Keeping watch: models of prescription monitoring

Featured
By
David Barbeler
-

Victoria has begun rolling out its SafeScript real-time prescription monitoring program, prompting many to ask: When will pharmacists see a national system?

Wading through the harrowing details of many thousands of prescription-drug related deaths, Australian coroners have been calling for real-time prescription monitoring (RTPM) since the 1980s.

But those calls accelerated after, in the space of just a few years between 2007 and 2013, the number of accidental deaths due to opioids increased 68%.1 As a result, pharmaceuticals now kill more Australians than car crashes or illicit drugs – they play a role in 80% of overdose deaths and 70% of all drug-related deaths.2-4

But there’s been a lack of media and awareness around the issue said Bee Mohamed, the CEO of ScriptWise – a non-profit organisation dedicated to preventing the harms associated with prescription medication use.

‘The media has been highlighting how big an issue ice [crystal methamphetamine] is,’ she said. ‘But we don’t hear about the 200% increase in overdose deaths relating to prescription opioids in regional New South Wales over the last 10 years.’

Tackling the problem

To address this increase in harm, PSA is calling for governments to prioritise the implementation of a nationally connected real-time monitoring system for all drugs of dependence.

Research has suggested that RTPM can reduce inappropriate prescribing, prescription shopping and adverse events, while improving multimodal pain management and quality of care.5,6

Tasmania became the first Australian jurisdiction to roll out an electronic prescription monitoring solution with its Drugs and Poisons Information System (DAPIS) in 2011.

Since then, the Tasmanian Coroner’s Office found deaths associated with prescription opioids had fallen by more than a third and the quantity of opioids supplied fell from 140% of the national average to 95%.7

RTPM approaches

TASMANIA

In Tasmania, prescribers and pharmacists can access a light version of DAPIS – DAPIS Online Remote Access, known as DORA.

DORA is a secure webpage-based system storing patients’ dispensing data relating to Schedule 4 and 8 opioids, and all other Schedule 8 drugs.

PSA Tasmania President Dr Ella van Tienen said there was no question the state’s efforts had increased patient safety and given pharmacists access to more information.

‘Tasmania is lucky to essentially have two systems running side by side – one being the real-time transfer of dispensing data to the Pharmaceutical Services Branch (PSB), and the other being DORA, which we are able to access to support clinical decisions on supply to high-risk or unknown patients,’ she said.

‘The real-time system integrates seamlessly with our dispensing software so has no impact on our usual activities but does enable the pharmacists at PSB to contact us if our dispensing activity has raised a red ­flag. DORA is a separate system which is quick and easy to use.’

Dr van Tienen said Tasmania had been able to lead the way on RTPM in Australia thanks to two factors working in its favour.

‘We were lucky to have a chief pharmacist, team of PSB pharmacists, and alcohol and drug services really passionate about tackling inappropriate use of opioids in our state,’ she said.

‘We also had the advantage of being small and relatively isolated from other states – working with prescribers and pharmacists to implement the system was easier.’

More than 95% of Tasmanian pharmacies now securely report their Schedule 8 data in real time.8

VICTORIA

Victoria meanwhile, is set to introduce its own RTPM initiative – SafeScript – later this year. Via each pharmacy’s Prescription Exchange Service (PES), SafeScript computer software will automatically transmit prescription records for high-risk medicines, in real time, to a centralised database.

Prescribers and pharmacists will then receive pop-up notifications alerting them when it’s necessary to review a patient’s history in SafeScript.

Ms Mohamed said the Victorian model was ScriptWise’s preferred model.

‘The SafeScript system is robust enough to include Schedule 4 benzodiazepines and codeine from day one,’ she said. ‘It can also add medications as drug trends change.’

PSA Victoria President Benjamin Marchant added that SafeScript also provided the first ‘workable mechanism’ to easily identify Victorians who would benefit from further support.

‘A key component of the SafeScript system is referral pathways, through local support and addiction medicine and counselling services to assist patients who are identified as having issues with medication misuse,’ he said.

The $30 million roll-out will begin with the Western Victoria Primary Health Network catchment area before extending across the state in early 2019. However, Mr Marchant said more could be done on a governmental level to provide training and support for pharmacists’ use of the system.

‘Ensuring all pharmacists and doctors are provided adequate training and ongoing support in all healthcare settings is a real challenge and needs to be done prior to the roll-out of SafeScript,’ he said.

AUSTRALIAN CAPITAL TERRITORY

The ACT is following Tasmania’s lead, and will become the third Australian jurisdiction with RTPM, when it gives health professionals access to DORA by March next year.

An ACT Health spokesperson told Australian Pharmacist: ‘The ACT Government is committed to implementing DORA – to improve and support safe and appropriate prescribing and dispensing of medicines and to keep people safe.’

ScriptWise’s Ms Mohamed, however, cautioned that the DORA system was not necessarily best practice. ‘The system needs to be something that’s integrated into the clinician’s regular software – the feedback from peak medical bodies was that if they have to log-in to a separate portal [like DORA] they won’t necessarily do so because it disrupts their workflow,’ she said.

‘While the majority of the pharmacists do use the [DORA] system in Tasmania, the uptake of GPs using the system is not very high.’

Tasmania’s Department of Health Acting Chief Pharmacist, Sam Halliday, however, said negative feedback from users of DORA had been negligible.

‘PSB has received feedback from users that they ­find DORA to be a useful clinical tool and have overwhelmingly supported the utility of the webpage in informing their clinical decision making with respect to these substances,’ he said.

TABLE 1. Monitoring system

Monitoring system
Jurisdiction Current Planned
New South Wales Customised ERRCD used to record authorisations to prescribe as part of the New South Wales Opioid Treatment Program. Also records client admissions to, and exits from, treatment, the details of prescribers and dosing points.

Monthly reporting.

 A spokesperson for eHealth NSW told AP:

‘NSW is working with the Commonwealth and other states and territories to progress a National Real Time Prescription Monitoring (RTPM) system.

‘A review is underway to consider existing platforms in use across the country and alternative options in the market to ensure best outcomes for the NSW Health system and its consumers.’
Queensland Schedule 8 prescription drug monitoring.

Weekly reporting of prescriptions dispensed.

 A Queensland Health spokesperson told AP:

‘Queensland has committed to developing a system that connects to and interfaces with the Commonwealth system to achieve a national solution.

‘Planning and further work into this system is currently underway.’
South Australia Schedule 8 prescription drug monitoring.

Monthly reporting of prescriptions dispensed.

 SA Health Director, Food and Controlled Drugs, Fay Jenkins told AP:

‘We are undertaking the necessary work to support a national solution and project planning for real-time prescription monitoring.’
Tasmania Tasmania is the only state with a real-time prescription monitoring system.

The Drugs and Poisons Information System Online Remote Access (DORA) was introduced in 2011.

Mandatory real-time reporting of all Schedule 4 and 8 opioid dispense events, and all other Schedule 8 drugs.

Use of the DORA website by clinicians considering prescription or supply of these substances is voluntary.
Victoria S8 permit process for prescribers.

Starting late 2018, Victoria will transition to a RTPM software and database solution, SafeScript.

 SafeScript will monitor all Schedule 8 medicines as well as other high-risk medicines including Schedule 4 benzodiazepines, z-drugs and quetiapine.

From 2020 it will be mandatory to check SafeScript prior to writing or dispensing a prescription for a high-risk medicine.

Pharmacists will otherwise face a penalty of more than $15,000 (100 penalty units).
Western Australia Schedule 8 prescription drug monitoring.

Monthly reporting of prescriptions dispensed.

 Department of Health Chief Pharmacist, Neil Keen told AP:

‘WA Health intends to replace the existing system with a one capable of receiving dispensing data in real time and providing health practitioners with secure, online access to patient Schedule 8 prescription histories and other relevant information.

‘This project is underway and anticipated to be delivered in phases throughout the later part of 2018 and during 2019.’
Australian Capital Territory Drugs and Poisons Information System (DAPIS) to monitor the supply of Schedule 8 medicines.

Weekly reporting of prescriptions dispensed.

 Expanding DAPIS to introduce the DAPIS Online Remote Access (DORA) by March 2019.

Voluntary – doctors and pharmacists will not be required to use the system prior to prescribing or dispensing. May become mandatory once there is a nationally compatible scheme.

Proposed daily reporting.
Northern Territory Schedule 8 prescription drug monitoring via the Drug Monitoring System (DMS) database.

Weekly reporting of prescriptions dispensed.

Other jurisdictions

FEDERAL LEADERSHIP

The Federal Government has been urging states and territories to adopt its RTPM system – the Electronic Recording and Reporting of Controlled Drugs (ERRCD), itself based on the DORA system – since 2013.

But with states and territories unable to agree on a RTPM model, many jurisdictions have been hesitant to act. In April, however, a breakthrough came when the Council of Australian Governments (COAG) Health Council met.

The Council’s Communique stated: ‘The Ministers agreed to progress national real-time prescription monitoring as a federated model with jurisdictions committed to progressing development and adaptation of systems to connect to and interface with Commonwealth systems to achieve a national solution’.

Asked to expand upon what this would mean, a spokeswoman for the Federal Department of Health told Australian Pharmacist:

‘The national RTPM system will be made up of a number of components, including the National Data Exchange (NDE) component and jurisdiction-speci­fic regulatory components’.

‘The NDE layers receive and broadcast prescription dispensing events to all jurisdictions to prevent cross-border drug shopping.’

The spokeswoman said that $16 million in federal funding would be spent on the design, build and delivery of the NDE component of the national RTPM system, ‘including interoperability of the NDE with jurisdictions’ regulatory systems and interoperability of the NDE with clinician software’.

It’s unclear how the system might integrate with My Health Record.

Other jurisdictions

Since the COAG agreement, New South Wales Health Minister Brad Hazzard, has commissioned research on the need for an RTPM, the potential bene­fits and risks.

The state’s Labor Opposition has gone further, promising to implement SafeScript RTPM if elected in 2019. PSA NSW President Professor Peter Carroll welcomed the move.

‘Without a RTPM system for drugs of misuse such as opioids, deaths will continue to occur, which could have been prevented,’ he said.

Meanwhile, Western Australia’s Department of Health Chief Pharmacist, Neil Keen, said that state would start replacing the existing system with one ‘capable of receiving dispensing data in real time and providing health practitioners with secure, online access to patient Schedule 8 prescription histories and other relevant information’.

WA’s current Monitoring of Drugs of Dependence System (MODDS) is more than 20 years old and unable to be upgraded to meet current needs, such as receiving real-time reports. The new system will be a modi­fied version of the ERRCD.

‘This project is underway and anticipated to be delivered in phases throughout the later part of 2018 and during 2019,’ he said.

Queensland and South Australia have indicated they are working towards a RTPM system.

More to be done

In addition to advocating for a nationally connected real-time monitoring system, PSA has asserted that it must be accompanied by a robust implementation plan which includes appropriate workforce training.9

Establishing appropriate referral pathways for pharmacists will also be important so that patients with speci­fic health concerns can be supported in a timely manner.

Ms Mohamed added that while RTPM software was an important part of the solution to prescription-drug-related harm, education was essential.

‘Our message is not just for ministers to implement the software, but also to ensure they put funding aside to train health professionals to better understand the issue and make the community really aware of it too,’ she said.

The PSA view

To implement a national monitoring tool, PSA believes that the system should be:

  1. a compulsory system, the use of which is mandated through legislation to ensure the implementation of a consistent and comprehensive response
  2. a national system – ideally this means one single connected system to overcome interoperability issues
  3. functional for genuine real-time use, so that a prescriber or pharmacist concerned about a particular patient can access accurate, up-to-date data with confidence no matter their geographical location of practice
  4. effectively integrated with prescribing and dispensing systems to ensure seamless use by prescribers and pharmacists as a clinical decision making tool
  5. for all drugs with the potential for addiction
  6. focused on managing and supporting patient safety and quality use of medicines rather than being a policing tool for compliance and enforcement
  7. accompanied by appropriate workforce training to prepare and provide ongoing support to health professionals – this must include the identification of referral pathways for pharmacists and access to appropriate services for patients identified with suspected substance use disorder
  8. underpinned by a robust implementation plan which includes appropriate data capture, inclusion of health-related targets and evaluation methodology
  9. supported by the adoption of nationally uniform regulatory controls for drugs and poisons.

View the PSA position statement on RTPM at www.psa.org.au.

References

  1. NSW Parliamentary Research Service. Pharmaceutical drug misuse Brie­fing Paper No 1/2018. 2018. At: apo.org.au/system/files/175626/apo-nid175626-793116.pdf
  2. Penington Institute. Penington Institute releases Australia’s Annual Overdose Report – 2016. 2016. At: penington.org.au/overdoseday/
  3. Monheit B, Pietrzak D, Hocking S. Prescription drug abuse – A timely update. RACGP. 2016;45(12):862-866. At: https://www.ncbi.nlm.nih.gov/pubmed/27903034
  4. Penington Institute. Penington Institute releases Australia’s Annual Overdose Report – 2016. At: penington.org.au/overdoseday/
  5. Islam, M and McRae I. An inevitable wave of prescription drug monitoring programs in the context of prescription opioids: pros, cons and tensions. BMC Pharmacol Toxicol. 2014;15:46. At: https://www.ncbi.nlm.nih.gov/pubmed/25127880
  6. Shand F, Campbell G, Hall W, et al. Real-time monitoring of Schedule 8 medicines in Australia: evaluation is essential. Med J Aust 2013;198(2):80-81. At: https://www.mja.com.au/journal/2013/198/2/real-time-monitoring-schedule-8-medicines-australia-evaluation-essential
  7. Reynolds A and Boyles P. Clinical care and regulation of opioid use: The Tasmanian model. Medicine Today 2017;18(3 Suppl):17-21. At: https://medicinetoday.com.au/system/files/pdf/MT2017-03SUPPL-PRESCRIPTION_OPIOID_MISUSE.pdf
  8. Department of Health and Human Services Tasmania. DORA – Drugs and Poisons Information System Online Remote Access. 2018. At: dhhs.tas.gov.au/psbtas/publications/general/dora
  9. Pharmaceutical Society of Australia. PSA position statement: real-time monitoring of drugs of dependence. 2018. At psa.org.au/