piloted in a handful of PCTs 28 29. The current developments brought about by EPS are in line with the commercial and business aspects of community pharmacy and its relationship with the NHS rather than the potential clinical benefits to patients. For example the logistics of the electronic transfer of prescriptions

and submission of claims for re-imbursement has been largely worked out. This presents great commercial opportunities for pharmacy companies, whilst it is said to save the Prescription Pricing Authority in the region of 20 million pounds a year 30. Whereas the arrangements for ensuring that there is an allergy status for every patient, data contained which is within the Summary Care Record and clinical interventions regarding patients to be communicated via the NHSmail is still in the pilot stage. The next step in the development of pharmacy PMR is in the direction of clinical functionality which enables medicines management 8, 31 . To maximise the contribution of medicines management to patient care, the totality of patients medication needs to be known as well as the clinical indication for which the medicines have been prescribed. This means that access to the Summary Care Record is essential 32 as well as the ability of PMR systems to receive and interpret clinical codes such as SNOMED CT 33. Clinical functionality will also be greatly enhanced by the availability of clinical information regarding medicines as part of the dm+d. Finally pharmacists interventions and medication reviews for patients need to be documented using Clinical Document Architecture and communicated using NHSmail. Conclusion The NHS National Programme for IT in England, in particular the Electronic Prescription Service has had a huge impact on the development of pharmacy PMRs. The systems have been transformed from very diverse, unsecure, outdated, stand alone computer records which were used mainly for labelling and ordering to modern interoperable systems capable of fast, secure and reliable exchange of data which are integrated in to the NHS structure and allow pharmacists to deliver patient benefits in terms of easy access to prescriptions and with further developments clinical benefits.

Appendix 1. Tables used in the Document

Table 1. Search Sources, Keywords and Articles found

Search Source Medline CINAHL Biomedical Reference Index International Pharmaceutical Abstracts Pharmaceutical Journal Google Keywords used electronic prescription service, NHS national program for IT electronic prescription service, NHS national program for IT electronic prescription service, NHS national program for IT electronic prescription service, NHS national program for IT electronic prescription service Evaluation of Electronic Prescription Service Useful references collected 7 6 4 4 Over 300 references over the past 2 years Discovery of academic groups who are funded to carry out an evaluation of EPS

Table 2. Releases of Software and Phases of Implementation

Release of Software Release 1: Prescribing and dispensing system suppliers to upgrade their systems to meet the requirements of the service. After testing and safety review to undertake one initial live implementation of the system with a paired GP and Pharmacy. Systems termed as compliant and can be deployed to users. The software has essential functionality but there is no digital signing of prescriptions messages, nomination of pharmacies or electronic reimbursement. Phases of Implementation 1. Initial implementers. Initial sites were selected based on systems in use and PCTs and Strategic Health Authorities. 2. National deployment. 90% of GP and Pharmacy systems compliant. N3 Connectivity and registered with Smart Cards. Electronic messages represented by barcodes printed on paper prescriptions, thus allowing either paper systems or electronic systems to be used. For patients there is no difference in taking their prescriptions to a pharmacy with or without a compliant system. 3. Transition To move away from a parallel paper and electronic service towards a predominantly electronic service Suppliers of Release 2 systems to deploy latest software Prescription Pricing Authority to reimburse against electronic claims in addition to paper claims. Secretary of State for Health to make electronic prescriptions legal, area by area. 4. Full ETP Default position is the use of electronic prescriptions digitally signed.

Release 2 Development of additional functionality eg digital signing of electronic prescription messages, patient nomination of preferred pharmacy, electronic reimbursement claims.

Figure 1 Diagrammatical Representation of EPS with Release 1 Software Release 1 Release 2

References
1

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2 3

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6

NHS Prescription Pricing Authority. Drug Tarriff. http://www.ppa.org.uk/edt/November_2010/mindex.htm .

7

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9

PSNC . N3. http://www.psnc.org.uk/pages/n3.html .

10

Paul Frosdick, Christine Dalton. "What is the dm+d and what will it mean for you and pharmacy practice." The Pharmaceutical Journal, 2004: 199-200. 11 PSNC. EPS. http://www.psnc.org.uk/pages/eps.html . 12 Connectinf for Health. "EPS Implementation Plan." Connecting for Health. http://www.connectingforhealth.nhs.uk/systemsandservices/eps/publications/impstrat.pdf . 13 Reported. "Independents must prepare for EPS to avoid disadvantage." The Pharmaceutical Journal, 2007: 598. 14 Reported. "NPA issues EPS warning Pharmacists who are not prepared for the EPS are running a significant business risk." The Pharmaceutical Journal, 2007: 279. 15 Reported. ""Repeat my medicines" a service Launched by Numark." The Pharmaceutical Journal, 2010: 284. 16 Reported. "Allowances for EPS agreed by the DoH and PSNC." The Pharmaceutical Journal, 2005: 471.
17

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18

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19

Department of Health . Patient Confidentiality and Access to Health Records. http://www.dh.gov.uk/en/Managingyourorganisation/Informationpolicy/Patientconfidentia lityandcaldicottguardians/DH_4100550 . 20 Connecting for Health. Care Record Gurantee. http://www.connectingforhealth.nhs.uk/crs_guarantee.pd .
21

Reported. "Use of EPS by community pharmacies is consistent and growing." The Pharmaceutical Journal, 2008: 326.
22 23

Reported. "EPS problems due to local systems." The Pharmaceutical journal, 2008: 411.

Reported. "Completing the prescription process in a virtual world- EPS Release 2." The Pharmaceutical Journal, 2009: 175.
24

Department of Health. Electronic Prescription Service. http://www.dh.gov.uk/en/Healthcare/Medicinespharmacyandindustry/Prescriptions/Electr onicPrescriptionService/index.htm . 25 Connecting for Health . Systems and Services. http://www.connectingforhealth.nhs.uk/systemsandservices/eps/staff/roadmap/dispstatus /oct.pdf 26 Primary Care Commissioning. PCC Pharmacy News. http://www.pcc.nhs.uk/pharmacynews/538.
27 28 29

PSNC . Summary Care Record. http://www.psnc.org.uk/pages/nhscrs.html . PSNC . NHSmail. http://www.psnc.org.uk/pages/nhsmail.html .

Reported. "Community Pharmacists could be given access to NHSmail." The Pharmaceutical Journal, 2006: 595.
30 31

Reported. "PPA aims to save 20 million a year." The Pharmaceutical Journal, 2005: 595.

Reported. "Lack of Access to patient records will threaten modernisation agenda." The Pharmaceutical Journal, 2007: 333.
32

Reported. "Lack of Access to patient records will threaten modernisation agenda." The Pharmaceutical Journal, 2007: 333.
33

Kapoor, Monica. "For NHS Care Record the Future's Bright Its SNOMED CT." The Pharmaceutical Journal, 2008: 534.