Ch 8f eps

Chapter 8f - High Quality Medication Records & The Electronic Prescription Service

8f.1 Introduction

NHS Connecting for Health has developed the Electronic Prescription Service (EPS). This new service enables GP practices to send an electronic prescription message to a central store -- the 'Spine' from where it can be downloaded for dispensing at the patient's chosen pharmacy or appliance contractor. In the majority of cases this can happen without the need for a paper prescription. Walk-in centres and other NHS settings where dispensing takes place can also use EPS. There is less need for patients with repeat prescriptions to go to their GP practice just to collect their paper prescription.

Community pharmacies and dispensing appliance contractors will also be heavily involved in using EPS.

8f.2 High quality medication records

High quality medication information is important for a number of reasons:

  • It is clearly clinically import to be able to view a high quality prescribing record

  • Most systems have automated decision support which check such things as interactions, allergies, sensitivities and contraindication and can only do this insofar as they have a high quality computable medication record.

  • Systems also provide a range of medicines management facilities and these too require a high quality computable medication record.

The quality of the medication record will depend on two things;

  • How effectively the prescribing facilities in your system are used.

  • How effectively the recording of medicines not prescribed by the practice is handled

Users will automatically generate most of a typical GP medication record as they use the system to produce prescriptions and these records should accurately reflect prescriptions produced by the system and subsequent actions in relation to prescriptions issues. However to ensure that this is case users of systems should ensure that;

  • No handwritten changes are made to computer-generated prescription including the manual addition or deletion of items. Always cancel the prescription and issue a new corrected prescription.

  • Where a script is not subsequently issued to the patient or returned unused it should be destroyed and recorded as cancelled on the system.

  • Where a pharmacy queries a prescription and changes are agreed a new prescription should be issued to the pharmacy who should be asked to return the old prescription for cancellation as above. In the case of a script sent by ETP the script should be cancelled and a new script issued electronically.

  • Handwritten prescription issued by the practice should be recorded on the system. All systems provide facilities to record a prescription without generating a new paper or electronic prescription.

  • *Where an item is discontinued for a reason which mean you would not wish to use that medicine with the patient in future (e.g. Intolerance or ineffective) the fact and reason of discontinuation should be record as some system will warn the prescriber if they attempt to prescribe a medication previously discontinued in such circumstances *

It is also important that medicines not prescribed by the practice but which are of future clinical significance are recorded on the practice system. Discovering and recording all medication taken by the patient can be onerous and practices need to establish a policy, which defines the circumstances in which they consider it useful and practical to record such information, which might include;

  • Medicines prescribed by other healthcare professionals.

  • Over the counter and general sale (including those purchased online) medicines bought and taken by the patient.

  • Herbal preparations bought and taken by the patient

In general practices should seek to discover and record any medicines that patients are taking on a continuing basis. Some examples of situations where patients might be taking medicines not prescribed by the practice of particular clinical significance include;

  • Psychiatric drugs being managed by mental health and home treatment teams including depot injections.

  • Chemotherapy being managed by cancer treatment services

  • Immunosuppressant drugs being managed by in secondary care following transplant surgery or for the treatment of autoimmune diseases

How information is recorded will depend on the purpose to which the information will be put which falls into two categories;

  • Medicines where the practice will be taking over ongoing prescribing (e.g. hospital outpatient of discharge medication where the GP has agreed to take over ongoing prescribing). In this a new prescription should be issued from the agreed date of transfer of care with details of any current prescription issued elsewhere record as such.

  • Medicines where the practice will not be taking over ongoing prescribing. In the case the medication should be record as being managed elsewhere such that prescriptions for the item cannot easily be accidentally produced by the practice system

Systems handle the recording of prescription issued elsewhere in different ways and few systems fully support the recording of the partial data that might be all that is necessary or available when medicines are managed elsewhere. Ideally information should be recorded so that it appears on medication lists and is available in a computable form to prescribing decision support tools. Users should seek system specific advice from their supplier.

Where is not possible to record medicines managed elsewhere in the medication record a note or alert should be placed elsewhere in the record such that prescribers will be warn of the existence of such prescribing. Again the best way to do this will depend on the system in use and Users should seek system specific advice from their supplier.

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8f.3 Why is the EPS service being introduced?

Around 1.5 million prescriptions are now being issued every working day in England, and this figure is expected to continue rising by 5% each year. The move from the current paper-based system to an electronic one should be:

  • More efficient

  • Consistently accurate

  • Better able to cope with expected further increases in prescription volumes.

8f.4 Different Releases in EPS

Release 1 of EPS introduced the technical infrastructure to enable prescribers and dispensers to operate EPS. Release 1 will still print the prescription (which in itself is the legal entity) and it will have a barcode at the side. Release 1 has also allowed robust testing of the infrastructure of EPS and Release 2 will help practices to reduce the administrative burden associated with generating large volumes of repeat prescriptions.

Release 2 allows both the prescribing information and the advanced electronic signature to be sent from the prescriber's computer to the patient's nominated pharmacy (explained below). It also allows electronic cancellation of prescriptions, which increases safety and the whole process is smoother if electronic repeat dispensing is used by the practice. Release 2 also allows electronic submission requests for reimbursement endorsements.

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Figure 8f.4 -- EPS Release 2 token with barcode

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Figure 8f.5 EPS Release 2 Functionality

8f.5 EPS Release 2

8f.5.1. If a patient chooses to nominate a pharmacy, prescribers will no longer need to generate a paper token (unless they want to or are asked to do so by the patient). This will not only reduce the prescriber's workload, but also the workload of administrative staff who usually issue and sort repeat prescriptions to patients (and pharmacy collection services).

8f.5.2. Release 2 will make it easier to administer repeat dispensing regimes. This will reduce the administrative burden associated with patients requesting regular repeat prescriptions. Where a repeat dispensing regime is administered, the prescriber will only need to print a single prescription token as opposed to a number of paper batch issues as at present. Prescribers will also be able to cancel electronic prescriptions making it possible for them to maintain an element of control over the repeat dispensing regime.

EPS will not limit patient access to their medications. If a patient wishes they can choose not to send a prescription electronically. They can request for a paper prescription to be printed and they can take that away with them to a pharmacy of their choice for dispensing.

8f.5.3 Prescribing Tokens

A practice can issue paper tokens at any time. They must also be issued in the following situations;

  • At the start of a repeat dispensing regime

  • Where clinical information needs to be communicated to the patient (i.e. on the 'right hand side' of the prescription)

  • At a patients request

  • If the prescriber deems it necessary to do so

8f.5.3 Nomination

A patient can nominate three different types of dispensers -- one in each field;

  • Community pharmacy of their choice

  • Dispensing GP practice -- if they are classed as a dispensing patient

  • Dispensing Appliance Contractor if they receive such items

Patients can change their nomination by asking their pharmacist to do this for them or patients can ask their GP practice to do this.

8f.5.3 Acute and Repeat Medication

Messages will be transmitted from the prescriber's computer at different times depending on the type of message. An acute authorisation of medication will be sent immediately via the Spine to the nominated pharmacy in readiness for dispensing. If a prescriber renews and issues repeat medication on their terminal then the message will also be sent immediately to the nominated pharmacy. If however repeat medication is 'bulk signed' then that message will be sent overnight to the nominated pharmacy.

8f.5.3 Advance Electronic Signatures

These are unique to an individual user and applied by using their Smartcard and pass-code. The Smartcard allows different users to have different levels of access depending on their role within their organisation. It is the application of the advance electronic signature to the electronic message that turns it into a legal prescription.

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8f.5.4 Electronic Repeat Dispensing

Patients do not have to go to the same dispenser every time to get their repeatable prescription fulfilled. If a patient wishes to have more than one issue dispensed at the same time (e.g. if they are going on holiday etc.) then they can request this.

Existing agreements in place for paper based repeat dispensing can be used for electronic repeat dispensing. If a patient can be transferred manually from paper based repeat dispensing to electronic repeat dispensing the prescribing system will notify the prescriber. A patient will always receive a prescription token when they receive a repeatable prescription and the patient can use this token to get medication dispensed from any EPS Release 2 dispenser.

When a patient changes their nominated dispenser, all repeatable prescription issues not downloaded will transfer to the new nominated dispenser however all items on a repeatable prescription issue must be processed (dispensed or not dispensed) before the next issue can be released

8f.5.5 Electronic Cancellation

A prescriber (or an authorised member of staff) can cancel an electronic prescription at any point prior to it being downloaded from the 'spine' by a pharmacist for dispensing. GP clinical systems will allow cancellation of either the whole prescriptions or individual items on that prescription. The reason for cancellation can also be added to the record.

Prescriptions cannot be amended once sent -- they must be cancelled and regenerated.

8f.5.6 Controlled Drugs

Initially, arrangements for dispensing controlled drugs will remain the same, with all controlled drugs to be prescribed using paper prescriptions. They will not be transferred electronically. Work is being undertaken to ensure that controlled drugs will be part of the electronic message as soon as possible.

8f.5.7 Mapping of Drugs

Every drug has an electronic code, which is sent to the Spine. There are a small percentage of common drugs that have not got the necessary coding structure to allow the message to be sent. If this is the case then that drug will be printed out on a prescription to be handed to the patient. If there are other items on the prescription that can be sent to the Spine because they have the correct coding then they will be processed without being printed out. (This is system dependant).

Further work is being undertaken to ensure that most of the remaining unmapped drugs will have the correct coding structure.

8f.6 Getting Ready for EPS

In order for a practice to be ready for when EPS release 2 is switched on then they should ensure they work closely with their PCT (or successor organisation) during the transition to EPS R2;

  • Prescribing and dispensing processes are centred around the patient

  • Practices and dispensers work in partnership

  • PCTs must broaden and deepen their approach to support IT enabled change

GP practices can change their clinical processes by reviewing how;

  • Prescribers can take advantage of enabling repeat dispensing

  • Practice staff can manage the repeat dispensing process along with medication review and reauthorisation processes using protocols designed by the clinical staff

All of the GP software system suppliers are working with CfH to enable Release 2. Some are at different stages of preparation and up to date information is published on the NHS CfH website^1

8f.7 EPS consultation process

In order to deliver a robust and fit for purpose system, NHS CfH has actively sought input from key stakeholders throughout the design and development of the Electronic Prescription Service.

Purpose-formed user groups, meeting on a regular basis, have provided different perspectives on key design issues. This work has included looking at the live operation of the service in the initial implementer sites.

Reviewing the early operational experiences at these sites has helped to ensure that the potential benefits of the new service can be maximised. The output from these groups has been and will continue to be used to inform communication and guidance material.

The user groups include the;

  • the general practitioner and community pharmacy user group

  • the patient and public user group

  • the dispensing appliance contractor user group

The user groups will continue to operate during the implementation of EPS Release 2.

8f.8 Benefits for patients and carers

Some of the major benefits will be to patients who will find it much easier to order and collect their prescriptions. They should also find;

  • Reduction in the need to contact the GP practice to reorder and collect prescriptions, particularly once they are on an electronic repeat dispensing regime.

  • Greater freedom of choice, making it simpler to use a pharmacist convenient to them.

  • Potential to reduce waiting times as the pharmacist can prepare medication items in advance of patient arriving.

  • Improved patient safety with electronic cancellation increasing the ability to ensure patients do not receive medication they should not be taking and it also allows prescribers to make any immediate changes in medication that are necessary after prescribing.

8f.9 Benefits for Prescribers

Prescribers in the NHS should have a streamlined service along with;

  • Reduction in workload for staff at GP practices generated by patients collecting individual prescriptions from the GP surgery.

  • The ability to sign prescriptions electronically will be more efficient for GPs.

  • The ability for GPs to electronically cancel prescriptions at any point until they are downloaded prior to being dispensed.

  • With repeat dispensing regimes in place in a practice the prescriber has more control over drugs prescribed for a patient.

  • In time, will remove the need for pharmacy staff to collect prescriptions where they offer a prescription collection service.

EPS will allow new ways of working. It could allow further enhancement of the telephone consultation and allow prescribers to send an electronic message to the patients nominated pharmacy for medicines that the prescriber deems necessary.

8f.10 Smartcards

In order to ensure that only authorised personnel are able to access the Electronic Prescription Service, access will be via the NHS Smartcard.

The Smartcard will grant users with different levels of access depending on their function within the prescribing/dispensing process. Essentially, people with the appropriate level of access to the system will only see details of the prescription. This makes EPS safer both for patients and clinicians.

8f.11 Release 2 readiness (& figure)

PCTs must be ready to implement Release 2 in their area before they can move forward. A PCT must be included in the EPS Authorisation Directions before prescribers in that PCT can apply an electronic signature to prescriptions. This requires approval by the Dept of Health and a notice period of 3 months. There is no restriction on any dispensing contractor wishing to implement an accredited EPS Release 2 dispensing system.

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8f.12 Security & confidentiality

The strongest security measures are in place and patients can choose whether to have their health information shared^2.

Although the new systems and services are changing the way in which patients\' health information is stored and shared, they will not change the duty or commitment of the NHS to keep patients\' health information safe, secure and confidential[^3].

The NHS Care Record Guarantee^4 sets out the rules that govern information held in the NHS Care Records Service^5. It covers people\'s access to their own records, controls on others\' access, how access will be monitored and policed, options people have to further limit access, access in an emergency, and what happens when someone cannot make decisions for themselves.

8f.13 Access control

All NHS staff using the new systems and services must register to be an authorised user and be issued with an NHS Smartcard^6.

Even then, authorised staff can only see a patient\'s information if they have a \'legitimate relationship\' with them, which means they are involved in that patients' care^7. They only see the information they need to do their job.

Users should ensure that they take reasonable precautions to maintain patient privacy and confidentiality in the workplace (e.g. log-out when leaving a terminal and ensuring screens cannot be viewed by unauthorised individuals)

An audit trail noting when, where and by whom patient records are accessed, will help to assure confidentiality.

8f.14 EPS unsupported prescriptions

The following prescribing models are not supported at present and, therefore, still require a hand-signed FP10 paper prescription:

  • Scenarios where the prescriber does not have access to the EPS (for example home visits and out of hours)

  • *Personal administration of medication *

  • Private prescriptions

  • Bulk prescriptions (Drug Tariff Part VIII note 9) for a school or institution

  • *Controlled drugs - Schedule 1, 2 or 3 of the Misuse of Drugs Regulations *

  • When the patient chooses not have an electronic prescription

  • In the initial stages of the EPS where a patient has not nominated a dispensing contractor

  • Where the prescription contains one of the very limited number of items that are not directly expressible using the NHS Dictionary of Medicines and Devices (dm+d).

[^3]: GMC Confidentiality http://www.gmc-uk.org/guidance/ethical_guidance/confidentiality.asp

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