Summary overview

The facility exists for NHS prescribers to request prescribed medicines to be dispensed by the community pharmacist in instalments of specified intervals.  One such use is for patients on opiate drug substitution programmes to receive daily methadone.

However the management of multi-instalment prescriptions within a pharmacy is complex and involves a considerable paper trail. The process must be rigorously and proactively managed to minimise the risk of medication errors. The collective professional, technical and managerial time involved in seeing a multi-instalment prescription through from receipt to completion is onerous and costly.

This is the experience of one city centre pharmacy located in a socially deprived area with some 450 or so patients who are in regular receipt of multi-instalment prescriptions of various forms. The workload generated by this volume of patients was fast becoming unworkable. Existing community pharmacy electronic Patient Medication Record systems were unable to resolve the management issues, so the proprietor along with a colleague experienced in developing software, decided to design a bespoke system.

The purpose was to develop a database to relieve the workload on the pharmacist whilst at the same time improving the controls on the processing of multi-instalment prescriptions. The resulting software programme, MicaPharm™, has succeeded in doing this, releasing significant time savings for all grades of staff whilst also substantially enhancing the controls on prescriptions.  Additional benefits were also realised such as the generation of a new label format that allowed particular label characteristics to be highlighted.

Introduction

The facility exists for NHS prescribers to request the community pharmacist to dispense a prescribed medicine in instalments of specified intervals, such as daily. The first and subsequent dispensings generate a fee for the pharmacy that varies depending on whether or not the item is a controlled drug. Prescriptions for patients on opiate substitution programmes are arguably the most frequent use of the instalment dispensing option. For some patients supervision of the self administration of Methadone oral liquid may also be requested. Many permutations of collection days can exist to reflect the instalment intervals and stated supply days, for example twice weekly could be Monday and Thursday, Tuesday and Friday, or Wednesday and Saturday.

The practical aspects of dispensing associated with multi-instalment prescriptions are not accommodated particularly well within many of the standard pharmacy IT systems. This suggests there is a gap in the market place for a pharmacy support system to facilitate the tracking of prescriptions requiring instalment dispensing or supervision of administration.

Management of the prescription through its duration may involve numerous searches for the original script to check, for example, dispensing days and script end dates. All this information, whilst still available on the original script could be more easily searched using a database functions.

Aim

To develop software to support a risk management approach to the dispensing by instalment and supervised administration of prescribed medicine in a community pharmacy.

Objectives

The objectives of the project were: 

Ø      To facilitate the tracking and management of an individual prescription.

Ø      To produce computer generated records that meet legal requirements, for inclusion in the Controlled Drugs Register for prescriptions tracked through the software system.

Ø      To automate the generation of daily dispensing labels from multi-instalment prescriptions.

Ø      To ensure supervision of self administration of methadone is accurately monitored and recorded.

Ø      To generate reports on workload statistics.

Ø      To automate the recording of data required for processing claims.

Method

An approach was made by the proprietor pharmacist as the key stakeholder in this initiative to a friend and colleague with experience of developing computer software to help write and trial a bespoke IT system to automate processes with his community pharmacy.

The brief was to develop a user friendly IT system that would improve working practice within the speciality of dispensing multi-instalment prescriptions.   In particular the need was to reduce the time spent on manual activities such as documentation for claims purposes and Controlled Drug Register entries.

The existing dispensing process was examined to identify the current systems in operation including the labelling process; professional and technical prescription checks; procedures for amending or stopping prescriptions; meeting legal requirements; and processing claims for remuneration.

Following its design and development, the software was installed on the pharmacy system to ensure its compatibility.  It was then trialled for an eight week period to assess system and user acceptability. During this time the pharmacy’s existing manual procedures were also followed and a comparison was made of all computer generated records and information to validate the new system.

Results

Microsoft® Access 2000 was determined as a suitable database for the application. The application was designed as a single user model but with a split database to maintain segregation between the data and the programming. As such it can easily be developed into a multi-user database which may be better suited for larger pharmacies.

Data was divided into a number of relational tables to meet database normalisation requirements and allow the efficient use of data. The key data element throughout the database is the 13 digit prescription number, which is absolutely unique to a patient, a GP, and to one or more courses of medication.

Detailed discussions and extensive trialling allowed development of a user friendly scheme of interlinked forms. The main Control Panel (see screen dumps in appendix) allows access to all the functionality through a series of sub panels, with ultimately all forms closing back to the main Control Panel.

All programming has been undertaken using Microsoft® Visual Basic for Applications within MS Access.

Data flow was carefully monitored to allow maximum effectiveness from minimum input of data, since efficiency was a key objective. Almost all data entry is by way of drop down boxes, from pre-registered tables of data. Alternative paths are all clearly available through command button selection. The programming allows automatic calculation of script end dates, and also accommodates the variety of potential collection patterns specified by GPs.

Recognising the professional importance of verifying that the system has been instructed to produce the correct labels for any given script, careful attention was given to creating a visual clarity for the data presentation. Prior to acceptance of the data into the system the pharmacist is shown all the dispensing labels that will be generated for the prescription based on the data entered, together with a check to ensure that the sum of all the separate instalments equals the figure on the original prescription. At this point the prescription can either be accepted, or rejected so that an erroneous data entry can be corrected.

Once the prescription has been accepted an instalment listing is produced, with a separate listing for each drug on the prescription. These listings are attached to the back of the prescription and are used to monitor instalments and, if required, supervision. This listing also shows the total quantity, number of instalments and number of supervisions that will be generated if the full prescription is utilised.

Dispensing labels are generated from a command button which gives options to print today’s labels, tomorrow’s labels or labels for a specified date. The latter is the one used most. Labels are printed to a Zebra label printer which allows greater flexibility than a dot matrix. The date of supply (as opposed to the date of printing) is included on the label. Also, as relevant, SUPERVISED and/or LAST appear, highlighted for immediate recognition. This visually striking reversal technique is also used to separate sugar free METHADONE MIXTURE 1MG/1ML SF from normal METHADONE MIXTURE 1MG/1ML SUGAR. The risk of any error in dispensing is consequently greatly reduced.

Label sequence was developed experimentally to proactively minimise risk and simplify the technical aspects of dispensing. The final sequence chosen is by drug, and then by supply quantity. This means that all the Dihydrocodeine 30mg tablets are together in descending supply quantity, followed by all the Dihydrocodeine 60mg tablets. This is particularly useful with Methadone since the pump can then be set, for instance, to 50ml for all the 50ml labels.

Security is provided by required logon to reach various functions and all such sensitive actions are tagged with the operator’s code. This makes it much easier to find out who may have an understanding of an issue if it arises. There is additional programmatic security surrounding the Methadone Register to ensure that any tampering with data would be immediately recognisable.

Searching has been made very flexible with full search capabilities for patient name and prescription number. The patient name searches are the most utilised and once identified their full prescription history is available. Double clicking on a drug will show all the dispensing labels generated for the prescription, together with a tag to indicate if a prescription has been stopped. If this is the case then the reason for the stop can easily be called up.

Reports are generated on demand. The main reports are the Methadone Register and the listing of supervisions. A listing of all Methadone issues for the day is used as a check document. The automated reporting from the database allows for significant improvements in both speed and accuracy.

A statistical reporting package is easily accessed. This shows all relevant data in any period as determined by initial input.

Discussion

The database was developed through collaborative consultation between two friends, a pharmacist and a database programmer. The input from both parties was essential to its success.

All the original aims and objectives were met by the database which performed well and remained stable. It is estimated that the ongoing time savings amount to 20 hours of technician’s time and 8 hours of pharmacist time each and every month. Additionally approximately 2 hours per day are saved through the generation of the entries for Methadone in the Controlled Drug Register.

Further trials of the software with other community pharmacies are now required to ascertain if the system is compatible with the differing dispensing procedures in use by individual community pharmacies.

Conclusion

The next stage in this process is to encourage other local community pharmacies to trial the software to confirm its acceptability to a wider user group.  Thereafter its wider marketing and dissemination would suggest the potential for a useful tool for community pharmacies handling large numbers of prescriptions requesting instalment dispensing and supervised self administration of medicines.

Adopting a systematic approach to complex dispensing procedures is a recognised means of minimising risk within the pharmacy profession.   Such a systematic approach facilitates the ability of the pharmacy to handle large patient numbers in a safe manner.  

Freeing the pharmacist from paperwork and laborious dispensing routines allows more time for professional involvement in pharmaceutical care of patients.  Such appropriate skill mix in community pharmacies will be a vital component in realising the vision for pharmacy laid out in key strategy documents such as ‘The Right Medicine: A Strategy for Pharmaceutical Care in Scotland’1   

References