Abstract
Introduction
Since the last decade, electronic prescriptions (e-prescriptions) have been under lively discussion among the other e-health solutions processing healthcare-related data. E-prescriptions refer to “messages for electronic information exchange of prescription sets sent by a prescriber to a dispensing healthcare party (dispensing agent) and to healthcare persons/organizations or official authorities as permitted by national regulation.” 1 Only the prescriptions processed with the assistance of a computer were considered; telephone and fax prescriptions did not meet the criteria.
E-prescriptions have been considered to improve the quality and safety of patient care. At the simplest, they escape errors associated with difficult handwriting. Decision-assisting programs can effectively improve drug therapies 2 by checking the dosages, possible contraindications, and interactions with other medicines and even by taking into account other patient-related factors important in drug metabolism. 2 –5
E-prescriptions also assist in administrative tasks such as reimbursement, which can be a complex procedure. In Finland, for example, the patient needs his social security card if he wants direct reimbursement at the pharmacy; otherwise, he must apply for it with a paper form and all receipts from the purchase. In Estonia, the physician has the financial responsibility of choosing the right reimbursement himself: when wrong, he has to pay the difference. In the United Kingdom, the situation is similar. 6
Our study in 2002 on the use of e-prescriptions in the European Union (EU) member countries (15 in those days) showed that only two Scandinavian countries, 7 Denmark and Sweden, had e-prescriptions in daily practice and three other EU countries reported future or ongoing piloting projects. Even though the coverage of the study and the quality of the answers were not ideal, and some contrary findings were presented in some other studies, the trend was clear: e-prescriptions were still a rare phenomenon. This was the case though the EU has greatly supported the integration of information technology into the everyday life of the citizens, including the healthcare sector. Despite application of substantial resources on research and communication in this field, and also the fact that Community legislation strives to make the Union information technology (IT) friendly, countries are making progress on their own. The Union has no mandate to legislate national healthcare systems. 8 Instead, the actions have been, in general, on voluntary bases in the field of e-health, because the member countries have been free to decide on their own plans.
E-prescriptions could have a great future in the European internal market. Ordinary prescriptions should already be acknowledged in another member country as stated in the Council Recommendation in 1995 9 and in the Commission positions, 10,11 yet the practice has varied between the member countries. 12 The proposal for health service directive is a step forward, but the legislative process is still on its way. 13
The aim here was to study whether the e-prescriptions were more commonly used in the EU member countries compared with the situation in our study in 2002. Special interest was placed on the possibilities of cross-border e-prescribing. The present study was to cover the enlarged EU with the new member countries in central and Eastern Europe, altogether in 27 member countries.
Materials and Methods
A 12-point semiopen questionnaire was prepared with yes/no answers and a possibility to freely provide additional information on the matter of concern (Table 1). The questionnaire was developed on the basis of the query from 2002. 7 Similar to the first query, the questions covered the use of e-prescriptions, the type of e-prescription systems and models (including assisting software solutions and possibility to cross-border use), and problems associated with e-prescriptions. The same questions were applied to cases where e-prescriptions had been piloted, were being, or would be piloted. Separate questions on integrity and authenticity of the prescription and identification of the physician and patient were not included, unlike the previous study. These matters were seen to be covered by a question on problems related to e-prescriptions. In addition, since financing the technology investments was assumed to significantly influence the national implementation of e-prescriptions, a question on financing was included.
Questions Asked from National Contacts on the Use of Electronic Prescriptions
e-prescriptions, electronic prescriptions.
The chosen target group was the pharmacists, as they were one of the main partners of the e-prescription process. The European Commission suggested contacting the Pharmaceutical Group of the EU (PGEU) to obtain the best possible connections in the EU member countries. As a result, we e-mailed the questionnaire to the heads of delegations of the member pharmacist associations of the PGEU. The PGEU covers 24 EU member countries, excepting Estonia and Lithuania. The PGEU represents the community pharmacists at the EU level, and its members are national associations of community pharmacists. If there were more than one PGEU member association in a country, each would be contacted. Repeat e-mailing was done in case of no reply a maximum of four times at 1 month's interval. Estonia and Lithuania were contacted directly via the PGEU.
Results
Replies were received from 19 PGEU Member Associations or other PGEU contacts covering 19 of the 27 EU member countries. These included 7 new member countries from the enlargement of the Union into central and Eastern Europe in 2005 and 2007.
Use Of E-Prescriptions
Belgium, Denmark, The Netherlands, Spain, and Sweden reported that they had e-prescriptions in everyday use. The e-prescriptions were used nationally in Denmark and Sweden but regionally in The Netherlands. In Belgium, the use was only in local hospital pharmacies. In 2003, e-prescriptions were used only in Denmark and Sweden (Table 2).
Use of Electronic Prescriptions in the European Union Member Countries in 200X and 2009
Results of the two studies by Mäkinen et al. (Ref. 7 and present study).
Piloting projects were being launched, scheduled, or planned for the next years in several countries including Belgium (for community pharmacies), the Czech Republic, Estonia, Finland, Germany, Italy, Latvia, Slovakia, and the United Kingdom. The responder from Cyprus reported about a possibility of implementing the e-prescription or a pilot within the next few years. In Italy, a legal act was to be expected, after which each region could implement e-prescriptions. In comparison, the study from 2002 reported that pilot projects were scheduled in Finland and Germany, whereas in Belgium and Italy there were no plans for e-prescription usage.
The pilots were nationwide in some countries, for example, Estonia and Czech Republic, but regional or local in others, such as in Finland and the United Kingdom. Meanwhile Austria, Bulgaria, France, Portugal, and Romania reported that they had neither pilots nor plans for implementing e-prescriptions. However, a local pilot had been carried out in Portugal between years 2005 and 2006 involving some hospitals' physicians' offices at healthcare centers and pharmacies.
The E-Prescription Systems
One e-prescription model and system for the whole country was the most common choice. Five countries including Belgium, Finland, The Netherlands, Spain, and the United Kingdom reported that there was more than one system. Belgium had one system for the hospital pharmacies and was to have another for community pharmacies. In Spain, each region was developing its own system based on three or four models. Likewise, England, Wales, Scotland, and Northern Ireland in the United Kingdom were developing separate systems. Further, in the United Kingdom, the National Health Service had a system called Connecting for Health (NHS CfH), separate systems for the community and hospital, and also non-CfH compliant systems in some other hospitals. The Netherlands had some vendor-specific systems and a few e-prescription models in use.
The standards chosen were divergent, following a national or an international standard for e-prescription systems. In Belgium, a national standard had been chosen. In Germany, the national standard was similar to the traditional paper form prescription. In Sweden, an international standard ENV 13607 was used. Some countries used the same international standard: EDIFACT in Denmark, Medrec 3.2 G (based on the Danish EDIFACT model) in The Netherlands, and HL7 in Finland, Estonia, and in most Spanish solutions.
Technology Involved
Smartcard was chosen in Estonia to authenticate the prescribing physician and the dispensing pharmacist (Table 3). In Finland, the physician needed a smartcard to perform the e-prescribing and the pharmacist to enter the prescription center where e-prescriptions were stored. In Germany, there was a health professional card (HPC) for the physician and the pharmacist and a patient data card for the patient. Both the HPC and the patient data card were needed for the prescription process, and the healthcare professionals signed the process with a PIN code. Smartcard was also used in The Netherlands and Slovenia where the system required identification and authorization of the partners. In Spain, the patient needed a smartcard to allow the patient access to the national healthcare system. HPC in Spain allowed health professionals to access to digital patient data and to carry out prescribing, dispensing, and invoicing. In the United Kingdom, the physician and the pharmacist needed a smartcard to access the data system of e-prescribing (NHS CfH).
Used Systems in Everyday Use, Piloting Projects, and Plans
E-record system installed in the surgery and Web-based prescribing; both use same national extranet and mailbox.
Passwords were used by physicians in Denmark to log into Value Added Network Service and by pharmacists to log into a central database where they could download e-prescriptions. In Slovakia, passwords enabled access to the information systems. In Spain, cryptographic HPCs were used with username and password. Levels of access were defined by the competence of the healthcare professionals; different types of measures require different authorization. In Sweden, the physicians used passwords when sending e-prescriptions via national extranet, Sjunet, to the national mailbox. In the United Kingdom, both the physician and the pharmacist needed a password with the smartcard.
E-signature was to be used in Czech Republic and Slovakia and was in use with the help of a PIN code in Germany and in The Netherlands. In Spain, the e-signature was embedded in the HPC to allow prescribing, dispensing, and invoicing of a prescription. In the United Kingdom, the smartcard and password were needed to identify registered physicians before allowing them to use the e-signature.
Database, a central one, was used to store e-prescriptions in Denmark, Finland, Portugal, Spain, Sweden, and the United Kingdom.
Investments
Governmental or communal resources were used to finance investments needed to set up e-prescriptions systems in Belgium, Denmark, Estonia, Finland, The Netherlands, Spain, Sweden, and the United Kingdom. In Czech Republic, The Netherlands, Spain, and the United Kingdom also, there was private funding, for example, system users, pharmacies, hospitals, and physicians. In Denmark, essential local development of the systems was to be paid by the users, for example, pharmacies. In Germany, a special organization for e-health card program (financed by health insurance funds) offered financial resources. In Estonia, private investors supported the end users to adopt information systems. Slovakia had not decided on the investors.
Associated Software
Software assisting the decision making was used in the electronic procession of prescription in Belgium, Denmark, Finland, Germany, The Netherlands, Slovakia, Spain, and the United Kingdom and in the dispensing process in Germany and Spain. Software was used in decision-support systems that helped selecting the drug, checking of dosages and interactions, contraindications, and side-effects and offered scientific and tariff information and information to substitute a drug. However, this software was not necessarily directly linked to e-prescription systems. Reimbursement was or was to be associated with e-prescribing (dispensing process) in Estonia, Denmark, and the United Kingdom. In Denmark, there was a central database where pharmacists up-dated individual patient data online and got information on the current individual reimbursement. A central database was to be developed to offer patient-related information to the prescribing physician.
Dispensing The E-Prescription
The patient could freely choose the dispensing pharmacy in Belgium, Czech Republic, Denmark, Estonia, Finland, Germany, The Netherlands, Slovakia, Spain, and Sweden. In the United Kingdom, the patients could choose the pharmacy, but only within the county in which it was prescribed. In Denmark, any pharmacy could dispense an e-prescription from the central database; yet, the traditional way was to address the prescription to a certain pharmacy. In the latter case, the patient could still change his mind and go to another pharmacy, in which case the first pharmacy released the prescription to the central database.
Acceptance Of Non-National Prescriptions and E-Prescriptions
Traditional, non-national prescriptions were accepted in most countries, Belgium, Czech Republic, Denmark, Estonia, Finland, Italy, The Netherlands, Portugal, Sweden, and the United Kingdom. Non-national prescriptions were not accepted in Spain and Finland; in the latter, exceptions were the Nordic prescriptions.
Non-national e-prescriptions were not accepted in any country. Reasons for this included lack of standardization and lack of legislation, or the fact that legislation forbade it. Problems were seen in authentication and verification and in addition to interconnectivity, safety, and confidentiality reasons. However, Denmark mentioned that some local tests on accepting the non-national e-prescriptions had been initiated.
Problems Associated with E-Prescriptions
Financing e-prescription systems was found to be problematic in Belgium, Czech Republic, Estonia, Finland, Slovakia, and the United Kingdom; multiple systems in Finland, Sweden, Spain, and the United Kingdom; data security in Czech Republic, The Netherlands, Slovakia, and the United Kingdom; data integrity in The Netherlands, Slovakia, and the United Kingdom; data security in Czech Republic; authenticity in The Netherlands and Slovakia. Other problems mentioned were lack of standardization (emotional) resistance by the users, problems related to the schedule. In Denmark, the problem was the instability of the central database, as the pharmacist had to work online at the moment of the sale. In addition, the e-prescription form had changed when the central database had been introduced, but the physicians still used the old form.
Conclusions
The study showed that e-prescriptions were still scarce in everyday practice; at the time of the study, five countries announced having adopted them into daily practice nationwide or into a limited use. In addition, since 2010, e-prescriptions have been used in everyday practice also in Estonia (personal information). Still, the usual case was that a country had had, was having, or was to have pilots within the next few years. The literature was supportive to this finding. The pilots and plans already announced in the previous study had not became a daily practice or were delayed, for example, for financial reasons or due to IT problems.
There were six countries, three old and three new EU member countries, which reported that they had no plans to pilot and use e-prescriptions. This might have been also the case when no reply was received from a country. There can be several reasons for this. If the healthcare sector, especially primary care, is already using IT for medical and administrative purposes, it is more readily prepared to take the next step toward e-prescription. Protti 14 found that there were computerized general practitioners' offices and automated medication prescriptions in seven EU member countries in 2005, of which this study showed six to be using or piloting e-prescriptions in 2009.
IT requires huge financial investments and human resources just to establish electronic health record systems. The study showed that in the countries where the e-prescriptions were already used or piloted in 2002, the government, community, or other-than-user based financing had been used to finance the infrastructure. Financing was found to be a problem where the use had not spread nationwide or developed into a daily process. Thus, the adoption of e-prescriptions is likely to be slow also in the future. European countries are struggling with increasing costs in medical field and also in other fields of the society. The new member countries are also less well-off, and this can hinder even the planning of adopting e-prescriptions into healthcare. However, several of them have managed to test e-prescriptions, and Estonia is even using them at the moment.
When the users should be directly involved in financing e-prescriptions, there are other factors that matter. The type of practice setting can have an effect on the availability of information technology needed for e-prescribing, as shown in a U.S. study. 15 Financial rewards and assistance in purchasing technology 3,16,17 have been introduced to increase adoption of e-prescriptions into healthcare in countries where the physicians and pharmacists themselves should participate in financing the new system.
Reasons that have influenced the adoption of computer technology into a physician's office can influence the adoption of e-prescribing as well. Bleich and Slack 18 noticed that the key to enthusiastic acceptance of computers and electronic patient records was easy and helpful usage. In addition to financial support by the government or similar organizations, Protti et al. 19 argued that medical associations and peer influence and collegial support have played a significant role in Denmark, England, and Scotland.
Great diversity of the systems and standards chosen for e-prescriptions was discovered in the study. This was evident between the countries, but also different areas within a country could have been developing their own systems that did not communicate with each other. Communicating systems and data content standardization will be needed if e-prescriptions were to be used in different countries, which is not the case today. Restricted availability of e-prescriptions may be a marginal disadvantage to the majority of European citizens, but there is likely to be a growing number of people for whom it is not so. People who travel or study abroad and take (long-term) medications may profit from cross-border e-prescriptions. The EU financed epSOS project is likely to offer an answer to this matter. The project involving 12 EU member countries aims at offering interoperable e-prescription services between different national solutions within a few years. 20 Different drug selections and trade names in member countries is another, probably manageable, problem in cross-border e-prescribing.
The recent actions of the Commission and the European Court of Justice show that cross-border health services have their support. The first building block for this goal is the interoperability of relevant IT-systems. Close co-operation between the health professionals, legal experts, and IT experts from both the member countries and the EU institutions is needed. The “Cross-border patient market” may not be realized shortly, and it may not even be the target, but certain functions such as effective use of e-prescribing, also across the borders, would certainly benefit healthcare in Europe.
Footnotes
Acknowledgments
We would like to thank Mrs. Flora Giorgio, Scientific Officer in the European Commission, and Ms Ivana Silva, Pharmaceutical and Professional Affairs in the PGEU, for their assistance in finding the contacts; and the heads of delegations of the PGEU member associations and other PGEU contacts for their country-specific information.
Disclosure Statement
No competing financial interests exist.