ePrescribing: learning from the Swedish experience

Bengt Åstrand
Senior Director Licensed Pharmacist
Apoteket AB
e-Health Services and University of Kalmar
e-Health Institute
Kalmar
Sweden

The use of electronic prescriptions – ePrescriptions – has been shown to have a positive impact on the prescribing and dispensing process, suggesting that ePrescribing can improve safety, quality, efficiency and cost-effectiveness.(1-4)

For hundreds of years, doctors have used handwritten prescriptions to communicate decisions on drug therapy and to impart instructions to pharmacists on the dispensing of medication. The dosing information contained in prescriptions has also informed patients on how to use the medication to maximise its benefits.

One of the earliest-known statutes on the control of drugs regulated dispensing prescriptions written by apothecaries (see Box 1).(5) Both the “recipe” for drug composition and the dispensing process at pharmacies have become increasingly regulated and subject to inspection to ensure quality of service. Pharmacists are now obliged to check that prescriptions are accurate, complete and correct at the time of dispensing. However, handwritten prescriptions hold well-recognised risks such as varying standards of legibility, which can lead to problems with interpretation and risk of falsification. One-way communication also suffers from lack of feedback, and patients may find the information supplied with the drugs difficult to understand.(6)

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Drug prescribing is now at a transitional stage, and adapting a traditional process to the new electronic era presents a formidable challenge. Sweden, Denmark, the UK and the USA are among the countries that have made considerable efforts in recent years to implement ePrescribing more widely.(7–12)

Transforming the doctor’s surgery
The Swedish experience of ePrescribing goes back to the early 1980s when a group of doctors, pharmacists and computer experts developed and tested a multi-user touchscreen microcomputer at a doctor’s office with decision support for the prescription of drugs.(13–15)

ePrescribing was claimed to mark the start of a transformation of the doctor’s surgery, offering several interesting lines of eDevelopment. These included: appointment planning; healthcare records; drug prescribing; information retrieval; communication (laboratory, X-ray, pharmacy); diagnosis and drug statistics; and adverse drug events reporting. Regulations were changed to allow the introduction of electronic transfer of prescriptions (ETP). The first pilot was followed by many others at various healthcare organisations during the 1980s, with both handheld and stationary computers, stand-alone systems and integration with electronic medical/healthcare records (EMR/EHRs). Standardisation of the ePrescription format (both information content and communication protocols) was also subject to several years of intense work, gaining approval from stakeholders both nationally and internationally.

ePrescribing in Sweden has increased rapidly since a new strategy was developed in the late 1990s, producing an ETP penetration rate of 65% for all new prescriptions. By April 2007, there were 2.2 million ePrescriptions per month. A national mailbox for ePrescriptions allows the patient to access a valid prescription at any pharmacy simply by presenting identification. Patients can also store their prescriptions in a national online repository. New services, such as mail-order prescription drugs, are also available.

Some of the smallest Swedish counties have been the earliest adopters of the new technology, but the largest implementation project has been carried out in Stockholm. Since 2002, the number of prescriptions transferred in Stockholm has increased from a very small proportion to more than two-thirds.(16) Surveys have shown a very positive attitude towards ePrescriptions among patients, prescribers and pharmacists.

To achieve a high level of acceptance for implementation of a new healthcare technology, stakeholder engagement is vital both locally/regionally and nationally. All aspects of the interaction between man, machine and medicines have to be addressed. Questions of technical communication, standardisation, IT availability and functionality as well as attitudes and acceptance among prescribers, patients and dispensing pharmacists must be addressed. Legislation, security and personal integrity are also key issues. Resistance among users to the new technology may be due to their experience of using less appropriate solutions, but may also simply be a reaction towards change and reflect feelings of exclusion.(17,18)

Unfortunately, many IT systems currently in use cannot exchange information. There may also be legal restrictions to their use. In many countries, the issue of interoperability is high on the agenda, but the majority of nations choose to develop their own regulatory standards. An initiative to achieve European standardisation would be welcome, as would the capacity to send prescriptions between healthcare organisations in different EU nations.

Improved safety and other potential benefits
Medical errors, which result in a large number of inpatient admissions, are one of the most important problems in healthcare, and mistakes made in prescribing are among the most common. ePrescribing holds clear potential for improving safety, quality, efficiency and cost-effectiveness. However, the new technologies could lead to new errors in the prescribing and dispensing process.(19,20) Because stored ePrescription information may be used not only for writing the actual prescription but also for future clinical decision-making and epidemiological research, it is vital to carry out systematic monitoring of the quality of the electronic prescribing process. But EHR software is not generally subject to the same level of inspection as other medical technologies. This applies, in particular, to certification and inspection.

Why evaluation is essential
There will always be a need for evaluation of the chain of events which begins when a doctor uses a decision-support system and ends with ePrescriptions being issued at a pharmacy and potent pharmaceuticals being consumed by patients. Is the prescribing sound and safe and in line with evidence-based practice and recommendations? Is the patient receiving duplicate, or interacting, medications from other prescribers? Are there unknown adverse effects in the use of some drugs not recognised in clinical studies? Research questions such as these may be better answered in the future with the use of individual-based patient registers in clinical practice,(21) as well as epidemiological research, which may also be combined with other healthcare databases.(22)

New registers of dispensed medications have been introduced in Sweden. The National Prescribed Drug Register is intended for statistical, epidemiological and scientific research. They allow investigation of drug/disease associations and the risks, benefits, effectiveness and economic effects of drug use. For clinical purposes and in a bid to improve drug use, the same information is made available by the National Pharmacy Register, which holds prescription dispensing information on most of the population. The medication history of individuals may be accessed online by registered users, prescribers and dispensing pharmacists.

Better evaluation and certification of IT systems that produce drug prescriptions is required with the large-scale implementation of ePrescriptions. This is essential now that stored data can be not only used by someone writing a prescription but also accessed by other prescribers as a source of patient information. Patients can also use it as a record of past and current medications when they access new healthcare services, while for scientists it provides a source of epidemiological research.

Conclusion
ePrescribing has been introduced in many countries, and paper prescriptions are now becoming the exception rather than the rule. Where there has been early implementation, the attitude to regulation has been pragmatic. Where ePrescribing has seen later implementation, there has been greater emphasis on legislation and safety issues before introduction. In both cases, ePrescribing provides an opportunity for achieving systematic improvements in healthcare safety. But because new technology could also introduce new errors, systematic evaluation of the prescribing and dispensing process is vital. In order to increase safety and quality, as well as developing efficiency and cost-effectiveness, ETP technology should become a two-way communication process between the prescriber and the pharmacist, with automated checks on missing, inaccurate or ambiguous information.

Bengt Åstrand’s thesis – ePrescribing – studies in pharmacoinformatics – is available to download for free at http://urn.kb.se/resolve?urn=urn:nbn:se:hik:diva-32

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