121 S. Goundrey-Smith, Information Technology in Pharmacy,
DOI 10.1007/978-1-4471-2780-2_5, © Springer-Verlag London 2013
For people in many countries, their predominant experience of healthcare will be of primary care , whether that is the general medical practitioner’s consulting room in UK or European medical centres, the family physician’s of fi ce in the United States, or through community pharmacies or nurse-led clinics in any of these settings. Throughout the Western world, many healthcare needs are met without the need for hospital refer- ral, and the allocation of resources re fl ects that. In the UK NHS, prescribing in pri- mary care accounts for around 80 % of the total medicines budget [ 1 ] .
Given the sheer fi nancial and human resources allocated to the primary care net- works in many health economies, it is essential that systems used for enabling medi- cines management and pharmacy practice in the community ensure high quality of care, ef fi cient use of resources and appropriate use of the skills of all professionals involved in the medicines user process. In particular, the relationship of the commu- nity pharmacist with other members of the primary care team is vital, and systems used for medicines management in primary care must support and enable this rela- tionship, so that the pharmacist’s unique knowledge and expertise is brought to bear to ensure high quality pharmaceutical care, and the minimization of adverse events.
This chapter will examine the functions of general practice (medical of fi ce) com- puter systems, in general but with a speci fi c focus on the prescribing process , and also the process of electronic transfer of prescriptions (eTP) in the community, which is being adopted in the US, UK and other countries, and how the eTP process could support pharmaceutical care.
The Development of Systems for Medicines
appliance contractors. Increasingly, however, the distinction is blurred; in many countries, pharmacies are increasingly being located on the same site as medical practices, and in some cases medical practices are working with internet or mail- order pharmacies to supply medication.
Nevertheless, medical practices and community pharmacies have historically been distinct as institutions, and have been managed in different ways. This is why historically systems used to support medical and pharmacy practice in primary care have largely developed as separate entities.
In the UK, systems used in general medical practice ( GP systems ) have been in routine use since the 1970s. First and foremost, these systems enable doctors to maintain patient records to support good quality patient care and to ensure continu- ity of care, as well to provide a record of decision making for medicolega l purposes, as discussed in Chap. 2 . GP systems also need to support the working practices of general medical practitioners, such as referrals to specialists, processing of test results and provision of contracted medical services ( items of service ) such as vac- cinations and contraceptive services.
Clinical systems for medical practices in England are provided by the commercial sector, and are regulated by the GP Systems of Choice (GPSoC) initiative. The mar- ket leader in the UK, with 60 % of the market, is EMIS, but other suppliers include InPractice Systems (INPS)(Vision), iSOFT (Synergy and Premiere) and Microtest.
Traditionally primary and community care health professionals require patient record systems that have the following functionality [ 3 ] :
To enable the clinical care of the patient by helping the health professional to
•
structure the consultation and make appropriate decisions To provide a record of previous consultations
•
To store and display test and investigation results
•
To display
• referrals to and from other clinicians
To enable sharing of patient information with other professionals who have
•
access to the system.
To enable the transfer of the record to another medical practice if the patient
•
moves to another area
The GP system should also support the following activities:
Epidemiology and
• public health monitoring
Identifying target groups for screening and health promotion schemes
•
• Medical audit and activity monitoring (to support bids for service provision and to improve quality of care)
Patient access and contribution to records
•
Provision of
• medicolegal evidence in cases of medical negligence, or third party claims (e.g. occupational illness or pharmaceutical product complaints)
To support social bene fi ts claims
•
To enable
• commissioning of community and secondary healthcare services To support health professional education and
• continuing professional develop-
ment (CPD) To support
• clinical research and adverse event reporting
123 The Development of Systems for Medicines Management in Primary Care
GP system records also need to be available to out-of-hours medical services, which provide a medical service to a locality during the evenings and at weekends, when GP surgeries are closed. There are two approaches to GP system access for out of hours services:
(a) a read-only system giving access to an external electronic health record system (for example, the Graphnet system)
(b) Read and write access to a single logical record – or separate records (e.g. TPP SystmOne and EmisWeb respectively)
There is an increasing trend towards centralized medical records derived from GP systems being accessed in other healthcare contexts by other healthcare profes- sionals, as shared records. These are typically summary records containing mini- mum details (e.g. current medications, allergies, diagnosis and medical history), which are bene fi cial to support unscheduled care, typically in the out-of-hours (OOH) medical service, but also other services such as accident and emergency and community clinics.
These would include:
• Summary Care Record (SCR) in England
• Emergency Care Summary (ECS) in Scotland
• Individual Health Record (IHR) in Wales
Regional healthcare systems, such as those that have been established in Italy [ 4 ] and Sweden [ 5 ] , enable a shared medical record to be used across primary care and unscheduled care settings. Some systems operated by US healthcare insurance pro- viders – e.g. Veterans Administration (VA) and Kaiser Permanente – also provide a shared medical record for patient care in a number of primary care contexts (see Chap. 2 ).
There are potential bene fi ts of shared records in terms of improving the quality of care in each care encounter, improved patient safety, improved access to care and better cost-effectiveness. However, there are risks associated with shared records, associated with record management and security, and responsibilities for maintain- ing the record. In the UK, the Royal College of General Practitioners (RCGP) has addressed some of these issues in its Shared Record Professional Guidance project [ 6 ] . This project elucidated a number of principles governing the use of a shared record (see Chap. 2 ), which covered:
Obtaining
• consent to store and share data
Clear assignment of clinical responsibility in care records
•
Health professionals using records in a way that is consistent with their legal and
•
professional obligations.
Procedures for amending errors and offering differences of opinion in
•
records
Clear identi fi cation of the originator of any record entry
•
Appointment of an
• information governance guardian for the organization.
In future, shared medical records may be used to support device integration and telecare (see Chap. 8 ).