The Pharmaceutical Journal
Vol 269 No 7212 p242-244
24 August 2002

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Department of Health speeds up ETP assessments as pilots make slow start

The Department of Health is now committed to making a preliminary decision about how to proceed with electronic transmission of prescriptions in England by the end of the year, despite a slow start in two of the three pilot schemes. Jonathan Buisson and Zoë Gross (both on the staff of The Journal) have visited two of the pilots sites and report on the progress made to date

Related websites
Department of Health (ETP) (more)
Flexiscript (www.flexiscript.co.uk)
Pharmacy2U (ETP) (more)

The Department of Health says that it wants to see the three pilot schemes for electronic transmission of prescriptions (ETP) in England completed by the end of November. This will allow the independent assessors for each pilot to produce an initial report by the end of the year and a full report by the end of April 2003. The Department will produce a specification for how pharmacy and general practitioner computer systems can become ETP-enabled by April 2003.

With the ETP pilots having been under some strain to meet the June 2002 deadline for starting to send live electronic prescriptions, this seems to be a tight timetable, even if the three consortia running the pilots are publicly expressing belief that they will achieve any necessary targets.

Flexiscript in Peterborough

Flexiscript is currently running its ETP pilot in eight pharmacies and eight GP surgeries in the North and South Peterborough primary care trust areas. The consortium, which consists of Boots The Chemists, UniChem, National Co-operative Chemists, SchlumbergerSema, Microsoft and Cable & Wireless, aims to have its pilot scheme operating in 28 pharmacies and 22 GP surgeries by the end of the year. It was reported in June that over 2,500 patients had enrolled in the pilot. To date, around 3,000 patients have signed up. The pilot involves the electronic transfer of prescriptions at the request of the patient and is planned to involve the electronic transfer of repeat prescriptions.

A spokesperson for Flexiscript says that the number of prescriptions transferred electronically since the start of the pilot could not be revealed but that the pilot is on target for completion by the end of the year. Mike Dent, project manager, Flexiscript consortium, comments: "We are happy with our progress."

Shabbir Hassanali Damani, pharmacist at Thomas Walker Pharmacy, told The Journal, during a visit to Peterborough last week, that before a pharmacy can be involved in the pilot it has to pass a user acceptance test. The intention is for all pharmacies in Peterborough to join the pilot. This will allow patients to continue to have a choice of where they want to get their prescriptions dispensed. Pharmacies involved in the pilot have had scanners provided by the consortium but have previously updated their own systems, he says. An ISDN line is arranged for all pharmacies involved in the pilot.

He explains that prescriptions are sent electronically by the GP to a central computer. At the same time a paper copy of the prescription with a barcode and serial number on is printed and given to the patient. The patient can take the prescription to a pharmacy of his or her choice and, if the pharmacy is participating in the pilot, the pharmacist can scan the barcode, enter the serial number into the computer system and download the items on the prescription from the central computer. It takes just seconds to retrieve data after a barcode has been scanned.

All patient consents are held by SchlumbergerSema and are acknowledged by the system. Every user has a user number to enable only authorised persons to access patient details. Both the pharmacy system and the GP system are linked to the Prescription Pricing Authority and endorsement details are sent electronically from the pharmacy to the PPA. The system also has sort codes for entering details of exemptions from payment.

Patients can telephone ahead to any pharmacy involved in the pilot to ask to have their prescriptions ready for when they come to collect them.

Mr Damani adds that patients can go to any pharmacy involved in the pilot but unless they provide the pharmacy with a paper prescription, prescription medicines cannot be released to them. Another benefit of the system is that the GP is able to attach a message to the electronic prescription for the pharmacist.

Mr Damani comments that the ETP system reduces the time spent keying in data. It also speeds up label processing as well as freeing pharmacists' time, which can then be better spent training staff and counselling patients. Patients will be getting better health care as a result, he says.

It takes approximately 20 minutes for an acknowledgement of the prescription by the PPA to arrive back at the pharmacy terminal. Mr Damani says that this saves time at the end of the month. In addition, payments made by the PPA can be checked on the system. However, he adds that "sending information to the PPA directly does not mean that you get paid earlier than with the paper versions".

Mr Damani says that it is difficult to say exactly how many prescriptions have been sent electronically so far to the Thomas Walker Pharmacy but comments that it is "down to the patient as to what goes through the system". He adds that one disadvantage of the system is that there are currently no central drug codes agreed between pharmacies and GP systems.

Deirdre Tunney, head of pharmacy and medicines management, North Peterborough and South Peterborough PCTs, comments that after completion of the trial period the consortium expects to carry on with ETP. "As a PCT we would want to continue until such time as a national model is introduced," she says. One of the aims of the PCT is to move repeat prescribing away from GPs and into pharmacies. She adds: "By the time ETP is in place, we will have a platform for medicines management."

She says that it would be preferable for the system to work on an "opt-out basis" so that all patients are included but can opt out if they wish to do so. Convincing patients of the confidentiality and benefits of such a system may dissuade them from opting out.

Another future development would be to have a central patient medication record system available to all pharmacists so that patients' data can be accessed from any pharmacy. However, she was not in favour of making electronic medical records available to pharmacists and says that GPs themselves have concerns about what information is made available.

Pharmacy2U in Leeds/Stockport

Pharmacy2U currently has 11 GP practices issuing live electronic prescriptions and a further two which are registering patients to enter its pilot. Ten of these practices are in south east England and transmit their prescriptions directly to Pharmacy2u's central dispensary at its office in Leeds. The other three practices are in Stockport and will be transmitting to local pharmacies owned by Co-op Health Care.

As well as the Leeds pharmacy, six Co-op pharmacies in Stockport have passed the Prescription Pricing Authority's user acceptance test (a test pack of 51 prescriptions) and have been accredited to receive electronic prescriptions. All the GP practices use the EMIS system and the pharmacies use Hadley Healthcare's Eclipse system.

Dr Julian Harrison, commercial director of Pharmacy2U told The Journal, during a visit to Leeds last week, that the pilot has transmitted more than 5,000 messages to date. Each message can be either a prescription, a request for a repeat prescription, an authorisation for a repeat or a denial for a repeat. Each electronic prescription, as with the paper version, can hold more than one item. Dr Harrison says that so far more than 5,000 items have been dispensed as a result of electronic prescriptions received. The upper limit for the pilot is 100,000 messages which he expects to achieve before the end-of-the-year deadline.

When prescriptions are received, they are dispensed in the normal way except that all details are entered automatically into the labelling system for the pharmacist to check. At present a replica paper prescription is printed because the PPA requires an exemption declaration to be signed. In Leeds, this prescription is used as a picking list for the dispenser and as a repeat reminder for the patient. Once picked and checked, prescription items are dispatched by registered mail.

Pharmacy2u's ETP pilot revolves around the management of repeat prescriptions using its own administration software. This holds details of all enrolled patients, their prescription charge exemption status and how they can be contacted. Each day the system generates a list of patients who may need to order repeat prescriptions (based on the last date of dispensing). Patients are contacted by one of four pharmacists or by trained call handlers using patients' stated preference — home, work or mobile telephone or e-mail — and asked if they want Pharmacy2U to order a repeat prescription for them. Alternatively, they may be told to revisit their GP for a clinical check. Dr Harrison says that the quickest time that a repeat prescription has been received in Leeds, after speaking to a patient and electronically requesting one from a doctor, is 14 minutes.

Using unique identification numbers and passwords, patients can enter a website linked to the administration system and order repeat prescriptions themselves. They can also see the status of any prescriptions ordered. Dr Harrison says that patients can see real benefits from this system and there has been a low drop out rate from the pilot.

Concern has been expressed that the Pharmacy2u pilot does not currently involve any independent community pharmacies. Dr Harrison says that both his company and Co-op Health Care have put significant investment into the pilot, which does not receive any financial support from the Department of Health. "We have offered independent pharmacies an opportunity to participate in our pilot, but they would have to pay to do so and we have not found any who are willing or able to do this," Dr Harrison says. "I do not want to create any perception that we are excluding independents — we are not — but it is all about funding."

TransScript in East Hampshire

TransScript, which includes PharMed, AAH Pharmaceuticals and BT, declined to allow The Journal to visit its pilot site saying that a visit was not possible until all of the consortium's pilot was up and running. The TransScript pilot is taking place in the East Hampshire PCT area and is currently running in one pharmacy and one GP surgery.

The consortium would not disclose number of patients enrolled or the number of prescriptions transferred electronically. Martin Strange, operations director, PharMed, says that the number of patients enrolled is sufficient for surgeries to be "comfortable", but the number of prescriptions transferred electronically so far is "not as many as we would like".

"Our targets are still to be achieved," he says, adding that the consortium "will get to the stage where it will have enough information to see how the pilot has gone". One of the hurdles is the length of time it takes to get such a pilot up and running. Explaining the new technology to patients, especially older patients on multiple medicines, is also difficult, he says.

Diane Drew, communications manager, PharMed, says that three other pharmacies are "in the process of building up their patient numbers". She comments that "this is being done gradually to ensure that the [GP practice currently involved] is comfortable with the number of patient registrations it receives." A fifth pharmacy has a live system but is waiting for a local GP surgery to be ready. The pilot is about to go live in seven GP surgeries. TransScript expects 22 pharmacies and 16 surgeries to be eventually involved in the pilot.

The pharmacy system suppliers for the TransScript pilot are Link and NDC, and the GP system suppliers are EMIS and Microtes. Pharmacies are being given funding to help upgrade their computer systems and to connect to the NHSnet. Link and NDC are updating systems, the consortium is providing printers and BT is providing connections to the NHSnet.

Ms Drew explains that patients with one-off prescription items will be given digitally signed, barcoded paper prescriptions. The barcode can be scanned in the pharmacy, allowing the data to be transferred directly into the system. "The barcodes offer a workable interim solution for acute prescriptions and will allow all computer-generated prescriptions to be sent electronically from pharmacies to the PPA," she says. Details of the medicines prescribed are also printed on prescriptions to allow patients to take them to any pharmacy, regardless of whether the pharmacy is taking part in the ETP pilot.

The TransScript pilot uses a model that focuses on the electronic transmission of repeat prescriptions. Patients can nominate a pharmacy participating in the pilot to receive repeat prescriptions electronically. These prescriptions are digitally signed by the issuing GP and sent via the NHSnet.

"As for patients, we are concentrating on developing a patient-focused system that offers a quicker and more efficient prescription service," she says. Patients will benefit from having their prescriptions sent directly to their chosen pharmacy. "In some instances, repeat prescriptions could be requested via the pharmacy, making the process easier and less time consuming," she says. Ms Drew comments that the new technology will enable prescriptions to be dispensed and be ready for patients or their representatives when they come to collect the medicines.

Department of Health's views

The Journal asked the Department of Health to comment on a number of aspects of the ETP pilots and on its future plans for a national rollout of the scheme.

The Department regards all three pilots as being live. John Stanley, ETP project manager at the Department, says: "To date, in excess of 2,000 'dispensed' messages have been transmitted, and payments on a proportion of those have already been made by the PPA. The majority of those messages so far have been from the Pharmacy2U pilot, which was the first of the three to go live."

Concerns have been expressed about the cross-section of pharmacies included in each of the pilot schemes, but Mr Stanley is not worried: "Pharmacies currently registered include a reasonable mix of independent, small and large multiple sites, operating in urban, suburban and rural areas.

"The pharmacy population may not be totally representative of the national picture, but we will be looking for differences in attitude and outcome between different types of pharmacy."

The initial pilot schemes are to be completed before the end of the year, but it is not clear what will happen to them after that. Mr Stanley says that a decision has not been made on this yet. He believes that while it would be inappropriate to withdraw services that are delivering benefits to patients, the Department wants to see a clearly defined and managed process for implementing ETP nationally.

Another aspect that is not yet clear is whether any national ETP system will be based on a single "winning" pilot or will include successful elements from all three systems. Mr Stanley explains: "The pilots were established to inform national standards that would enable any GP or pharmacy system supplier which met those standards to participate in national rollout. The ETP workstream is currently being established and the key objective will be the development of the business case for national rollout. This will consider the options, including that of a preferred national model, taking into account the work of the pilots and the need for integration with the objectives of the overall programme."

No decisions have been made either on funding system upgrades or connections to the NHSnet for community pharmacies.

The Department still expects that it will meet the targets set out in its guidance document "Delivering 21st century information technology support for the NHS" published in June this year. These are in two phases — the first to see 50 per cent of prescriptions in England sent electronically by December 2005, the second to see all prescriptions included "with full clinician and patient functionality" by December 2007. Although the use of paper prescription forms is expected to decrease gradually, the Department expects that they will still be needed for some time yet.

Going well or still on the grid?

Looking at the three pilot schemes, different impressions of them are formed. In Leeds, at least, to use a motor racing analogy, the Pharmacy2U pilot has raced into a clear lead. Its system is efficiently dealing with the not overwhelming number of prescriptions it is currently receiving. Paper forms are still being used in some parts of the pilot, but only because the PPA still wants to see signed declarations of prescription charge exemption status. While some pharmacists have privately been expressing concerns about the Pharmacy2U model of centralised dispensing of repeat prescriptions, it is clear that from a patient's point of view the scheme is attractive and offers benefits above those currently offered even by existing collection and delivery services. Despite predictions to the contrary, Pharmacy2U has, so far, "failed to fail".

Making a slower start, but clearly getting under way, is the Flexiscript pilot, now on the verge of expanding across Peterborough. Its scheme, with barcoded prescriptions, is closer to the existing model of prescribing and offers patients flexibility in where they have their prescriptions dispensed while offering pharmacists and the NHS the benefits of electronic transmission, including reduced keying in of data and providing information about prescriptions that are not dispensed.

Meanwhile, it is difficult to avoid the conclusion that the TransScript pilot has stalled on the grid. Despite an earlier pre-pilot of ETP, it is not yet in a position to show off its current system in practice. Two of its initial supporters have left — one (UniChem) to join another consortium, the other (Phoenix Medical Supplies) to sit in the stands. It will need a lot of hard work to reach the finishing line in time.

Despite this, the Department of Health is pressing ahead with its plans to evaluate the ETP pilots quickly ahead of starting on a national rollout programme early next year.

For pharmacies not taking part in the pilots the future is still unclear. ETP is coming, but which system will be chosen, when it will be available and who will pay for it are all still to be decided. Contractors will need to keep a close eye on developments in ETP and hope that their negotiators can secure a good deal for them when it arrives.