A few column’s ago I welcomed the move towards making pharmacy slightly less paper based. The era of the paperless electronic prescription is almost upon us. Concurrently we will have a paperless controlled drugs register, attendance register and daily prescription report. Before you get carried away, these will only happen when the IT systems are configured in a way that is deemed acceptable. Inevitably, as we get closer to implementation some things begin to crystallise. Deadlines have a great way of concentrating minds. Perhaps the most salient has been that of attribution. This centres around the concept of an audit trail where individual’s details are logged, tied to particular events. People are genuinely concerned that their names will be associated with actions that were not of their making. This would, be definition, fly in the face of any concept of natural justice, not to mind proper record keeping.

For context, recently the PSI closed it’s public consultation on the new proposed rules surrounding electronic record keeping in pharmacies. Historically, giving submissions to the PSI for its consultations haven’t always been seen to be particularly useful. It has been frustrating for a pharmacist to see a strongly felt, carefully worded, argument reduced to a single word response, ‘noted’. This has led to an almost fatalistic attitude towards consultations, where people felt that there was little point in going to the effort of making a submission. On the flip side, the IPU has a robust and dynamic process for creating responses. Many, including this particular pharmacist, let the Union do it’s talking.

Starting from first principles. Unarguably, it is important that a professional takes responsibility for their work and the decisions that they make. However, as always, the devil is in the detail. The modern pharmacy is, by definition, a team environment. A dispensed prescription is typically a product of the labours of a number of people. While you may still find a very rare situation where a prescription is dispensed by an individual, this is very much the exception.

A second principle is that a prescription is a complex document. While it is useful to use the paper analogy, is grossly oversimplifies what can be an extremely lengthy process that can span many days. Indeed, I would be of the view, that a prescription is a living document. This means that I have fundamental problem with the concept of a monolithic original prescription, as specified by the PSI. It is too simplistic.  Within this, dispensing is an even more complex and collaborative process. If we start with a simple paper prescription for one item, it is generally a trivial exercise to assign a workflow. The patient arrives to the pharmacy, hands it to a trained member of staff, who ensures that all relevant information is captured and associated with that piece of paper. It is then passed to the dispensary team. The risk analysis has already started. For instance, we may ask the patient, or their representative, if they have any known drug allergies. If a relevant allergy is not noted at the time, we are already heading into difficult territory. On to the prescription queue. At this stage a technician may assess the document for any obvious discrepancies or issues. It is then passed on to the pharmacist who will determine the appropriateness and safety aspects. Once these are satisfied, the prescription will be entered on the PMR, where further checks take place, and labels are generated. Simultaneously a technician will gather the medication using the prescription as the primary source. Then the label will be united with the medication. At this stage both the technician and the pharmacist will typically initial the label to indicate that the were responsible for this prescription. Simple isn’t it.  What if the drug is unavailable and you had to contact the prescriber for an alternative unlicensed drug? If you only have half the quantity? The technician goes on lunchbreak? Then you start dealing with twenty item hospital discharges late Friday of a bank holiday weekend. Where multiple decisions on multiple discrepancies and issues arise. Where the sheer volume transactions often mean that more than a single pharmacist is involved. Where every prescription line item would have its own, individual, audit trail.

A third principle is that modern computer systems have the equivalent of infinite storage. They can store the most minute details of any set of transactions. For instance, it could store a video recording of the full dispensing process, from initial interaction with the patient to the final handover. However, this has to be counterbalanced by the practicality of relevancy, privacy, complexity and indeed the costs, including environmental, of such an approach. Our PMR systems have a long way to go to deal with modern pharmacy. We are shoehorning inherently flawed solutions into the technology we have to work with. But we will get there.