A national ETP system for the NHS offered a tool for pharmacists to provide better, more integrated care because it would allow everyone access to the same, complete record of a patient’s dispensed medication. But with different service models proposed, and dispensary system suppliers jostling for business, the drawbacks of implementation got the lion’s share of publicity.

Fast-forward to 2006 and paperless prescribing in primary care is at last just around the corner. By July 2006, over 10,000 pharmacists had signed up for their smartcards, which will allow them access to the Electronic Prescription System (EPS), and two early adopter sites were already dispensing prescriptions that GPs had uploaded electronically from their surgery computers on to the central ETP site.

Currently around 70 per cent of the million or so prescriptions issued every day are repeats, and the volume is rising inexorably. This brings the benefits of ETP into sharper focus. A national shared PMR should give pharmacists more control over workload, make label production faster and more accurate, and streamline the reimbursement process. It could also make patient registration a reality.

The Co-op at Keighley West Yorks was the first to go live with Release 1 of the NHS EPS software, which allows the pharmacy to call down prescription details by scanning a barcode on the printed prescription form the patient hands in.

Connecting for Health (CfH), the organisation which has to deliver the NHS national programme for IT (NPfIT), says the aim of Release 1 is to “lay the technical foundations” for EPS. And there certainly have been glitches to solve at the two early adopter sites. Users needed to be trained and registered, the ETP software had to recognise drug codes from a range of GP systems, and the barcode IDs on scripts had to scan properly and connect up to the NHS spine.

ETP is just one part of the hugely ambitious NPfIT programme in which local health records kept in surgeries and hospitals will automatically upload key information onto a summary patient record, held electronically in the NHS Care Records Service ‘spine’. ETP (and the much maligned Choose and Book service) actually sits outside the spine, but communicates with two key spine databases: The Personal Demographics Service, the central source of demographic information and where patients would nominate their chosen pharmacy and provide details of consent, and the Personal Spine Information Service (PSIS), which will contain key information such as drug allergies, medical conditions and medication history.

But it’s not clear at the time of writing (summer 2006) how the information flows when a script is pulled down and dispensed in the pharmacy, and there is lack of clarity on what pharmacists will actually have access to at the point of dispensing. CfH publicity talks about PMRs being written back into the PSIS but it is not clear if this information also stays on the EPS as it would in a pharmacy PMR system. If it doesn’t, then pharmacists would need to access the PSIS records to see a patient’s medication history. To do this, they could need to have explicit patient consent.

Early implementer sites may be tearing their hair about these uncertainties, but from the patient’s point of view, nothing has changed yet. If things go to plan, and CfH can get all pharmacies and GPs signed up to Release 1, the next step is a very big one because the electronic prescriptions that GPs send up the spine will have electronic signatures, making them legally valid. Patients can still get a printed token script, which any pharmacy in England will be able to unlock. But if patients have nominated a particular pharmacy in their electronic care record, that pharmacy can pull down their scripts at any time, without the need for any paper at all.

This change has important implications for patient-professional communication. The patient has nothing in their hand to show what the prescriber ordered, and there is nothing to trigger a discussion about their medicines.

Unknown factors

What do people think about the plans to phase out paper prescriptions? We don’t really know. There is a patient user group for EPS, but CfH keeps membership and agendas strictly under wraps. The CfH website contains patient stories illustrating the advantages that a shared electronic health record could bring them, but there is nothing specific about ETP. Not surprising really, as few people have actually experienced it yet.

However there is some research, done by the Consumers’ Association for NPfIT, on the broader topic of electronic health records. This showed that people thought electronic records would be faster to find and more accurate than paper ones, but also be more vulnerable both to system failures and to unauthorised access. They were most concerned about security, and believed that access should be on a ‘need to know’ basis by people actively involved in their treatment.

Many participants used a traditional definition of the NHS that excluded pharmacists and opticians. A significant proportion of patients felt they should be asked for consent before these health professionals had access to their health records.

These public surveys were done in 2002–03, before any electronic services went live, and services like Choose and Book and ordering repeat prescriptions online seemed far-fetched. People wanted to believe that NPfIT would make the NHS visibly more efficient, but they honestly weren’t sure the NHS could cope with this much change.

Evidence from hospitals

In reality there is evidence from secondary care that ETP and electronic sharing of health records can be made to work. Most hospitals are way behind primary care in terms of computerised prescribing and record-keeping. But at Queen’s Hospital Burton (QHB) virtually all inpatient prescribing, dispensing and administration of medicines, ordering of tests and recording of patient data is done electronically through the Meditech hospital information system.

There are no paper drug charts – instead a nurse calls up a patient’s current drug list and records medicines given on a laptop that sits on the drug trolley. Doctors and pharmacists can access records and make changes from anywhere in the hospital. A shared electronic patient record has been a reality since 1999.

In 2005, London School of Pharmacy researchers interviewed a small number of QHB inpatients. These patients, many of whom had experienced paper systems in the past, said they felt safer with the electronic system. Their prescriptions were always legible, and their notes could always be found. They felt that less paperwork and better information communication reduced the risk of errors by tired staff.

In contrast to the NPfIT surveys, these patients saw electronic health records as more secure and more confidential than a paper chart at the end of the bed. They were familiar with the access controls for staff, as they could see them typing in PINs for every transaction. They liked that: they didn’t want ‘Joe Public’ viewing or changing their details.

Similar benefits were cited in a pilot of the Serve Rx system at Charing Cross Hospital, which uses an electronic drug trolley with barcoded drugs dispensed into individual patient drawers and mobile laptops for prescribing.

Before computerisation, patients were unsure what to expect. Some thought it sounded exciting, but there was an inherent mistrust of computer systems. After implementation a different set of patients voiced fewer concerns and instead compared the computer system favourably to paper. As at QHB, the electronic system was seen as safer, always legible and it saved time on queries.

Both sets of patients were asked to rate their enthusiasm for paper and electronic medication record systems. Before and after implementation, the average score for the system they had now was higher than the system they didn’t have.

It’s natural to be wary of change. But this evidence from two hospitals using paperless systems for drugs and patient records is encouraging because it suggests that – unforeseen disasters aside – the average patient, who just experiences the new, electronic NHS without being involved in discussions beforehand, will probably rate it more highly than the system that went before.

Further information

If you have views about or experiences of ETP, the writer would be interested to hear them. Please contact Imogen Savage on email: This email address is being protected from spam bots, you need Javascript enabled to view it