Publication Date 01/07/2014         Volume. 6 No. 6   
Information to Pharmacists


From the desk of the editor

Welcome to the July 2014 homepage edition of i2P (Information to Pharmacists) E-Magazine.
At the commencement of 2014 i2P focused on the need for the entire profession of pharmacy and its associated industry supports to undergo a renewal and regeneration.
We are now half-way through this year and it is quite apparent that pharmacy leaders do not yet have a cohesive and clear sense of direction.
Maybe the new initiative by Woolworths to deliver clinical service through young pharmacists and nurses may sharpen their focus.
If not, community pharmacy can look forward to losing a substantial and profitable market share of the clinical services market.
Who would you blame when that happens?
But I have to admit there is some effort, even though the results are but meagre.
In this edition of i2P we focus on the need for research about community pharmacy, the lack of activity from practicing pharmacists and when some research is delivered, a disconnect appears in its interpretation and implementation.

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While doctors remain disempowered doctor shoppers needing help will die.

Dr Ian Colclough

articles by this author...

Dr Ian Colclough is an independent consultant well versed in the politics, vagaries and complexities of the health care industry. He has over 35 years experience in health informatics in a career spanning medical practice, public hospital administration, business development, market analysis, health software research and development, and strategic and tactical sales and marketing in the corporate health and ICT sectors in Australia, South Africa and the United Kingdom.
Vision - Strategy - Execution - Innovation
Integrated ehealth Strategies & Market Development

Doctor shopping concerns everyone. It costs lives, erodes the fabric of our society and imposes unacceptable cost burdens on the Australian health system.
Online eScripts and Script Exchange interoperability are pivotal to solving doctor shopping and managing S8 and S4 drugs of addiction.

Doctor shopping concerns everyone. It costs lives, erodes the fabric of our society and imposes unacceptable cost burdens on the Australian health system. Online eScripts and Script Exchange interoperability are pivotal to solving doctor shopping and managing S8 and S4 drugs of addiction.

On 1 August 2011, at the Inquest into the Death of James, Coroner John Olle said “For over a decade, Victoria's coroners have been calling for the State to introduce a real-time prescription monitoring program. I merely add my voice to the chorus of coronial voices throughout Australia, who for years have recommended the development and implementation of a computer-aided system to endeavour to manage the problem of doctor shopping and pharmacy shopping.”

Past attempts to fix the doctor-shopping problem have been driven at the pharmacy or supply end of the process by attempting to stop dispensing in the pharmacy; this approach has failed. The reason is because the doctor shopping problem manifests itself first and foremost at the clinic when the patient makes a request for a prescription.

It is during the consultation, at the point-of-care moment, when the doctor is most empowered to sensitively broach the subject of addiction and misuse of drugs. This is the very best time for the doctor to provide the guidance and counselling needed to assist the ‘patient’ in securing help to break the dependency habit. 

Quite apart from this frontline point-of-care moment being the ideal time to assess and assist the patient, the surgery remains the only environment in the care chain that provides the complete privacy so essential to achieving a positive outcome for the patient. As pharmacists provide their services in a public setting which is not conducive to lengthy sensitive confidential counselling the pharmacy is hardly a suitable place to address a private and confidential issue such as the addiction to a particular medicine. By comparison the privacy of the consulting room is ideally suited to addressing the issue of doctor-shopping.

The problem at present however is that the doctor does not have readily available the information needed to know the patient has an addiction or other drug problem.  This is the major obstacle to managing doctor [prescription] shopping. As a consequence this lack of access to timely, accurate and reliable information renders doctors relatively powerless to do anything about it because they do not have to hand the evidence they need to share with the ‘patient’ and commence the counselling support dialogue.

Doctors know and accept that a realtime prescription monitoring system will help them do their job, provide better care to the patient, and diminish the sense of helplessness which they experience when they lack access to the essential clinical information they need at the point of care. 

On 15 February 2012 Coroner John Olle made a very clear straightforward Recommendation; that:

“The Victorian Department of Health implement a real-time prescription monitoring program within 12 months, in order to reduce deaths and harm associated with prescription shopping. The program should include the following functionality: (a) a primary focus on public health rather than law enforcement; (b) recording of all prescription medications that are prescribed and dispensed throughout Victoria without exception; (c) provision of real-time prescribing information via the internet to all prescribers and dispensers throughout Victoria without exception; (d) a focus on supporting rather than usurping prescribers’ and dispensers’ clinical decisions; and (e) facilitating the ability of the Victorian Department of Health to monitor prescribing and dispensing to identify behaviours of concern.”

Of particular significance is the Coroner’s requirement for “recording of all prescription medications that are prescribed and dispensed throughout Victoria without exception”.

Further, Coroner Olle commented “that if the system only captures information at the dispensing end of the process, doctors will not be engaged sufficiently in the prescription monitoring process and most responsibility for prescription monitoring will be shifted onto dispensers.”

He added “I reiterate my view that information should be captured both at the point of prescribing and at the point of dispensing. I consider doctors should have access to accurate, up to date information in the exercise of clinical judgement. Patients’ best interests must be served if doctors are appraised of the full clinical picture.”

It was reassuring to hear Guild President Kos Sclavos reaffirm the Coroner’s position as reported in Pharmacy News on 23 April 2012 when he said “doctors should reserve the right to only prescribe controlled drugs for patients where they can see the full list of medications dispensed and prescribed.”

Kos is to be applauded for acknowledging that the proper place to start in the push for a real-time monitoring program is on the doctors' desktop at the point of prescribing during the consultation. This means that as MediSecure and eRx have the essential technology already in place in most medical practices and community pharmacies throughout Australia it should now be possible to make rapid progress to fix the doctor shopping problem.

On 14 March 2012 at the Australian Pharmacy Professional [APP] Conference Health Minister Plibersek, in referring to the uptake of the electronic prescription fee, said that “one of the key issues to be resolved here is the interoperability of the prescription exchange services”. “My Department is committed to working with all those affected to improve interoperability so that prescribers and dispensers will be able to take full advantage of the electronic prescription fee available under the Fifth Community Pharmacy Agreement”.

The Minister too is to be applauded. She has the power to sweep aside the political obstacles which, for so long, have been preventing the widespread deployment of eScripts and online prescription monitoring and her commitment to support the immediate development of interoperability between the two Prescription Exchange Services will be widely welcomed. This single affordable step will rapidly drive engagement, collaboration and ‘co-operation’ between the two largest groups of primary care providers who lie at opposite ends of the prescribe-dispense prescription supply chain. Without doubt it is the most cost-effective utlisation of eHealth dollars available to government.

The unarguable core of the business case for GPs is that there is a well-defined medical and social need to better manage 'doctor shopping'.  By better monitoring the activities of doctor shoppers, concerned medical practitioners will be able to access information that will allow them to detect patterns and behaviours of doctor shoppers and addicted drug 'abusers' at the time they present to the doctor for a prescription.  

Perhaps there is light at the end of the e-Health tunnel after all.

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