ePrescript logos

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ePrescript

• Workshop on e-Prescription

Telematics_at_health.be symposium 7 December 2006
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Agenda

• Presentation of the ePrescript project
• ePrescript scenarios and implementation options
• Demo of ePrescript services
• Challenges and Roll Out issues
• Is there an added value?
• Debate
• Conclusions Invitation to participate

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The ePrescript Project

• eTen project for the validation of e-prescription
  prototypes (ePrescribe / eTranscript)
• ePrescribe the assisted prescription (with or
  without EHR)
• eTranscript the transfer services via a
  prescription pool server
• International consortium Belgium, Ireland and
  Poland
• Belgian partners
• MediBRIDGE NV, coordinating partner
• OmegaSoft (Medical as well as Pharma)
• Ministry of Health
• Dates from June 1st 2006 to November 30th 2007

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ePrescript specific services

• Web-based full electronic prescription
• Secure prescription transfer services
• International equivalence search services
• Cross border transcription services
• A prescription issued in another country (border
  pharmacy) (syntax translation)
• Dispensing message services
• Initially a copy of the prescription with a
  status dispensed
• Later on including relevant products dispensed
  without any prescription

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ePrescript is NOT

• a permanent drug prescription repository
• a drug delivery database for
• for pharmaco-epidemiology or pharmaco-economics
• for prescription research
• for billing purposes
• nor for prescription profiles!
• there is even no ID of the prescribing physician
  in the PPS prescription message !!

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ePrescription validation status

• Yet available within ePrescript
• Standard prescription
• INN prescription
• Foreseen
• Magisterial prescription
• From a formulary
• A reference to the pharmacy register
• Based on the composition
• Only ingredients
• Ingredients and pre-packed medicinal products
• Completed with a minimal set of clinical data,
  e.g. allergies

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Agenda

• Presentation of the ePrescript project
• ePrescript scenarios and implementation options
• Demo of ePrescript services
• Challenges and Roll Out issues
• Is there an added value?
• Debate
• Conclusions Invitation to participate

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ePrescript scenarios

• Two main options
• Non addressed prescriptions (default)
• Addressed prescriptions (on explicit individual
  request of the patient or in special settings)
• Two files/messages
• A header with ID of sender, patient and
  prescription message encryption key ? addressed
  to a TTP Trusted Third Party
• The prescription message as such with solely the
  prescribed medicinal products, addressed to the
  PPS Prescription Pool Server

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Non-addressed Message
TTP
PPS
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Addressed Message
TTP
PPS
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Feedback (Addressed Message)
TTP
PPS
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ePrescript security issues

• The prescription remains permanently encrypted
• Decryption is done by the addressee/receiver
  based on a key obtained through the header
  message
• Content of the prescription never accessible by
  the PPS provider
• The prescription as such does not contain
  identification data
• Identification data (patient as well as the
  physician) are only available on the TTP server.
  The TTP doesnt have the prescription as such (no
  recombination of information possible)

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Content of the electronic prescription

• Should contain at least everything legally
  required in a paper based prescription
• but the message definition needs to allow the
  inclusion of all possible elements of a
  prescription
• Content will obviously depend on the kind of
  prescribed products, e.g.
• A national code (CNK) can be sufficient sometimes
• More data required for a magisterial prescription
• The ePrescript prescription contains some
  clinical data, e.g. allergens, some risk factors,
  co-treatment aspects

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Structure of the electronic prescription

• Kmehr based with officially approved additions
  / changes
• Introducing the concept of specialised
  transactions as foreseen in Kmehr2.
• Kmehr2 enables transactions with a different
  content in the same message prescription (s),
  essential/important clinical data
• Full validation through x-schema approach
• One transaction of the type prescription per
  message
• Completed with a transaction of the type
  Sumehr, restricted, with some clinical data.
• Per prescription one to n items (prescribed
  medicinal products).

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Content of a dispensing message

• In principle a copy of the original prescription
  message
• Without any clinical data transaction
• With a status flag added to each item
• Dispensed
• Refused
• Cancelled if not dispensed within a reasonable
  timeframe
• Or still Prescribed if not yet processed
• In case of an INN prescription replacing the INN
  name with the name of the dispensed product

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What is CardSpace?

• CardSpace is a Indentity Selector Mechanism for
  users
• Available on Windows XP, Windows Vista 2K3
• Available on other platform in the future
• Goal
• Simplify and improve the safety of accessing
  resources and sharing personal information on the
  Internet
• Based on the experience of Microsoft Passport

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Why CardSpace?

• The Internet is a dangerous place!
• Identity theft, spoofing, phishing, fraud, misuse
• Username password is weak and overwhelmed
• Poor choice
• Poor management
• Poor (re-)use
• How do we safely, reliably identify a site to a
  user
• and a user to a site?
• Good phishing sites fooled 90 of participants
  Harvard
• The weak link is often the user himself

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The  laws  of identity

• User control and consent
• Minimal disclosure for a defined use
• Justifiable parties
• Directional identity
• Pluralism of operators and technologies
• Human integration
• Consistent experience across contexts
• CardSpace fulfills all these requirements

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Windows CardSpace

• Reduces reliance on usernames passwords
• Consistent experience for login and registration

• Helps end users avoid some phishing attacks

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InfoCards

• Simple abstraction for digital identity
• Metaphor of physical cards
• Virtual cards for managing claims
• Self-issued cards
• Authority Issued cards
• Link to smartcard like Belgian EID
• Secure subsystem
• Protected UI, anti-spoofing,encrypted storage
• Vista, XP, Server 2003, IE7

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CardSPACE
eTClient
Relying Party
Identity Provider
Relying Party
Identity Provider
Relying Party
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Demo

• In the EHR
• Configuration of the ePrescription function
• Production of a prescription
• Export of the prescription
• Collection of the prescription from PPS
• Display of the content of the prescription within
  the pharma application
• Delivery of the medicinal product
• In ePrescribe production of a prescription

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Agenda

• Presentation of the ePrescript project
• ePrescript scenarios and implementation options
• Demo of ePrescript services
• Challenges and Roll Out issues
• Debate
• Conclusions Invitation to participate

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Challenges

• Legal issues
• Content related issues
• IT Framework Context
• Structure related issues
• Operational issues

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Legal issues

• Royal Decree nr 78 of 10th November 1967 on the
  exercise of medical profession
• Art. 21 mentions that any prescription has to be
  signed and dated by a doctor or dentist

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Modifications by the Law of 22nd December 2003

Article 21 opens the possibility to use
e-signature A Royal Decree can determine the
modalities
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Legal Conclusion

• The possibility to use an e-prescription is
  inserted in the legal framework
• The e-signature must be
• advanced (based on asymmetric encryption)
• realised by a qualified certificate
• And through a secure way
• A Royal Decree can modalize the use of an
  e-prescription but is not necessary and not yet
  adopted

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Management of the Informed consent the
Dispensing Message

• There is no unanimity regarding the need of
  informed consent for
• the electronic prescription
• the delivery feedback
• Initial implementation informed consent foreseen
• Is there a difference between the holder of the
  GMD/DMG and the other prescribers?
• Informed consent is shared between the involved
  parties but how do we handle conflicting
  consents?
• Recording an informed consent does not harm

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Challenges

• Legal issues
• Content related issues
• IT Framework Context
• Structure related issues
• Operational issues

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Content related challenges

• Definition of relevant OTC products delivered
• Standardisation of / consensus on a large number
  terminologies. The terms used in CBIP/BCFI, in
  APB, in Kmehr and in some proprietary databases
  are different!
• gtConsensus required on
• Pharmaceutical (product) forms
• Dispensing forms and dispensing units
• Ingredients / substances
• Physical forms and generic pharmaceutical
  product forms (for the INN prescription)
• Route of administration
• gtCan be handled within a closed environment
• gtWork to do at national level before national
  roll out!!

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Challenges

• Legal issues
• Content related issues
• Structure related issues
• IT Framework Context
• Operational issues

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Importance of structuring

• Purpose of the electronic prescription improved
  processing of the prescription
• The model is very (ideally) structured. Not all
  the providers are able to produce this now.
• Processing of free text still immature (at least
  within low end applications)
• Better to limit export than to use free text

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Challenges

• Legal issues
• Content related issues
• Structure related issues
• IT Framework Context
• Operational issues

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Challenges IT framework context

• Availability of authentication services
• Legal validity of the electronic prescription
  and/or acceptance by the social security
  authorities
• A solution for the regulated medicinal products
• Validation and acceptance of Kmehr2
• Granularity of the prescribing applications are
  they able to produce structured prescriptions?

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Challenges

• Legal issues
• Content related issues
• Structure related issues
• IT Framework Context
• Operational issues

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Challenges operational issues

• Weekend Urgency
• Partial delivery
• Simultaneous prescriptions / renewals
• Validity and expiration date
• Need for autoregulation
• Roll out strategy

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ePrescript roll-out strategy

• First operational pilot sites Q1 2007
• Hove/Lint
• Leuven / Kortenberg
• Heist-op-den-Berg
• Domino based roll-out
• Important rate of users of applications
• Sufficient level of local goodwill between
  physicians and pharmacists
• Open documentation involving other providers of
  EHR systems and/or PhIS

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e-Ten ePrescript pilot goal
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ePrescript added value?

• The realisation of an added value in a
  win/win approach is a prerequisite for
  e-prescribe services to succeed
• A win/win is not possible without goodwill of the
  main stakeholders the prescriber, the pharmacist
  and the patient
• Added value for the pharmacist
• Reduction paper (archive)
• Exchange / availability of some reliable clinical
  information
• Less fraud
• Impact on stock management
• Simplify dispensing process, especially when
  linked to a robot
• Improvement of service level to the patient

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ePrescript added value?

• The realisation of an added value in a
  win/win approach is a prerequisite for
  e-prescribe services to succeed
• A win/win is not possible without goodwill of the
  main stakeholders the prescriber, the pharmacist
  and the patient
• Added value for the pharmacist
• Reduction paper (archive)
• Exchange / availability of some reliable clinical
  information
• Less fraud
• Impact on stock management
• Simplify dispensing process, especially when
  linked to a robot
• Improvement of service level to the patient

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ePrescript added value

• Added value for the physician
• No more paper mobile prescription
• Dispensing message as a starting point for
  improved compliance management.. Increasingly
  important, more especially also for INN
  prescriptions
• Less fraud
• Some information on the dispensed OTC products
• Added value for the patient
• Pre-preparation of prescribed medicinal products,
  e.g. the extra-temporaneous prescriptions,
  leading to an enhanced comfort (only for the
  addressed prescription)
• Completeness of the patient file resulting a more
  secure care providing

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Is it possible to get even more added value?

• ePrescript message already enables the transfer
  of social security information (e.g. an approval
  for reimbursement)
• Potential for an important added value for
  physician and pharmacist
• Concept transmitted to RIZIV/INAMI and Ministry
• Sick funds seems to have technical problems
• The mobile prescription

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Cooperation

• All documentation available for free
• Domain experts requested for the coding tables
• EHR providers PhIS providers should produce /
  integrate the electronic prescription
• 28th February technical meeting for developers
• Info can be obtained anytime at the partners
  offices or at eprescription_at_eurorec.org

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Questions?