In April 2020, legislation was implemented in Ireland to allow electronic prescription transfer (EPT) from a prescriber to community pharmacies using Healthmail, without the requirement for a signed paper prescription copy. While the primary need for this legislation included minimising in-person interactions during the COVID-19 pandemic and ensuring continued medication supply to patients, it was unclear how this new initiative would affect pharmacy staff, prescribers, and most importantly patient care. Given the importance of gathering key stakeholders’ views on initiatives like this, a survey study was conducted by researchers in University College Cork to evaluate the perspectives of pharmacists practising in Irish community pharmacies regarding the introduction of EPT via Healthmail, its impact on pharmacy practice and patient care, as well as the potential implications for future EPT use.

 

Survey distribution and respondents

The developed survey was distributed via email to all pharmacists listed on the PSI’s email list for those who had noted ‘community pharmacy’ as their area of practice and who consented to receiving research-related emails (n=3,780). The initial email was sent on 10 November 2020, a reminder email sent two weeks later, and the survey was closed on 8 December 2020. A total of 494 responses were received, which included a diverse range of pharmacists based on years of experience, role, pharmacy type, and pharmacy location — suggesting that the sample should be somewhat representative of the national pool of community pharmacists. This article is based on a survey study which is published in a peer-reviewed journal, Exploratory Research in Clinical and Social Pharmacy (ERCSP). The article can be accessed by scanning the QR code.  

Survey findings and discussion of potential implications

All of the study’s results can be found in the published journal article, available via the QR code. Over these pages in the IPU Review, a subset of some of the study’s findings are discussed, that could be considered having higher priority implications for prescription practices and patient care. Suggestions to inform and optimise future approaches to transferring prescriptions electronically are also set out.  

Patient safety

In comparison to physical prescriptions, most pharmacists agreed that Healthmail prescriptions were easier to read (89.5%) and over one third agreed that they had noticed less medication-related errors made by prescribers on Healthmail prescriptions (35.6%). Approximately two-thirds (66.1%) agreed that using Healthmail for EPT improved patient safety; although that may not seem high, only 7.7% disagreed while 26.2% remained neutral.  

Integration into workflow

Most pharmacists found Healthmail easy to use overall (92.5%) and agreed that it was an efficient and convenient method of prescription transfer (89.7%). Regarding the impact of seeing a prescription before the associated patient or representative presented to the pharmacy: over three-quarters of pharmacists agreed they felt more prepared to counsel the patient or their representative (78.9%), while over two-thirds agreed they could inform the patient if an item is not in stock before they present to the pharmacy (67.9%). With future electronic systems, it will be important to consider this aspect of providing pharmacy staff advanced notice of prescriptions that will likely be dispensed in their pharmacy to facilitate being better prepared to address prescription-related issues.  

Prescription format and layout

Over half agreed that Healthmail prescriptions often lacked one or more legal requirements (54.3%), whilst only 44.5% agreed that Healthmail prescriptions containing controlled drugs generally met all legal requirements. Pharmacists pointed out that prescriptions being stored in Healthmail could only be amended after printing them out; an associated risk is that dispensing staff may re-print the original prescription from the email when repeat dispensing without realising that the prescription should be used in an amended manner. Pharmacists suggested that there should be a mechanism to correct prescription errors electronically, as this would allow pharmacists to amend the prescription online once checked with the prescriber rather than a new one being issued. Pharmacists desired having better search functionality within Healthmail inboxes, and most pharmacists agreed that electronically-transferred prescriptions should have a universal template (91%), which could help with searching for prescriptions and streamline processes overall.  

Prescription security and access

Most pharmacists believed that Healthmail reduced the number of prescriptions that have ‘gone missing’ or ‘gotten lost’ (82%). Meanwhile, over one-fifth of pharmacists often had difficulty identifying the prescriber (22.6%), and several pharmacists perceived that some Healthmail prescriptions were sent by administrative staff in practices without definitively knowing if there was prescriber oversight. Future systems need to have greater security controls (for example, through an audit log) to keep track of what users have access to specific functionalities in systems involving the transfer of prescription-related information.  

Communication with prescribers

Nearly two-thirds of pharmacists (64.6%) agreed that Healthmail improved their communication with prescribers. Most respondents replied to a Healthmail email to conduct an intervention (90.7%), and the majority agreed that some interventions did not receive a prescriber response so they had to take further action (81.9%), such as phoning the prescriber. Due to regular difficulties in receiving a timely response by phone, pharmacists expressed a desire to ensure that there is greater clarity regarding the expectations of healthcare professionals to utilise future systems for bi-directional communication regarding prescription issues so that these can be resolved as swiftly as possible.  

Patient involvement

Nearly half of pharmacists perceived that using Healthmail for EPT had a negative or strongly negative effect on patients’ understanding and overview of their medicines (46.1%). Related to this, nearly two-thirds believed that it had led to patients feeling less involved in the decision-making for their care (63.2%). For example, pharmacists described that some patients were uncertain of the item(s) on their prescription. To help potentially overcome these aspects, it was suggested that patients be provided with knowledge of what is on their prescription (for example, by incorporating a notification system that alerts the patient) and a mechanism to allow patients to flag what item(s) they want dispensed. Pharmacists believed that giving patients greater involvement and control would make them feel more empowered in managing their health.  

Stakeholder education, training, and consultation

Even though pharmacists perceived that Healthmail was easy to use overall for EPT, less than half agreed they received adequate information and training on the use of Healthmail (44%). Similarly, 70.5% agreed that patients did not have enough information about Healthmail, and 80% perceived that patients expected their prescriptions to be dispensed more quickly. Pharmacists emphasised that a significant proportion of patients required pharmacy staff to invest additional time explaining how EPT worked via Healthmail. It was suggested that having a public information campaign would have been beneficial and should be considered when implementing similar initiatives in future. While the implementation of EPT via Healthmail was swift due to the ongoing COVID-19 pandemic, this hindered an extensive stakeholder consultation at the time — especially important for those who would be most affected, such as prescribers, pharmacy staff, and patients. Survey respondents emphasised the importance of providing sufficient education to enhance stakeholders’ understanding of and experience with using a new system like this which affects prescription practices. Furthermore, pharmacists suggested that the provision of more guidance to healthcare professionals (for example, on best practices) could have enhanced communication between the stakeholders involved and minimised some of the issues experienced (for example, the same prescription being sent to multiple pharmacies).  

Informing the future electronic transmission of prescription-related information

Most pharmacists indicated that they would be comfortable in using an almost completely paperless electronic prescribing system (81.1%), that they were in favour of having access to patients’ electronic health records in future (75.9%), and welcomed having an electronic health record which integrated prescription and pharmacy dispensing records (81%).

As EPT via Healthmail functions as a ‘push’ model where prescriptions are sent electronically to a nominated pharmacy, this resulted in prescriptions being sent to the wrong pharmacies, meaning patients’ confidential information had been shared with people that should not have received it. Over half (52.9%) agreed that they would prefer if pharmacy staff could retrieve prescriptions from an electronic repository with patients’ permission (i.e. a ‘pull’ model), whereas 23.2% disagreed. If this ‘pull’ system were to be introduced, it would be of greater importance to ensure that user access is tracked to minimise the possibility of inappropriate access to patients’ prescription records.

Moving forward from this point

This research has shown that while pharmacists believed that using Healthmail for EPT has been a positive step overall, there have also been several deficiencies with its implementation and ongoing use, as well as having potential negative aspects on patients’ involvement in their care. Given that the HSE currently has an active procurement process ongoing for the national ePrescribing Programme, it is essential that these findings are carefully considered in the development and implementation of future ePrescribing systems. Furthermore, it is vital that the opinions of key stakeholders — including pharmacists, patients, and various prescribers — are gathered and utilised to help shape the future of electronic prescribing practices in Ireland, ultimately to enhance patient care.

Acknowledgments: The authors of the survey study were Dr Kieran Dalton, Ciara Kenny, Maeve Culhane, and Robert Callaghan, and they would like to thank the IPU for the invitation to write a piece to highlight these findings, as well as to thank all the pharmacists who responded to the survey and share their rich insights based on their experiences.