Submission by the Irish Pharmacy Union to the
Department of Health & Children
on the Health Information Bill
28 August 2008
IPU Submission on the Health Information Bill
1. Introduction
The Irish Pharmacy Union (IPU) is the representative and professional body for community pharmacists. Its mission is to promote the professional and economic interests of its members. Members of the IPU aim to provide the best possible professional pharmacy service to all members of the public. They are committed to delivering a quality, accessible, personal and professional service that puts the patient first and has as its primary goal the optimisation of the health and well-being of society. Pharmacists are accountable for their professional conduct and strive to maintain the confidence and respect of their patients, customers, the State and other professionals in the healthcare field.
The IPU welcomes the opportunity to make a submission on the proposed Health Information Bill which will deal with the collection, use, sharing, storage, disclosure and transfer of personal health information as well as the rights of individuals to control and access their health information. The Union agrees that there is a need to deliver better patient care and safety through using information more effectively to improve healthcare outcomes while ensuring that the privacy of personal health information is appropriately respected.
2. Role of the Pharmacist
An estimated 636,000 people visit the 1,580 community pharmacies in Ireland each week. This makes pharmacies the most accessible and visited part of the health service. Pharmacists are in a unique position to contribute to promoting an awareness of the potential benefits of e-health to the patient.
Drawing on existing resources always makes sense. Currently, pharmacists play a vital role in healthcare delivery but are still one of the most under-utilised resources in the health service. They are highly qualified healthcare practitioners who are easily accessible to the public in city and town centres, residential and rural areas throughout Ireland. People need no appointment and they have ready access in a familiar, informal environment to expert knowledge about medicines in particular and healthcare generally. Patients also have the opportunity to speak to the pharmacist in a private area of the pharmacy if they wish to discuss a confidential matter.
The primary role of the pharmacist is to improve health outcomes by safely dispensing medicines and advising patients on how to get the optimum benefit from them. However, as part of their broader advisory role, the pharmacist responds to thousands of spontaneous requests for information from patients on general health issues. Individual pharmacists also carry out various health promotion activities in their pharmacies.
3. Code of Ethics for Pharmacists
Pharmacists in Ireland are currently bound by the Code of Ethics which was adopted in 1996 by the previous Council of the Pharmaceutical Society of Ireland, the statutory regulatory body for pharmacists and pharmacies. This Code of Ethics provides a set of guiding principles by which the actions of every pharmacist should be judged.
- The pharmacist’s primary concern should be the welfare of the patient.
- The pharmacist should reserve the right to exercise his judgement to ensure that the welfare of the patient is at all times assured.
- The pharmacist should conduct his affairs and carry out his duties to the utmost of his abilities, striving at all times to bring honour and respect to the profession.
- The pharmacist should respect the trust and confidentiality inherent in his dealings with others.
- The pharmacist should respect the integrity and experience of his colleagues.
- The pharmacist should maintain a level of competence sufficient to provide professional services effectively and efficiently.
Following the enactment of the Pharmacy Act 2007, the new Council of the Pharmaceutical Society of Ireland is currently drawing up a Code of Conduct for pharmacists, incorporating ethics and principles. The Society is currently engaged in a process of consultation on the new code.
4. Information Technology and Patient Care
The development of an IT infrastructure has enormous potential to improve the safety, quality, and efficiency of patient care. Computer-assisted diagnosis and chronic care management programs can improve clinical decision making and adherence to clinical guidelines, and can provide focus on patients with those diseases. Computer-based reminder systems for patients and clinicians can improve compliance with preventive service protocols. More immediate access to computer-based clinical information, such as laboratory and radiology results, can reduce redundancy and improve quality. Likewise, the availability of complete patient health information at the point of care delivery, together with clinical decision support systems such as those for medication order entry, can prevent many errors and adverse events (injuries caused by medical management rather than by the underlying disease or condition of the patient) from occurring. Via a secure IT infrastructure, patient health information can be shared amongst all authorised participants in the health care community.
At the eHealth Conference held on 19 April 2007, representatives of the EU and EEA Member States adopted a common Declaration, agreeing to pursue coordinated and structured co-operation in the area of cross-border electronic health services throughout Europe. Electronic health services are applications such as Electronic Health Records (EHR) or Electronic Transfer of Prescriptions (ETP).
5. Information Systems in Ireland
The Joint Oireachtas Committee on Health and Children published a report in 2007 on the Adverse Side Effects of Pharmaceuticals. The report recommended that the following should be investigated further:
· creation of systems which enable prescribers to access information on patients from different sources such as hospitals, community medicine or pharmacists;
· electronic links should be established between hospitals, GPs and pharmacists ensuring that all sides have full information about common patients;
· exploitation of the database of the HSE Primary Care Reimbursement Service (PCRS) for macro trends in the consumption of different types of drugs;
· creation and dissemination of computerised decision making systems capable of screening for contra-indications and drug interactions when prescribers are considering drug therapies;
· dissemination of software, possibly linked to decision making support systems, which permit prescriptions to be printed in order to avoid mistakes caused by spelling and legibility problems.
The report goes on to say that, when the costs of medicines and adverse drug reactions are considered, even significant investment in computerisation and associated training of professionals, would seem to be justified on cost grounds alone.
6. Electronic Health Records (EHR)
There have been many different views of what constitutes an EHR system. Throughout the EU, some EHR systems include almost all patient data, whilst others are limited to certain types of data, such as medications and ancillary results. Some EHR systems provide decision support (e.g., preventive service reminders, alerts concerning possible drug interactions, clinical guideline-driven prompts) whilst others do not. Most current EHR systems are enterprise-specific (e.g., operate within a specific health system or multi-hospital organisation) and only a few provide strong support for communication and interconnectivity across the providers in a community. The functionality of EHR systems also varies across multiple settings from the perspective of both what is available from vendors and what has actually been implemented. Some EHR systems have been developed locally and others by commercial vendors. In summary, EHR systems are actively under development and will remain so for many years.
It should be noted that the motivation is not to have a paperless record per se, but to make important patient information and data readily available and useable. In addition, computerising patient data enables the use of various computer-aided decision supports.
An EHR system includes:
a) Longitudinal collection of electronic health information for and about persons, where health information is defined as information pertaining to the health of an individual or health care provided to an individual;
b) Immediate electronic access to person- and population-level information by authorised, and only authorised, users;
c) Provision of knowledge and decision-support that enhance the quality, safety, and efficiency of patient care; and
d) Support of efficient processes for health care delivery.
Critical building blocks of an EHR system are the electronic health records maintained by providers (e.g., hospitals, nursing homes, GP surgeries, pharmacies) and by individuals.
7. Electronic Transfer of Prescriptions (ETP)
ETP refers to the electronic transfer of information from the prescriber to the pharmacist and not to a prescription produced with the assistance of a computer.
When discussing a national strategy for ETP, it is important to take into consideration certain professional and legal aspects that apply to the provision of cross-border health services. The view of the EU Commission is that the dispensing of prescriptions from other EU countries should be allowed as otherwise it would be a barrier to the internal market and would somehow be inconsistent with existing legislation on the automatic recognition of professional qualifications. However, there are some practical and public health issues. Firstly, the pharmacist must be able to ensure that the prescriber in question is allowed to prescribe; secondly, the pharmacist must be able to contact the prescriber if any clarification is needed in relation to the prescription.
8. IPU Principles for EHR and ETP
The Union proposes that the following principles be considered when developing the Health Information Bill in relation to EHR and ETP.
1) The system must maintain confidentiality.
2) The system must not dis-improve patient safety.
3) The system must have in-built redundancy if the central server breaks down.
4) The system must be secure.
5) The system must be independent of commercial interests.
6) The system should be accessible to all pharmacists, prescribers, system vendors and patients.
7) System vendors must not be in a position to refuse pharmacists access to the system.
8) The system must permit any authorised prescriber to produce a prescription which can be accessed by any authorised pharmacist.
9) The system must be ‘pull’ and not ‘push’, i.e. the electronic prescription is sent, by the prescriber, to a virtual mailbox which any pharmacist can access (‘pull’ down) with the authorisation of the patient.
10) Prescriptions must only be generated by an authorised prescriber.
11) The patient should be allowed to opt in or out of the EHR.
12) The pharmacy should still maintain individual patient medication records to assist, for example, in product recalls.
13) Pharmacists must have access to all information relevant to the health status of the patient required to properly implement the provisions of Clause 9 of their contract, e.g. disease state, diagnosis, concurrent medication, liver function, kidney function, allergies, etc.
14) The system should be linked to the IPU Product File.
15) The system should be developed in a structured way, overseen by an independent body whose agenda is solely patient welfare, e.g. DoHC, HIQA, PSI.
16) An arm of the State, e.g. DoHC, HIQA, should be in charge of the database.
17) The HSE PCRS should only have access to the financial information relevant to community drug schemes.
18) Access to data mining and anonymised aggregated data should be restricted and only used in the interests of public health and not for any commercial interest.
19) The system must not be specific to any one vendor but must be based on recognised standards.
20) The system should, in addition, be able to provide information on medicines, side effects, interactions, contra-indications and electronic claiming.
21) The system should be future-proofed to ensure compatibility with encoding systems.
22) The system should prevent duplicate dispensing of the same prescription and alert the pharmacist with a meaningful message.
23) The system should be capable of sending alerts to health professionals (including pharmacists) in the case of a product alert/recall.
9. Conclusion
In conclusion, community pharmacists are an integral part of the healthcare system and therefore contribute to the overall objective of better performance, efficiency and effectiveness of healthcare systems. Ensuring that community pharmacists have access to patients’ electronic health records will assist pharmacists in contributing to the quality of life of patients.
The Union would be happy to meet with the Department of Health & Children to discuss the issues raised above or indeed any other relevant issues.
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