With improved access to IT and a clear professional strategy, the future is ours
In this third article in a series leading to a consultation among members about the Royal Pharmaceutical Society's Pharmacy 2020 project, Lindsay
McClure, head of information services at the Pharmaceutical Service Negotiating Committee, asks “are we ready for IT?”
With a budget of over £20 billion, the English National Programme
for IT in the NHS (NPfIT) is one of the most ambitious projects of its
kind in the world. Designed to connect the capabilities of modern IT
to the delivery of the NHS plan, the programme will, in the future, impact
on every sector of the profession including how pharmacy is practised
in the community and in hospitals, how the safety of new medicines is
monitored and how tomorrow’s health care managers will plan services
using the wealth of information that will be available to them. Similar
initiatives are under way in each of the other home countries.
Dispensing in the community
The first national NHS IT project to impact on community pharmacies
in England has been the electronic prescription service (EPS), which
enables
the electronic transmission of prescriptions between the prescriber,
pharmacy and reimbursement agency. The service is being rolled out
in phases with release 1 of the software already in use at over 50
per cent of pharmacies.
Functionality that will be rolled out in coming
years includes electronic repeat dispensing, electronic reimbursement
claims, the cancellation of e-prescriptions by prescribers and the
ability for patients to nominate their preferred pharmacy to receive
e-prescriptions direct. The system may one day also support reimbursement
claims for other pharmacy services, such as minor ailment schemes.
In Scotland, the electronic acute medication service (eAMS) and the
electronic chronic medication service (eCMS) will provide similar functionality
to the English EPS but there are currently no plans to allow patients
in Scotland to nominate a pharmacy to receive prescriptions in advance.
In
Wales, the Welsh Assembly Government has opted for “intelligent
paper” as an alternative interim solution: rather than sending
a prescription message electronically, a 2D barcode printed on the prescription
will hold information such as the patient’s name and address and
the prescribed medication. A timetable for deployment of the Welsh solution
will be agreed later this year with additional functionality, such as
the e-transfer of reimbursement claims added over time.
In the long term, the implementation of ETP may encourage the uptake
of complementary technology such as robotics. Although dispensing robots
have been shown to reduce dispensing errors, save storage space and increase
the efficiency of dispensing in hospitals, their use in community pharmacies
is still limited.
Robots are becoming more sophisticated all the time, with the latest
models offering features such as automatic loading, automatic labelling
and part-pack dispensing. Linked to a pharmacy system which is pre-populated
with an e-prescription there may, in future, be little human involvement
in the mechanical aspects of dispensing.
There is much that can be done now to maximise the potential benefits
of integrated robotic systems, for example, agreeing changes to policy
to enable full patient pack dispensing. Work is also in progress to standardise
the future tagging technology that may be used by manufacturers, including
2D barcodes and RFID (radiofrequency identification) tags; these technologies
may allow further safety checks to be carried out by robots and could
support the tracking and tracing of individual packs as they pass through
the supply chain.
ETP technology may also impact on the organisation of the pharmacy market
and drive the development of emerging dispensing models. Once NHS prescriptions
can legally be sent electronically, we may see pharmacies with an internet
or mail order business model increasing their market share. We may also
see an increase in hub-and-spoke dispensing, with repeat prescriptions
being sent to an automated central “hub” pharmacy to be prepared
and then sent to the “spoke” pharmacies to be collected by
the patient.
If regulatory barriers can be overcome, wholesalers equipped with sophisticated
automation at wholesaling depots are ideally placed to act as the hub
for independent pharmacies, delivering medicines that are already labelled
and packaged, ready to hand to patients. These developments would free
pharmacy staff time to provide additional professional services and would
allow pharmacies to reduce their stock holdings. Future regulatory change
to enable remote supervision could also potentially lead to the development
of controversial new uses for automation, such as unmanned dispensing
kiosks to support patient access to medicines out of hours. Supporting efficient hospital pharmacy
Although most GPs use their IT systems to support prescribing, few
hospitals support
e-prescribing, with prescriptions still being written by hand. In England,
the NHS Connecting for Health (CfH) e-prescribing programme aims to
enable medicines to be managed electronically from prescribing through
to administration,
realising benefits such as improved patient safety and improved efficiency.
Earlier
this year, CfH published a functional specification for e-prescribing
systems which will guide system suppliers in their development of
systems for the NHS. In Scotland and Wales, similar initiatives are being
scoped
and developed.
There is potential for e-prescribing systems to be linked to electronic
messaging functionality to send prescriptions and discharge medication
information electronically from secondary to primary care and, as
in community pharmacy, systems could be integrated with dispensing
robots.
Estimates suggest that approximately 10 per cent of hospitals in
the UK have already installed dispensing robots, with this number
steadily
increasing by the day. Supporting service delivery
Ruslan Gilmashin/Dreamstime.com
|
While ETP and robotics will support the existing pharmacy role of dispensing,
access to electronic patient records is likely to support the evolving
clinical role of pharmacists and enable the delivery of new services
in the primary care setting.
In England, the NHS care records service is an electronic record management
service that will allow authorised care professionals access to an individual’s
medical record 24 hours a day, seven days a week. It is a nation-wide
system that will help join up care across the NHS, including primary
and secondary care and social services. Protected by a range of access
controls, the system comprises both detailed records, which will be made
available to be shared within a locality, and a summary record, held
nationally on the system’s central “spine”. The summary
care record is currently being piloted but no deadlines have been set
yet for full implementation of the service.
Similar initiatives are being developed in the other home countries. The
individual health records service (IHR) forms the heart of Informing
Healthcare (IfH), the Welsh national IT programme. Following a recent
pilot, work is ongoing to support information sharing between GP practices
and out-of-hours services across Wales.
In Scotland, an emergency care
summary (ECS) record was set up in 2003 using extracts from GP records.
With explicit patient consent, out-of-hours medical centres and certain
NHS24 staff can use the service to access data on patients’ current
and repeat medication, allergies and basic demographic information.
Providing community pharmacists with appropriate role-based, read-and-write
access to patient records has the potential to improve patient safety,
improve interdisciplinary working and increase the quality and continuity
of care provided to patients by pharmacies. It will allow roles such
as independent and supplementary prescribing to be carried out more effectively
in primary care and will enable the efficient delivery of new services,
for example, by allowing pharmacists to share information such as diagnostic
tests results with other health professionals.
No decision has yet been made in any of the home countries on what information
community pharmacists will be granted access to in the future and this
is likely to be a key topic for debate in the coming years. How much
access do pharmacists need to undertake future roles? Do other members
of the pharmacy team also need access? Are pharmacists sufficiently skilled
in maintaining and interpreting medical records to meet the challenges
ahead? Potentially, different health professionals with different levels
of training and experience in medical record keeping will be sharing
the same information. Should consideration be given now to extending
undergraduate and postgraduate training in these areas?
It is likely that the future will also bring widespread patient access
to medical records. In England, this will be provided through the NHS “healthspace” website
and has raised a number of difficult ethical issues, for example the
use of clinician “sealed envelopes” to limit patient access
in certain scenarios. This, together with the growing use of the internet
as a patient information resource may see tomorrow’s pharmacists
increasingly acting as interpreters of information that patients have
found from other sources. Supporting efficient communication
Although the sharing of electronic records should, in time, greatly
improve interdisciplinary working there is also other functionality which
could
be developed to improve the efficiency of current NHS pharmacy services.
For example, secure coded messaging, integrated into pharmacy and GP
systems could support the transmission of medicines use review forms
electronically from community pharmacies to prescribers, improving
communication, decreasing workload and ensuring that the results of
the review become part of the patient’s medical record.
In advance
of a more sophisticated solution being available, a quick win would
be to provide community pharmacies and pharmacists with access to
an e-mail service, such as NHSmail, approved for secure clinical communications.
Messaging could also be used to support the timely transmission of
information to pharmacies about drug recalls. One system supplier
has already developed
an innovative solution that allows messages to be sent to its entire
customer base at the touch of a button, with a pop-up message appearing
on computer screens to alert pharmacy staff to an urgent issue. The challenge ahead
All of these developments are clearly on the horizon and most are expected
to be implemented within the next five years. But what will happen
beyond that time? And are all the existing pharmacy system suppliers
capable of delivering the future? The next raft of changes could be
enormous.
Will there be a need for the pharmacy service as it is provided today,
or could technology and advanced communications support different models
of pharmaceutical care? IT systems prompting pharmacists to check up
on their patients are already in use. Medicines packs that record the
time and date each medicine is removed from the pack are in existence.
These could be used to monitor and promote adherence to medication regimens.
One emerging area is tele-health and the use of assistive technologies
to support the monitoring of patients in their homes. During the past
year, there have been over 100 government- or EU-funded research projects
in this area testing diverse technology such as movement detectors, on-body
sensors and “smart clothes”.
One notable study has been looking
at the use of intelligent miniaturised biosensors that allow patients
to be monitored as they go about their daily lives; the sensors can warn
health professionals of potential critical events such as heart attacks.
This “big brother” technology could allow continuous monitoring
of patients and improve our knowledge of the effects of
medication.
This level of monitoring will only be used for a small minority of patients
with specific needs. For the rest, future IT developments will aid convenience
for patients, accuracy of information and dispensing, transfer of information
between health care professionals, and administration for the NHS. There
are clear risks and challenges ahead but also many opportunities. With
a clear strategy for the development of the profession’s roles
and responsibilities, the future is ours for the
taking. |
The
Pharmaceutical Journal