Accessibility in the Emergency Department to Patient's Medication History

Accessibility in the Emergency Department to Patient’s Medication History Margarida David OUT|2012 5ª ed Accessibility in the Emergency Department to Patient’s Medication History Margarida David OUT|2012 Prof. Dr. Pedro Pereira Rodrigues Dr. Fernando Rosa 5ª ed ii iii This Thesis is dedicated to my Family and to Bart for their unconditional support, patience and understanding. iv v Acknowledgements The realization of this master’s thesis was only possible thanks to the collaboration and contribution, directly or indirectly, from various people and institutions, to whom I would like to express a few words of thanks and deep gratitude. Foremost, I would like to express my sincere gratefulness to my advisors Prof. Pedro Pereira Rodrigues and Dr. Fernando Rosa for the continuous support of my research, for their guidance, patience, motivation, enthusiasm and immense knowledge. I would like to thank all the healthcare professionals from the Portuguese Public Hospitals who collaborated in this study. Their opinions and information shared through the questionnaire responses were crucial. I also would like to thank all the professionals from the public healthcare services in the Netherlands for having accepted the interviews. A special thanks to Bart Wouters, Information officer in Avans University of Applied Sciences, for doing the recruitment of interviewees and for being the interpreter during all the interviews. Also many thanks to Remco Janssens, managing director of the departments ED, Physiotherapy and Pharmacy in Zuwe Hofpoort Ziekenhuis, for being the connective link between the interviewees. To all my friends who have always been present at this phase of my life and always gave me unconditional support, courage and strength, a very special thanks. Without their friendship this thesis may not have been completed. I am also very grateful to José Adão for his precious help at the final stage of my study. Last but not the least; I would like to thank my family: my parents Valdemar and Natália, my brother Luís, my sister Lúcia and my aunt Maria, for the invaluable support and understanding, by the various sacrifices and the constant encouragement to pursue this study. And most of all to my boyfriend Bart Wouters for his love, patience, support and optimism given along the process of this thesis. Thank you. vi vii Context The idea for the subject of my Master's thesis came to mind while developing the project for the Medical Informatics discipline in the first year of this master’s degree. The essay of this project with the theme" Accessibility to a database with Patient's Medication History: Can Improve the patient's care and safety in the Emergency Department?" aimed to compare systems that provide the access to patient’s medications histories in real-time. This study made me realize that something should be done in Portugal in relation to this matter, since medication errors are a major concern worldwide and, more specifically, in Portugal. Most part of the hospital prescribing errors are attributable to incomplete medication histories when a patient is admitted at the emergency department. My professional experience as a consultant during 4 years, particularly in the implementation of electronic health records in several emergency departments nationwide, further intensified my interest in this subject. xiv • Prescription history ........................................................................................ 9 2.2 Scenarios in other countries .................................................................... 10 • Netherlands ........................................................................................... 10 • Ontario, Canada .................................................................................... 12 • Indiana, U.S. .......................................................................................... 12 • Andalusia, Spain .................................................................................... 12 2.3 Research Methods ..................................................................................... 13 2.3.1 Principles of questionnaire construction ............................................ 13 2.3.2 Analysing qualitative interviews ........................................................... 13 3. Methods .......................................................................................... 17 3.1 Questionnaire to ED physicians ............................................................. 17 3.1.1 Objective ................................................................................................. 17 3.1.2 Participants .............................................................................................. 17 3.1.3 Recruitment ............................................................................................. 19 3.1.4 Questionnaire Development ................................................................ 20 3.1.5 Data collection methods ....................................................................... 22 3.1.6 Statistical Analysis .................................................................................. 23 3.2 Interviews in the Netherlands ................................................................. 24 3.2.1 Objective ................................................................................................. 24 3.2.2 Participants .............................................................................................. 24 3.2.3 Recruitment ............................................................................................. 25 3.2.4 Interviews ................................................................................................ 26 3.2.5 Qualitative analyses ................................................................................ 26 4. Results ........................................................................................... 29 4.1 Questionnaire ............................................................................................. 29 4.1.1 Sample Description................................................................................ 31 4.1.2. How often physicians (frequency) seek for patient’s medication history ................................................................................................................ 34 4.1.3. Discussion about the importance of accessibility to medication history in the ED ............................................................................................. 35 4.1.4. Opinion about benefits with the access to medication history in the Emergency Department ........................................................................... 35 4.1.5. In a computer application which information should be accessible regard to patient’s medication history .......................................................... 37 4.1.6. Types of medications that should be included in the computer application ......................................................................................................... 39 xv 4.1.7. Other information that should be included in computer application ................................................................................................................. 40 4.1.8. Comments .............................................................................................. 41 4.2 Interviews in the Netherlands ................................................................. 41 4.2.1. By what way do pharmacies allow access to a patient’s medication history? .............................................................................................................. 42 4.2.2. The access to medication histories is through a computer application: All pharmacies use the same software? There are an institution in the Netherlands that certifies the software used in the pharmacies? ...................................................................................................... 44 4.2.3. The access to medication histories through pharmacies is national, regional or local? .............................................................................................. 46 4.2.4. Patients signed informed consent form? ........................................... 47 4.2.5. How does a physician/pharmacist identify himself when he wants to access information from the patient's medication history? .................. 49 4.2.6. By what way can the patient’s medication history be accessed? .... 50 4.2.7. Who can access patient’s medication information? ......................... 52 4.2.8. If patients can access their medication history, how can obtain it? ... ................................................................................................................. 53 • With their identification (Citizen Service Number)? ...................... 53 • To whom they can request this information? .................................. 53 4.2.9. Institutions in which information can be accessed: Public hospitals; Private hospitals. .............................................................................................. 54 4.2.10. Which departments in a hospital are allowed to access information from patient’s medication histories? ...................................... 55 4.2.11. What kinds of medications become available on the medication history of patients? .......................................................................................... 56 4.2.12. For how long the medication history is kept? ................................ 59 4.2.13. Which information is available regarding medication history (e.g. internal prescription)? ..................................................................................... 60 4.2.14. Which information is available regarding the medication history? .. ................................................................................................................. 61 4.2.15. Other subjects: Information campaign in the Netherlands “If you go to the doctor, bring your medication list” .............................................. 62 4.2.16. Other subjects: Family doctor and family pharmacist. ................. 64 4.2.17. Other subjects: The process of receiving the prescriptions in the community pharmacy ...................................................................................... 68 4.2.18. Other subjects: E-prescribing in the Netherlands ......................... 69 xvi 4.2.19. Other subjects: LSP – National Switch Point ................................ 70 5. Discussion ..................................................................................... 73 5.1 Main Findings ............................................................................................ 78 5.2 Main Recomendations .............................................................................. 79 5.3 Limitations.................................................................................................. 81 References ............................................................................................... 83 Appendix ................................................................................................. 87 Appendix I – List of Portuguese Public Hospitals with more detail Appendix II – Formal requirement for Questionnaire authorization Appendix III – Questionnaire Appendix IV – Article submitted for the 4th Medical Informatic’s Symposium, 2011 Appendix V – Question List (interviews in the Netherlands) Appendix VI – Example of an interview transcription feedback Appendix VII – List of hospitals which authorized the questionnaire and their respective number of answers Appendix VIII – Interviews transcriptions from the Netherlands xvii List of Abbreviations ACSS – Central Administration of the Health System (Administração Central do Sistema de Saúde, I.P.) CIC – Health Committee on Clinical Information Technology (Comissão para a Informatização Clínica) CRRNEU – Commission for the Reevaluation of the National Network of Emergency and Urgency (Comissão para a Reavaliação da Rede Nacional de Emergência e Urgência) ED – Emergency Department EMD – Electronic Medication Record EMR – Electronic medical record EPR – Electronic Patient Record EPD – Electronic Health Record GP – General Practitioner HL7 – Health level 7 INEM – National Institute for Medical Emergencies (Instituto Nacional de Emergência Médica) INFARMED – National Authority of Medicines and Health Products (Autoridade Nacional do Medicamento e Produtos de Saúde, I.P.) xviii LSP – Landelijk Schakel Punt (National Switch Point) NHS – National Health System (Sistema Nacional de Saúde) NICTIZ - National Information and Communication Technology Institute for Healthcare PDS – Portuguese Health Record (Plataforma de Dados da Saúde) RHAs – Regional Health Administrations (Administrações Regionais de Saúde) RNU – Users National Register (Registo Nacional de Utentes) SIGIC – System for management of (waiting list) patients waiting for surgery (Sistema Integrado de Gestão de Inscritos para Cirurgia) SPMS – Shared Services of the Health Ministry (Serviços Partilhados do Ministério da Saúde) SPSS – Statistical Package for the Social Sciences URL – Uniform Resource Locator WDH – Electronic General Practitioner’s Record xix List of Figures Figure 1 – Examples of countries which allow the accessibility to patient’s medication history ... 10 Figure 2 - Phases of qualitative data analysis (Miles & Huberman, 1994) .......................................... 14 Figure 3 - Schematic illustration of the sample ........................................................................................ 30 xx xxi List of Tables Table 1 - List of questions (Berkowitz, 1997) .......................................................................................... 14 Table 2 - List of Portuguese public hospitals based on the distribution of Regional Health Administrations - RHAs (MINISTÉRIO DA SAÚDE, 2012) ............................................................ 18 Table 3 – Questions ....................................................................................................................................... 21 Table 4 - Types of response scales.............................................................................................................. 22 Table 5 - Interviews in the Netherlands .................................................................................................... 25 Table 6 - Number of answers by Hospital ................................................................................................ 31 Table 7 - Questionnaire responses split by Residents and Specialists ................................................. 33 Table 8 - How often physicians seek for patient’s medication history ................................................ 34 Table 9 – Association between the workload at ED and how often physicians seek for patient’s medication history .......................................................................................................................................... 34 Table 10 – Importance of accessibility to medication history ............................................................... 35 Table 11 - Benefits with the access to medication history in the ED .................................................. 36 Table 12 – Which information should be accessible regard to patient’s medication history? ........ 38 Table 13 – Types of medications that should be included in the computer application ................. 39 Table 14 – Other information that should be included in the computer application ...................... 40 xxii xxiii Thesis Outline Chapter 1 Presents a brief introduction to the concept and services provided from the Emergency Department and shows the problem setting and the aim of this study. Chapter 2 Background shows a brief summary of the current Portuguese scenario and systems in other countries which allows access to patient’s medication history. Further shows the principles of questionnaire construction and displays one of the potential modes of analyzing qualitative interviews. Chapter 3 Exposes the methodology used throughout this study: explain the methods used to carry out the questionnaire in Portuguese Public Hospitals as well as the methodology used for the interviews with professionals from the public healthcare services in the Netherlands. Chapter 4 Presents the results of the questionnaire applied to the Portuguese Public Hospitals as well as the results of the interviews carried out in the Netherlands. Chapter 5 Discusses the results from the questionnaire applied to the Portuguese Public Hospitals as well as the results from the interviews carried out in the Netherlands. Moreover present the research limitations during this study, the main findings of this study and the main recommendations for a possible implementation of a project in this context in Portugal (bearing in mind the current scenario in the country). 6 Backgroud procedures that be subject to manufacturers, distributors, prescribers, pharmacies and other points of sale medicines. (INFARMED, 2012) The liberalization of the sale of medicinal products not subject to medical prescription in 2005, was one of the measures adopted by the Portuguese government. That is, the marketing of the formerly known "non-prescription drugs" started to be commercialized outside pharmacies. However, it required the presence of qualified technicians in their delivery to the public. This regime provides benefits for consumers since it increased the number of medicines points of sale and allowing more accessibility. (Ministério da Saúde, 2005) 2.1.2 The Electronic Prescription The Electronic Prescription is the procedure for issuing prescriptions through computer applications certified by the ACSS – Administração Central do Sistema de Saúde, I.P. – Central Administration of the Health System. (Ministério da Saúde, 2012) With the introduction of the Electronic Prescription, the Portuguese government sought to stimulate the health system informatization. At same time a better communication between professionals from different institutions, since there is a standardization of the format of the information that is exchanged. Reducing the risk of errors in prescriptions was another goal. This policy also had the objective of controlling the entire circuit of the medicinal products and consequently reduction of fraud. (Ministério da Saúde, 2011) The electronic prescription of drugs took effect on 1 August 2011. The electronic prescription applies to all medicinal products subject to medical prescription, but can also be used for prescription medications not reimbursed. (Portal da Saúde, 2012) After the introduction of electronic prescription users who go to a pharmacy with a prescription written by hand lose the drug reimbursement from the government. Unless prescribers are framed within the exceptions of the ordinance that regulates the electronic prescription: cases of unsuitability of the prescribing information, system failure or lack of access to the computer system, reduced doctor's prescription (less than or equal to 50 prescriptions per month) or carried out in the patient's home. (Ministério da Saúde, 2011) 2.1.3 Portuguese Health Record (PDS) Background 7 The Plataforma de Dados da Saúde (PDS) - Portuguese Health Record, was developed by the Comissão para a Informatização Clínica (CIC) – Health Committee on Clinical Information Technology and the Serviços Partilhados do Ministério da Saúde (SPMS) – Shared Services of the Health Ministry, and operates as national registry allowing healthcare professionals to access relevant clinical information from patients anywhere in the country. (Portal da Saúde, 2012) With the PDS the healthcare professionals from the Sistema Nacional de Saúde (SNS) – equivalent to NHS - can access patient’s clinical data that until now were dispersed in different information systems. The data that are available in the PDS remain located in their various original institutions spread over Portugal. The platform is confined to consult the different systems for delivering health information to healthcare professionals. The access to PDS is restricted and audited, being possible knowing who and when patient’s clinical information was consulted once the access it is registered. For example, the PDS allows the heath professional of the hospital accessing some clinical data from the Health Center without be able to change or damage. (i-GOV, 2012) Through the PDS, professionals in hospitals and primary care will now be able to view information from NHS institutions, the historical records of the Instituto Nacional de Emergência Médica (INEM) – National Institute of Medical Emergency, the historical records of the Plano Nacional de Saúde Oral – National Oral Health Plan, the patient's prescriptions history and the data that patient’s has entered in the Portal do Utente – Citizen Portal, depending if they have given permission to view, like contacts in an emergency situation or the medication in use. Also supplementary diagnostic performed in hospitals and primary health care, which are electronically stored in various information systems, should be progressively accessible through PDS to healthcare professionals who provide care in polyclinic, internment or emergency. (iGOV, 2012) A huge variety of data about the patient begins to be accessible to healthcare professionals by a unique platform. But this is an access that, nationally, is being made available through various phases. The PDS provides clinical information through different portals to different stakeholders: Portal do Utente (Citizen Portal); Portal do Profissional (Health professional Portal) and Portal Internacional (International Portal). (Portal da Saúde, 2012) 8 Backgroud a) Citizen Portal The Citizen Portal became operational in early May 2012 and allows citizens to fill in their health records and utilize several online services. The user has a reserved area for entering their data where can register emergency contacts, health data, habits, medication in use, allergies, illnesses, etc. The entire clinical information will be accessible throughout the country if the patient agreed to share their data with the SNS by default. This information will be accessible in the Citizen Portal by two different ways: a) information entered by the user or b) clinical information entered in various different information systems of the National Health Service. When the patient does not intent that clinical information should be shared then he should consult the website and state that he does not agree. It should be noted that the intention of sharing or not sharing clinical information expires after 12 months. (Ministério da Saúde, 2012) In the Citizen Portal, the user will also have access to “eAgenda”, a service that allows scheduling appointments with the GP and request chronic prescription; the “eRNU” – Registo Nacional de Utentes – Citizen National Register, which allows accessing the user data registration (e.g. identification, address, etc..) and the “eSIGIC” – Sistema Integrado de Gestão de Inscritos para Cirurgia –Integrated Management System for Surgery Subscribers, which allows to consult information regarding registration for surgery. (Ministério da Saúde, 2012) • Registration of medication in use The user (citizen) can enter data about his medication in use or previously used, prescribed or not prescribed by a physician. The user has the following fields available: a) active substance title for each medication; b) if currently his taking the medication; c) date of initiation of dosing; d) time of dosage of the medication; e) pharmaceutical form (e.g. oral); f) duration (e.g. less than 3 days); g) recurrence (e.g. daily); h) daily frequency (e.g. 1 per day) and i) reason why his taking that medication. The user can also edit the input data as well as delete the entered data. It has still available the option to export this data as a calendar to Outlook or Google Calendar. After fill in the therapy grid the user can print it. (Ministério da Saúde, 2012) Background 9 b) Health Professional Portal In the first phase, which coincided with the official launch in Porto, the PDS became accessible to institutions and health professionals under the coordination of Administração Regional de Saúde do Norte (ARS Norte) – North Regional Health Administration. Throughout this year the use of platform will be extending to other regions and ARS’s of the country. (i-GOV, 2012) The access to the Professional Portal is made from the information system of the institution (e.g. SAM – Sistema de Apoio ao Médico) where the healthcare professional is working. To access the platform, the physician should have an open session from the patient. Thus, selecting the icon of PDS, is opened a session in the professional portal that will focus on that patient. In this portal the health professional has access to various functionalities, including: map (area of connection between the systems of the various institutions of the country); timeline (perspective chronological of the patient episodes); Citizen Portal (Consultation of information entered by the user, but only if it has been authorized in advance by itself); oral health (a summary of oral health) and also the history of prescriptions. • Prescription history In the prescriptions history menu the healthcare professional can view the history of prescriptions issued in the last six months. The history of prescriptions is composed of several prescriptions emitted to the patient. In this menu the healthcare professional has access to the following information: (Healthcare Professional, 2012) • Information that identifies the prescription (date; recipe number unique, recipe state and renewal number of recipes); • Prescription details (name of the physician who prescribed the medications and location of the prescription) • Details of prescribed medications (active substance (e.g. Pantoprazole); prescribed dosage (e.g. 40 mg); pharmaceutical form (e.g. pills), tablets (e.g. 60 units) and amount of tablets (e.g. 1 unit)). 10 Backgroud 2.2 Scenarios in other countries Many organizations in many countries have already begun to redesign their clinical processes to improve the patient’s care and safety. One strategy to minimize the possible problems with medication errors is having electronic access to patient’s medication history, through databases from national community pharmacies. In this way, physicians have knowledge about what, when and how much medication was dispensed from the pharmacy to the patient. In the Figure 1 is shown a few examples of countries that already allow access to patient’s medication history. Figure 1 – Examples of countries which allow the accessibility to patient’s medication history • Netherlands The Dutch health care system is considered to be pioneer in the transition to electronic medical records along with other developed countries such as Denmark, Australia or New Zeeland. (Barjis, 2010) •The patient’s medication history is based on dispensing information retrieved from community pharmacies. Netherlands •The physicians from the ED’s are allowed to access (view and print) a patient’s medication history in real-time Ontario, Canada •Medication Hub allows in ED the accessibility to medication history: medications that the patient is taking at the moment or has already taken Indiana, U.S. •Diraya contains a patient medication profile, and can be accessed by ED physicians at any service location. Andalusia, Spain Background 11 Back in 1972, the Netherlands tried to build an integrated health system. Their first project was conducted at University Hospital Leiden in order to develop an integrated Hospital Information System. Since 1985 most of the general practitioners had been using an information system in their offices. (Barjis, 2010) The use of EMR’s is quite high in the Netherlands; however there are still several challenges ahead in order to build an integrated healthcare information system. In recent years the Ministry of Health together with NICTIZ, the national IT institute for healthcare in the Netherlands, is developing a nationwide system – the National Switch Point (LSP – Landelijk Schakel Punt), that provides the electronic exchange of medical data to qualified professionals throughout the country. (NICTIZ, 2008)The implementation of the Electronic Health Record (EPD) is being developed in several stages. Initially the aim is that an Electronic Medication Record (EMD) and an Electronic General Practitioner’s Record (WDH) will be introduced. (Barjis, 2010) There are certain aspects that facilitate the implementation of this project, such as the existing regional electronic exchange, the communication facilities between General Practitioners and pharmacists, and the fact that most part of the practitioners presently use EHR’s in their practice. Therefore, the future objective of NICTIZ is to connect all practices to the central database. (Department of Health Policy, 2009) For privacy reasons this project was canceled in November 2011. At present, the Ministry of Health has transferred the LSP to a separate organization called Vereniging van Zorgaanbieders voor Zorgcommunicatie (VZVZ) - Association of Healthcare providers for Healthcare Communications. In November 2012 the VZVZ will start a campaign towards patients to ask their permission to include their data in the LSP. They are going to inform how patients may authorize the provision of their medical records and ask them to fill in a form (at their doctor, pharmacy, or online). The objective is that patients allow their information to be accessible for all healthcare professionals in the Netherlands. If patients don’t give authorization until January 1, 2013, their data are not including on the LSP (but patients may also authorize after that). (VZVZ, 2012) 12 Backgroud • Ontario, Canada In Ontario, one of the provinces of Canada, the Ministry of Health and Long-Term Care provided most Ontario hospital ED’s with electronic access to the medication history of patients, through the Ontario Drug Benefit program (ODB). The electronic records of dispensing medications carried out in pharmacies are the source for the medication history. (Paterson , Suleiman, Hux, & Bell, 2008) The physicians from the ED’s are allowed to access a patient’s medication history in real-time. The major objective of this system is to help healthcare providers to quickly identify and prevent drug reactions, and provide more informed emergency care. Physicians who work in emergency when access this information can make a faster diagnosis and prognosis. (Paterson , Suleiman, Hux, & Bell, 2008) • Indiana, U.S. In Indiana, the Regenstrief Medication Hub aggregates data from the RxHub, a consortium of pharmacy benefit managers. The main objective of the Medication Hub is the availability of medication history. With this information the ED health professionals know what kind of medication the patient is taking at the moment or has already taken. (Simonaitis, Belsito, & Overhage, 2008) • Andalusia, Spain The Diraya system (Historia Clínica Digital del Ciudadano, or Citizen’s Digital Medical Record) allows healthcare professionals to access to a database for the region of Andalusia. (Suárez-Varela, Beltrán Calvo, Molina López, & Navarro Marín, 2005) Diraya took advantage of the fact that some physicians were already using computer-aided system for prescriptions, the Receta XXI. Furthermore, the Receta XXI is an electronic prescription system that connects the doctor’s office and the pharmacy. Diraya supports e-prescribing (Receta XXI) and the dispensing of medications. (Protti, 2007) Diraya contains a medication profile (medications prescribed and dispensed to patients), and can be accessed by physicians at any service location. The emergency care professionals can view patient’s information about the current and past medications in Diraya’s medication record. (Suárez-Varela, Beltrán Calvo, Molina López, & Navarro Marín, 2005) Background 13 2.3 Research Methods 2.3.1 Principles of questionnaire construction There is a large variety of ranges and types of questions that can be used in developing a questionnaire. Depending on the choice of these, the data collection and analyses will be affected. In the construction of a questionnaire might be used open questions, closed questions or both. Open questions allow respondents to expand their answers and give more and rich information to the researcher. On the other hand, requires that the researcher is prepared to analyze the amount of information which is sometimes excessive. (Rattray & Jones, 2007) The use of closed questions allows respondents to choose from a limited number of responses established by the researcher. Thus the researcher can synthesize the data results in a faster and easier way. (Boynton & Greenhalgh, 2004) Along the questionnaire the researcher can utilize multiple-choice questions (with two or more answer options) allowing the respondents to choose: a) one of two answer choices, b) choose one of many answer choices or c) choose many alternatives. In addition to the multiple choice questions the researcher also can resort to scales. The Lickert scale is one of the most widely used and since it is composed of fixed format responses, allows measuring the attitudes and opinions from the participants. (Boynton & Greenhalgh, 2004) The Likert scale is used to measure the levels of agreement or disagreement of the respondents. For each statement, the respondent is asked whether, and how strongly, they agree or disagree. A frequency scale can also be used in the construction of a questionnaire. With this type of scale it is possible to measure the frequency of behavior (how frequently the respondents execute certain actions). Another scale that is often used is the importance scale. This one measures the level of importance that respondents give a particular subject. 2.3.2 Analysing qualitative interviews The qualitative research involves the collection, analysis and interpretation of data, which can be collected from interviews, observations, focus groups and others. 14 Backgroud There are several analysis procedures that have been developed in the last years in the qualitative research area. A qualitative analysis can be performed according the approaches of the following authors. Berkowitz's supports that when the analyst is making a qualitative analysis of data, he must keep in mind a list of questions that he must constantly try to answer. (Berkowitz, 1997) The Table 1 shows the list of questions that the analyst should be “asking and reasking” Table 1 - List of questions (Berkowitz, 1997) Questions • What patterns and common themes emerge in responses dealing with specific items? How do these patterns (or lack thereof) help to illuminate the broader study question(s)? • Are there any deviations from these patterns? If yes, are there any factors that might explain these atypical responses? • What interesting stories emerge from the responses? How can these stories help to illuminate the broader study question(s)? • Do any of these patterns or findings suggest that additional data may need to be collected? Do any of the study questions need to be revised? • Do the patterns that emerge corroborate the findings of any corresponding qualitative analyses that have been conducted? If not, what might explain these discrepancies? The processes that Berkowitz presents for the analysis of qualitative data are based on the framework developed by Miles and Huberman (1994): data reduction, data display, and conclusion drawing and verification. (Miles & Huberman, 1994) Figure 2 - Phases of qualitative data analysis (Miles & Huberman, 1994) Miles and Huberman (1994) state that, "Data reduction refers to the process of selecting, focusing, simplifying, abstracting, and transforming the data that appear in written up field notes or transcriptions." (Miles & Huberman, 1994) Data reducing Data display Conclusion drawing and Verification Background 15 Data display is the next step in Miles and Huberman's (1994) model of qualitative data analysis. The data provides "an organized, compressed assembly of information that permits conclusion drawing..." (Miles & Huberman, 1994) Conclusion drawing and Verification is the final step of qualitative analysis. According to Miles and Huberman's (1994): "The meanings emerging from the data have to be tested for their plausibility, their sturdiness, their ‘confirmability’ - that is, their validity". (Miles & Huberman, 1994). 22 Methods Section I aimed to collect personal and professional data from the participants of the questionnaire. In section II the purpose was to measure the importance of access to patient’s medication history in the Emergency Department as well as the type of information that should be accessible in real time. The majority of the questionnaire contained closed questions allowing respondents to choose from a limited number of responses. Along the questionnaire the researcher has used multiple-choice questions and scales. In the Table 4 Is shown the types of scales used throughout the questionnaire. Table 4 - Types of response scales Type of response scale Example Agreement 1. Strongly Disagree 2. Disagree 3. Neutral 4. Agree 5. Strongly Agree Frequency 1. Always 2. Often 3. Sometimes 4. Rarely 5. Never Importance 1. Irrelevant 2. Not so important 3. Important 4. Very important 5. Determinant In the multiple choices questions the respondent always had an option for "other" to be filled in, if necessary. Only the last question in the questionnaire was open, allowing the respondent to write specific information that he thought relevant to the study. The questionnaire was developed in a way that the answers were not mandatory. Thus the respondents had the freedom to answer only the questions they wanted. 3.1.5 Data collection methods To conduct the questionnaire the web-based survey MedQuest was used. This application is based on web technologies, intended for the operation of online questionnaires in health. (Gomes, 2009) Methods 23 Using Web-based surveys has various benefits over conventional paper questionnaire. Once the data is collected electronically the researcher has immediate access to the answers given to the questionnaire. It also enables a faster and cheaper analysis of data. (Wyatt, 2010) After building the questionnaire was then needed to create the URL (Uniform Resource Locator). To each hospital that was part of the sample was created a specific URL. Thus the researcher would know immediately which hospital was replying to the questionnaire (the researcher had no access to respondent identification, only had access to the group number attributed to the hospital). 3.1.6 Statistical Analysis The data collected from the questionnaires was collected on July 31, 2012. Through the Export module of MedQuest was possible to export all the data into IBM® SPSS® (version 19) for subsequent statistical analysis. The data collected have been cleaned by removing the data from tests, only maintaining the data related to the questionnaires answered by the participating hospitals in this research. In statistical analyses of data were used specific tests, starting with a descriptive analysis followed by performing tests to find out if there were relevant differences between responses: Mann-Whitney U test (to compare differences between two independent groups) and Pearson Chi-square (to discover if there was a relationship between two categorical variables). Was also calculated a summary measure such as the median. The variables considered for the statistical analyses were the following: 1. Gender 2. Age 3. Medical training level 4. Medical specialty 5. Institutions where you work besides ED 6. Please mention the number of work hours per month at ED 7. In an emergency situation how often you seek for patient’s medication history medication history in the ED 8. Discussion about the importance of accessibility to medication history in the ED 9. Your opinion about benefits with the access to medication history in the ED 24 Methods 10. In a computer application which information you think should be accessible regard to patient’s medication history? 11. What kind of medications (prescribed and non-prescribed) you think should be included in the computer application 12. Other information that should be included in the computer application 13. Comments (other information considered relevant) 3.2 Interviews in the Netherlands 3.2.1 Objective To understand the operational aspects of the existing applications in the Netherlands, the researcher interviewed many different professionals from the public healthcare services. The purpose was to talk with all the stakeholders which could be important to accomplish one of the most important aspects, the Electronic Medication Record. 3.2.2 Participants The researcher conducted seven face-to-face interviews; all of them in the English language. Whenever necessary the researcher worked with the assistance of the interpreter – Bart Wouters. All the interviews were tape-recorded with the authorization of the interviewees and the interpreter. If such authorization was not granted by all interviewees the data collection have been made using the method of writing. The Table 5 comprises all the interviews from the Netherlands. Methods 25 Table 5 - Interviews in the Netherlands Date Name Function Hospital/Institution Region Nov 7, 2011 Dr. A. R. Hulsmann Pediatric Amphia Ziekenhuis Breda Dr. Marc Jonkers Pediatric Nov 7, 2011 Dr. Relin Verzijl Hospital Pharmacist Amphia Ziekenhuis Breda Nov 7, 2011 Dr. Renier van Dinter NBD Manager Janssen-Cilag B.V. Tilburg Nov 7, 2011 Dr Gert-Jan Schassfoort Family Physician Huisartsenpraktijk Markt EttenLeur Nov 8, 2011 Dr. Rob Kuiper Hospital Pharmacist Zuwe Hofpoort Ziekenhuis Woerden Nov 8, 2011 Dr. M. Stammers Local Pharmacist LLOYDS Apotheek EttenLeur Nov 9, 2011 Dr. Lily Heijnen Program Manager Amphia Ziekenhuis Breda 3.2.3 Recruitment The researcher was able to interview a variety of professionals from the public healthcare service in the Netherlands due to the contacts of Bart Wouters, which was the interpreter at all times. The objective was to talk with all the stakeholders witch could be important for the study of the electronic medication record. The researcher has managed to talk with all the stakeholders she intended to; with the exception of an Emergency Department Director. The recruitment of interviewees was made by Bart Wouters. The researcher explained to Bart which kind of professionals would like to interview for the research. Through his personal connections Bart found the right professionals and was the person who made the first contact by telephone to ask these professionals if they liked to participate in an interview. Later on he was also the interpreter during the interviews. After accepting the interview and setting a date and time, the interviewees received an email to confirm the interview. Two weeks before the interview an e-mail was sent explaining the subject and the objective of the study. That email included also an interview guide and an academic article with the theme “Accessibility in the Emergency Department to patient’s medication history”. This article was written for the 4th Medical Informatic’s Symposium, in October 2011, Faculty of Science, University of Porto. (See in Appendix IV). 26 Methods 3.2.4 Interviews The data collection method was comprehensive and detailed and was done through face-to-face interviews. It was used a combination of open-ended and closed-ended questions during the interviews, for which has been used a preprepared interview guide. The structured interview guide included keywords to help the interviewees, the interpreter and the researcher to combine the two types of questions. With this method the researcher gained a bigger amount of information and more clarification (See in Appendix V). The purpose of sending the interview guide to the interviewees in advance was for them to be prepared and know exactly the content of the interview. It was also very important during the interview because it facilitated a logical order of the interview with not to many deviations. All the interviews were face-to-face which allowed the researcher to further clarify and even adjust the questions as needed. The questions were repeated or reformulated when necessary. Like this the researcher could also be certain that the questions as well as the responses were correctly understood. The interviews were conducted in an informal way. Sometimes the order of the questions was changed during the course of the interview due to the professional interests of the interviewee. While the interview was recorded on audio support, some notes were being taken by the interviewer. The interviews took place in the interviewee workplace or in the boardroom of his department and lasted on average one hour. At the beginning of each interview, the researcher always explained the subject and the aim of the study as well why the choice of the interviews in the Netherlands. Has also been asked what the role of the interviewee in the hospital or institution was. The existence of an interpreter was vital, as sometimes the Dutch language was used when the interviewee could not clearly explain his point of view. The interpreter was properly prepared for the interview and knew exactly what was intended. He was also allowed to ask questions when needed. 3.2.5 Qualitative analyses The data collection has been based on qualitative methodology such as interviews. The data from the interviews consists of direct explanations from the interviewees about their views, practices and knowledge. Methods 27 The first step of this process was to make a transcript of the audio taped interviews. (See in Appendix VI)Thereafter the transcribed text was compared again with the recording. By this way the last mistakes and repetitions could be corrected. Some subjects mentioned in the interviews, particularly the software terms which are used in the Netherlands, had to be confirmed by using the internet and by consulting the interviewees. Next the transcription of the interview was send to all the interviewed. The researcher sent an e-mail thanking their collaboration and asking if they could read the transcript of the interview, and if necessary, correct or add any relevant information. The Question List was also sent again. The analysis of the interview transcripts was based on an oriented approach to identify themes, categories, patterns, and relationships in collected data. In the transcript of the interviews was taken into account issues such as overlaps, contradictions, recurrences, concordances, discrepancies and emphases. The researcher followed the approach of Miles and Huberman (1994) presented in the chapter Analysing qualitative interviews. • To organize the data collected from the interviews, and in an attempt to reduce the vast amount of the data, only the relevant information for the study in question has been taken into account. Has been especially focused on the list of questions that accompanied all the interviews. • In this step patterns and interrelations were identified. The data was organized according to themes – answers to the question list and other findings related with the question. The researcher had attention for all the data which occurred: overlaps, contradictions, recurrences, concordances and discrepancies. The data were summarized and the findings were interpreted and synthesized. For the verification and confirmation of the preliminary conclusions from the interviewees were asked for their feedback. It was also asked to explain the current situation in the Netherlands, specially the progress of the implementation of electronic prescribing and about LSP – the National Switch Point (See in Appendix VII). 28 Methods Results 29 4. Results This chapter presents the results of the questionnaire applied to the Portuguese Public Hospitals as well as the results of the interviews carried out in the Netherlands. For that reason this chapter has been divided into two sections: Questionnaire and Interviews in the Netherlands. 4.1 Questionnaire The responses to the questionnaire were collected on July 31, 2012 totaling 83 answers (n=83). The initial sample was composed by 41 hospitals, of which: 14 hospitals authorized the release of the questionnaire; 1 hospital did not authorized; 1 hospital authorized the disclosure but outside the deadline and 25 did not give an answer to the researcher within the time limit for the realization of the study. Thus, the final sample was composed by 14 hospitals. The sample is schematized in Figure 3. Fourteen (14) hospitals authorized the release of the questionnaire; however, the researcher did not receive responses regarding some hospitals. The main reasons for the lack of response by some hospitals were: • Not all physicians had personal or institutional e-mail, therefore the questionnaire URL was available on the computers in the doctors' room in the ED; • After approval from the Board of the Hospital, sometimes was asked to the researcher to contact the Director of the Emergency Department to explain the procedures to follow in the release of the questionnaire. That was not possible, even after several attempts by the researcher; 30 Results • Other hospitals requiring the physical presence of the researcher, which was not possible for him due to the geographic distribution of those in the country. Figure 3 - Schematic illustration of the sample The researcher also encountered a problem while receiving the survey responses, in particular the respondent wasn’t identified (the group number that corresponds to a hospital is not visible). For one reason nonspecific the URL sent to a hospital did not specify what it should. In the Table 6 might see the name of the hospitals and their corresponding answers (See in Appendix VIII the complete list of the hospitals that authorized the questionnaire and their respective number of answers). Initial Sample 41 Hospitals 40 Hospitals Final Sample 14 Hospitals Authorized, but outside the deadline (n=1) 39 Hospitals There was no reply to the request (n=25) Not authorized (n=1) Results 31 Table 6 - Number of answers by Hospital Group number Name of the Hospital Total of answers 101 Unidade Local de Saúde de Matosinhos (Hospital Pedro Hispano) 28 108 Centro Hospitalar de Trás-os-Montes e Alto Douro (Vila Real) 16 113 Centro Hospitalar de Vila Nova de Gaia/Espinho 15 120 Centro Hospitalar Leiria-Pombal 8 133 Centro Hospitalar do Oeste Norte (Caldas da Rainha) 5 103 Centro Hospitalar do Barlavento Algarvio (Portimão) 3 123 Unidade Local de Saúde de Castelo Branco 1 109 Centro Hospitalar Cova da Beira (Covilhã) 0 105 Hospital Distrital da Figueira da Foz 0 138 Hospital de Faro 0 150 Centro Hospitalar do Tâmega e Sousa (Penafiel) 0 106 Centro hospitalar de São João 0 111 Unidade Local de Saúde do Alto Minho (Viana do Castelo) 0 104 Hospital Infante D. Pedro (Aveiro) 0 Not identified 7* Total: 14 n=83 * For one reason nonspecific the URL sent to one or more hospitals did not specify what it should. It is also possible that some respondents in an attempt to access the questionnaire have copied only part of the URL. If the URL does not contain the information that corresponds to the group, it is impossible to identify the respondent. 4.1.1 Sample Description Of the 83 participants in the study, 52 (63%) were specialists, while the remaining 31 (37%) were residents, of which 6 (19%) were first-year residents. In the following, two groups will be analyzed separately and compared: specialists and residents. General information regarding personal and professional information of the participants is showing in Table 7. The proportion of gender in both groups was significantly different (p=0.019). Likewise, and as expected, the age distribution was also different (p<0.001), with specialists being older than residents (linear-by-linear p<0.001). With regard to medical specialties can be seen that the following stand out: General and Family Medicine in total 27%, followed by Internal Medicine 38 Results Table 12 – Which information should be accessible regard to patient’s medication history? Results, n (%1) Residents Specialists p-value* Total Posology 28 (93) 47 (90) 0,993 75 (91) Designation of the medicine (e.g.Paracetamol) 27 (90) 47 (90) 0,641 74 (90) Dosage (e.g. 500mg) 26 (87) 48 (92) 0,232 74 (90) Date of prescription 24 (80) 40 (77) 0,958 64 (78) Patient name 17 (57) 37 (71) 0,132 54 (66) Pharmaceutical form (e.g. pills or injectable) 18 (60) 32 (62) 0,754 50 (61) Amount of tablets (e.g. package with 30 pills) 16 (53) 32 (62) 0,376 48 (59) Number of packages prescribed (e.g. 2 boxes) 19 (63) 24 (46) 0,182 43 (52) Patient Birth Date 12 (40) 27 (52) 0,243 39 (48) Date of dispensing of medications 14 (47) 21 (40) 0,670 35 (43) Specialty of the doctor who prescribed 8 (27) 24 (46) 0,065 32 (39) Patient NHS number 9 (30) 22 (42) 0,226 31 (38) Patient telephone number 5 (17) 23 (44) 0,009 28 (34) Special Regime for Reimbursement of Medicines 7 (23) 19 (37) 0,185 26 (32) Location Prescription 8 (27) 17 (33) 0,508 25 (30) Healthcare System Responsible Entity 6 (20) 15 (29) 0,336 21 (26) Name of doctor who prescribed 6 (20) 9 (17) 0,815 15 (18) Authorization of generic medicine 5 (17) 9 (17) 0,890 14 (17) No authorization of generic medicine 4 (13) 7 (13) 0,942 11 (13) Patient insurance number 3 (10) 8 (15) 0,458 11 (13) Telephone number of the physician who prescribed 4 (13) 7 (13) 0,942 11 (13) Patient address 2 (7) 8 (15) 0,227 10 (12) Name of Pharmacy who dispensed the medications 3 (10) 5 (10) 0,993 8 (10) Contact of Pharmacy that dispensed medications 0 (0) 4 (8) 0,113 4 (5) Patient citizen number 0 (0) 4 (8) 0,113 4 (5) Patient Tax ID number 0 (0) 2 (4) 0,269 2 (2) Other 1 (3) 0 (0) - 1 (1) User defined Chronic medication 1(3) 0(0) - 1(3) 1 - Computed over participants who expressed at least one information * - Pearson’s chi-squared test In the Table 12 shown above we can see that stand out (over 50%) the following information that should be integrated in a computer application with patient’s medication history: Posology (91%); Designation of the medicine Results 39 (90%); Dosage (90%); Date of prescription (78%); Patient name (66%); Pharmaceutical form (61%); Amount of tablets (59%) and Number of packages prescribed (52%). On the other hand the information less prominent among these is: Contact of the Pharmacy that dispensed medications (5%); Patient citizen number (5%) and Patient Tax ID number (2%). It is also possible to conclude that in all the answers are no relevant statistically differences in both groups (residents and specialists), since the p-value is above 0.05. However there is an exception in relation to option "Patient telephone number” where the value p=0,009. 4.1.6. Types of medications that should be included in the computer application The results from the question number eleven “What kind of medications (prescribed and non-prescribed) you think should be included in the computer application”, are presented in the Table 13. Table 13 – Types of medications that should be included in the computer application Results, n (%) 1-Strongly Disagree 2Disagree 3 - Neutral 4 - Agree 5 - Strongly Agree Total Median p-value* 11.1. Medications subject to medical prescription Residents 0 (0) 1 (4) 0 (0) 7 (23) 22 (73) 30 (100) Strongly Agree 0,728 Specialists 0 (0) 0 (0) 2 (4) 10 (19) 40 (77) 52 (100) Strongly Agree 11.2. Medications not subject to medical prescription Residents 0 (0) 0 (0) 4 (13) 10 (33) 16 (54) 30 (100) Strongly Agree 0,915 Specialists 1 (2) 2 (4) 5 (9) 16 (31) 28 (54) 52 (100) Strongly Agree 11.3. Homeopathic medicines Residents 2 (7) 1 (4) 5 (17) 7 (24) 14 (48) 29 (100) Agree 0,093 Specialists 7 (14) 5 (10) 8 (16) 14 (29) 15 (31) 49 (100) Agree * - Mann-Witney U Test Through the displayed table (Table 13) it is clear that both groups (residents and specialists) agree in the options “Medications subject and not subject to medical prescription”, with the median equal to "Strongly Agree". With respect 40 Results to “Homeopathic medicines”, both groups also agree, but the median is “Agree”. The Mann-Witney U Test has been calculated and it is concluded that there is no statistical evidence of differences, since the p-value is above 0.05 (p=0,728; p=0,915; p=0,093). 4.1.7. Other information that should be included in computer application The answers from the question number twelve “Other information that should be included in computer application”, can be seen in the Table 14. Table 14 – Other information that should be included in the computer application Results, n (%*) Residents Specialists Total Allergies 30 (100) 51 (98) 81 (99) Adverse reactions to medicines 29 (97) 50 (96) 79 (96) Other 1 (3) 6 (12) 7 (9) User defined: Intolerance not clearly defined 0 (0) 1 (2) 1 (2) Interactions between administered medication alert 0 (0) 1 (2) 1 (2) Personal background including kidney or liver failure 0 (0) 1 (2) 1 (2) * - Computed over participants who expressed at least one information In the table shown above (Table 14) can conclude that 99% of the participants considered that allergies should be included in the computer application and 96% participants considered that the adverse reactions to medicines also should be included. Can also verify that seven participants selected the option “Other”, of which 1 is resident and 6 are specialists. However only 3 specialists responded with the following answers: Intolerance not clearly defined; Cross reactions alert between medication and Personal background including kidney or liver failure. Results 41 4.1.8. Comments The last question of the questionnaire allowed the participant to write some comments that he found relevant. It is verified that only two participants (one Resident and one Specialist) wrote notes. The Resident (in cardiology) considers that the existence of an application with the patient’s medication history would be useful. He further reported that in the institution where he works, he already can access the patient's medication prescribed by a doctor but faces the problem of patients that do not follow the prescribed medication and dosages. There will always be the need to verify directly with the patient about the medication that he is really currently taking. Regarding the remark made by the Specialist (surgeon) only stated that in his specialty, resorting to Emergency Department is usually away from the correlation between medication and acute situation. 4.2 Interviews in the Netherlands The results from the interviews are shown below, split by the questions. Note that the answers to the questions were properly updated through feedback received from the interviewees, after being sent an e-mail with the interviews transcriptions. During the interviews other topics were emerging which the researcher considered pertinent. These subjects are also shown in this chapter, following the initial order of the questions from the question list. The full information concerning the interviews carried out in the Netherlands can be seen in the transcriptions (See in Appendix VI). It is also possible to see the question list sent to the interviewees (See in Appendix V). 42 Results 4.2.1.By what way do pharmacies allow access to a patient’s medication history? • Via telephone • Via fax • Via e-mail • Via software application accessed in real-time The interviewees answered that they ask the patient’s medication history from a patient through phone, fax or e-mail. However the answers are different depending on the function that they perform or the institution. The hospital physicians (pediatricians) from Breda answered that they can ask patient’s medication history to pharmacies by phone, fax or e-mail. But they are talking about the outside medication (the medication prescribed by the General Practitioner). There are communication between the family doctor and the local pharmacy, in the cities. If the family doctor is entering the medication in the computer, the pharmacy can see it as well, so they can see both (just when they have the same software from Pharmapartners – Medicom for the GP’s and Pharmacom for the local/community pharmacies). But in the hospital they cannot look directly in their system to see the medication that the patient is using, just if they call/fax or send an e-mail to the pharmacy during the daytime. The hospital is implementing the Software EPIC: one system with different modules for each department, but EPIC doesn’t communicate with Medicom and Pharmacom. They only can see what was prescribed to patient inside of the hospital. In another hand, hospitals physicians referred that the pharmacies do call them as well about the patient’s medication. When it is not clear for them, sometimes the pharmacy calls them to ask what they want to prescribe (e.g. when different medication than the last time and it is not clear for them). The responses from the two hospital pharmacists are also different because they work in different hospitals (Breda, province of North Brabant and Woerden, province of Utrecht). However there are some points in common. Regarding the hospital pharmacist from Breda, it is important to talk about the indoor medication and the outside medication from the patient. The physicians can see in EPIC the medication of the patients and also their history. All this information is available in the hospital system and the physicians can view it in EPIC. That’s the medication that the hospital pharmacy provides to patients. In the hospital pharmacy they are also able to see the medication of Results 43 the patients outside the hospital in the electronic system of the community pharmacies from the region (Breda). They don’t need to call to the pharmacy, they can see in the system because they have a pharmaceutical service point but just from the local pharmacies in Breda. That service point is located on a few places in the hospital and only the pharmacy technicians can see that information (they have 12 computers in hospital where they can see Pharmacom). Note that in Pharmacom they can’t add or change anything and it’s only to look for the medication. For example, when the patient is coming to the hospital (e.g. for a surgery) the technician from the hospital pharmacy get a pre-operative screening of medication using the list of the community pharmacy (they print the list every day before the surgery). Then he asks (or the physician) the patient what kind of medication he is using and checks the list to know exactly what medication the patient is using. The hospital pharmacist also referred that: “We have about 700 000 meetings each year and all those times we have to know what kind of medication the patient is using. Most of the patients don’t know what they are using. We did some research a few years ago and about 20% and 50% of what the patient is saying (about their medication) is wrong.” The hospital pharmacist from Woerden state that there are two ways to access patient’s medication history: by fax and by software applications. Those are the same software applications that the community pharmacy uses. This way they can view the medication from the patient outside the hospital (through OZIS - It’s just a database which can be used by different software systems). OZIS It’s an Open Care Information System and is not just for the pharmacies, the family doctor they also use this system (not all, but some have access to that information). With OZIS it’s possible for pharmacists to exchange medication data by sharing a regionally accessible electronic medication record. The family doctor from Etten-Leur answered that the medication history can be seen using the pharmacy system – Pharmacom, it is via software application, accessed in real time. For emergencies at night and in the weekends they have a general practitioners post here in Etten-Leur and that post is also for the whole region around Etten-Leur. So it’s also for the small villages and surroundings. There are working 46 doctors or physicians and there´s also one pharmacist located there and they can look at all the systems of all the pharmacy’s here in the same region. Regarding the hospitals, they can they ask medication information via fax or telephone from the pharmacies. 44 Results The community pharmacist from Etten-Leur answered that usually physicians ask the medication history by fax or telephone. But they always send that by fax. And most of the times they send a fax with the signature of the patient. The NBD manager (New Business Development Manager) from Janssen-Cilag (Tilburg) explained that every pharmacy has a computer and in the computer they have all the patient medication histories. It’s online and realtime accessible. For GP’s (because mostly they use the same system: e.g. Pharmacom, for pharmacists and Medicom for GP’s) the medication information is in their system as well. Regarding hospital physicians, they need to ask the medication information to the pharmacies: “If a specialist would like to have an overview of the medication from a patient, then he would probably ask the pharmacy or the family doctor to come up with that overview (list). But mostly, in a hospital, it is done during an intake interview with a new patient at the hospital. Then one of the questions is what kind of medication you are using today.” Furthermore, he stated that hospital pharmacist and local pharmacist don’t have access to each other’s database, but some hospital pharmacists have an agreement with the community pharmacists and they can view the patient’s medication data (they have a service point where they can access to Pharmacom). 4.2.2. The access to medication histories is through a computer application: All pharmacies use the same software? There are an institution in the Netherlands that certifies the software used in the pharmacies? The hospital pharmacist from Breda answered that Pharmacom is the only software used from the local pharmacies in that region. However the hospital pharmacist from Woerden referred that access to medication histories is through a computer application, but pharmacies don’t use the same software, its different software systems but the same database (OZIS). He also state that there are an institution in the Netherlands that certifies the software used in the pharmacies, but he didn’t know the exact name. The family doctor from Etten-Leur explained that in the city (EttenLeur), all pharmacies (5 or 6) work with Pharmacom and half of the doctors are Results 45 working with Medicom. Pharmacom and Medicom belong to the same company – Pharmapartners. In his opinion “What I know is that Pharmapartners with Medicom and Pharmacom is the best integrated system for the medical history of patients.” Concerning the general practitioers there are also another systems: “Besides Medicom you also have Pro-medico. I think there still are 3 or 4 different systems.” The community pharmacist from Etten-Leur answered that all the pharmacies in Etten-Leur use the same software – Pharmacom. Besides he mentioned: “We use the Pharmacom software and we use OZIS for people who are from Breda, or other cities, and we use OZIS during evening and night shifts. In the general practitioners center, where the doctors are for the night shifts, we have a small pharmacy and they can access to all computers. And they use OZIS. I can use OZIS also because, for example, some people in Breda have a dentist in Etten-Leur and when they prescribe a medicine I can access to the medication history of this patient because I want to know if it’s safe to use the newly prescribed medication in combination with the medication the patient is already using. But like I said previously it’s readonly, so I can only read it and give to the patient a paper which tells what kind of medication we delivered to the patient and he has to give that to their own pharmacy. And that pharmacy needs to put that information in their computer again.” To conclude, the Pharmacom system is the connection between the pharmacies from Etten-Leur and the family doctors from EttenLeur (7 of them). And then there is a connection between all the pharmacies in this region (Breda, etc…) and they use OZIS to connect with each other, but that is readonly: “It’s for basic information: what is the latest medication that the patient uses; what are the allergies, which kind of diseases with which you cannot use certain medication, etc. But OZIS is not complete. So you have to ask to the patient, it’s your basis (core business) to always communicate with your patient. So this is what we want improve in the Netherlands with the National Switch Point”. The NBD manager (New Business Development Manager) from Janssen-Cilag (Tilburg) mentioned that in the Netherlands pharmacies don’t use the same software; besides Pharmacom (referred by the researcher) they have other providers. 46 Results 4.2.3. The access to medication histories through pharmacies is national, regional or local? The answers are quite different and depend on the function that the interviewees perform in their institution and the region of the institution. The hospital physicians (pediatricians) from Breda only have access to the medication that is prescribed in their hospital, not the medication from outpatients. They don’t have communication between hospitals and local pharmacies. For example, they want to know the medication of a patient that is from Amsterdam. In this case they can call to the pharmacy in Amsterdam, but it is only in daytime (in office hours). At night they call to the hospitals because they cannot reach the pharmacy. In relation to hospital pharmacists (from Breda, province of North Brabant and from Woerden, province of Utrecht), they both answered that the access to medication histories through pharmacies is local and maximum regional. The hospital pharmacist from Breda stated that “We can’t say that is national because in that case we need to call to the local pharmacy of the patient. National will be with the National Switch Point, but it is not working yet. With LSP it will be possible throughout the whole country to see all medication, also from a patient from the north of the Netherlands.” The Program manager from the hospital in Breda answered that the access to medication histories through pharmacies is local and a bit regional, but there’s always the problem and challenge to determine where a region starts and what areas it includes. “We have the connection between the regional hospitals and the pharmacies in the region of Breda…we have a very big region where our patients are coming from, there is lot of cities and villages that do not fall into that “region”, so you still have a big percentage of patients that are not connected to the system. That’s the problem.” Further added that some physicians and all pharmacists from the hospital can look into the system of the regional pharmacies (OZIS) but not contribute (add data). OZIS is a read-only system. “We have a kind of network but not all hospitals (throughout the country) are using it, it´s very old and not all pharmacists are connected to it. It is OZIS, the regional network”. She also mentioned that in OZIS pharmacists can access each other’s medication histories of patients, but only the local pharmacies (the hospital pharmacist don’t have access). The Family doctor from Etten-Leur answered that the access to medication histories through pharmacies is local and regional. In the case of a Results 47 patient from Amsterdam they just can have information if they call to his pharmacy in Amsterdam. The NBD Manager (New Business Development Manager) from Janssen-Cilag (Tilburg) mentioned that just on local and regional level physicians can ask the medication information. It is possible to access the electronic medication files from the pharmacies in the region, but only the pharmacies, not the healthcare professionals from the hospitals. The healthcare professional can call to the pharmacy or ask by fax and the pharmacy can send the list of the medication. He also stated: “(…) but the reason behind the two systems is that the healthcare professionals don’t want to include the indication in the system, for which you get the prescription. Because if the pharmacist want to know the indication, then you, as a physician, can be scared that the pharmacy will take over the rights of the physician (and tell to the patient “so this is the indication so you should have this product”). The physician wants to have the rights, the power, and the control to decide which product should be prescribed. And that’s the reason why the systems are not connected. When there already is connection between the systems it’s always without the indications. And for the next year, 2012, they are trying to overcome the first hurdle and include, I think, for 5 or 10 disease areas also the indication into the pharmacy system. That’s a transition and it’s a pilot. So let’s see if the pharmacies will use it. So it’s very important to understand that we have two different systems: one system for healthcare professionals, for the physicians, and one system for the pharmacies. And several hospital pharmacists can look into the regional pharmacy database.” 4.2.4. Patients signed informed consent form? The hospital physicians (pediatricians) from Breda answered that they are allowed to call to a pharmacy to ask the patients medication history but first they ask permission to patients. It is not a written informed consent, it is an oral consent given by patients. But physicians have to document in the patients file “patient allows us to ask the pharmacist”. The hospital pharmacist from Breda answered that patients don’t sign anything: “They should, but that’s very difficult to arrange.” It is impossible to make the things in the correct way because they get the information about the patient before the patient is visiting the hospital. For example, when a patient come to the hospital for a surgery they will get all kind of information about what he is going to do in the hospital, about the pre-operative screening and 54 Results The family doctor from Etten-Leur stated that the patient doesn’t have access to the system, only through him or the community pharmacies (they only can ask the medication list). The community pharmacist from Etten-Leur answered that patient come to the pharmacy to ask the list of his medication. They created a sort of a standard list, and all the pharmacies use that standard. The standard list contains the name of the pharmacy, the contra-indications, and intolerances for pharmaceutical things, allergies, the doctor which made the prescription, etc. But they developed other kinds of specific lists for the following situations: when patients are going in holidays (they have this list in Dutch and in English); for people who are unemployed and welfare (they need to show how much they spend on their medication); when people want to buy a house and need to show a list of your medication for the last 5 years, for example. Another very important information is that when a patient asks the list and the pharmacy prints that, the pharmacy always need to put the reason why print that for the patient. The NBD manager (New Business Development Manager) from Janssen-Cilag (Tilburg) also talked about this subject, in particularly about the development of a uniform drug list for the pharmacists: “The KNMP is the Dutch Association for the Pharmacists and together with the NVZA, the Dutch Association of Hospital Pharmacists; they developed a uniform drug list. So pharmacists have now a new system from which a uniform format medication list for patients can be printed.” So, patients can ask their medication list to the pharmacists. 4.2.9. Institutions in which information can be accessed: Public hospitals; Private hospitals. The hospital pharmacist from Breda answered that they have arranged connection with Pharmacom, because they have good connections with their community pharmacies. It was also mentioned that maybe the private hospitals don’t have that connection, so probably they need to ask to the patients when they are coming to their hospital. Or the patient needs to bring his own information, his medication list. For example, the dentist can also ask the medication list to the community pharmacy. The hospital pharmacist from Woerden stated “Public hospitals but also private hospitals by the same way. It depends on your profession and it doesn’t depend on the type of hospital.” Results 55 The family doctor from Etten-Leur answered that in this moment public and private hospital can ask the information by fax or phone. They can request information from GP’s or the pharmacist but only if the patient give permission for that. The community pharmacist from Etten-Leur mentioned that a private hospital can ask to the pharmacy the list of the medication but only with the informed consent. They need to send a fax with the signature of the patient. When the researcher ask if a private hospital could access a patient medication history, the NBD Manager (New Business Development Manager) from Janssen-Cilag (Tilburg) answered that depends on the way health care professionals are working together: “For instance, in Tilburg or in Breda, I think most pharmacists came together and said “ok, if we want to have shared services during nighttime or during the weekends, it is important that we have access to all the information of all patients in Breda. So let’s collect and connect all the available data in our region”. And that is the way Tilburg is working as well, because they agreed together to share the data, they can access the data from the other pharmacies as well to have a clear overview. For public hospitals I think is more or less the same. If a public hospital has an agreement with the other parties they would be able to access that information.” 4.2.10. Which departments in a hospital are allowed to access information from patient’s medication histories? The hospital physicians (pediatricians) from Breda answered that “All departments from the hospital can call to the pharmacy to ask the information and get the information. The principle is the same; it doesn’t matter if you are from intensive care or emergency department, etc.” The hospital pharmacist from Woerden answered that all departments in a hospital can ask to the hospital pharmacy for the list with the medication history. The family doctor from Etten-Leur referred that all the departments from the hospitals can have the information if they ask by fax or telephone. The community pharmacist from Etten-Leur mentioned that all of the departments of that hospital can ask the medication list, by fax, but only with the signature of the patient. 56 Results 4.2.11. What kinds of medications become available on the medication history of patients? • Prescribed by a doctor; • Medicines not subject to medical prescription; • Homeopathic medicines; • Are there exceptions? (e.g. HIV drugs) The hospital pharmacist from Breda referred that in Pharmacom (system from the local pharmacies) they can see all kind of medications dispensed by the pharmacy (e.g. normal painkillers), but it depends if the pharmacy put it in the system. Because of that, when they have patients in the hospital for their pre-operative screening, they ask what kind of medication the patient is using through the pharmacy but they always ask which “over the counter products” they are using. They always ask about the medication not subject to medical prescription including the homeopathic products: “When a patient uses four times a day one gram paracetamol, we put it in our system. There is no prescription that the patient has taken it and we want to know that the patient has taken it.” The interviewed also mentioned that if they don’t put that kind of information in their system then they can’t see the possible interactions between the medications, thus they enter as much information as possible in the system. Regarding the question about exceptions, the hospital pharmacist answered that in the hospital and in the pharmacy they do not have any exceptions. But it is possible that sometimes, in the system of a hospital in the Netherlands, you may not put in the medication if the patient requests that. Related to this question the interviewee also mentioned that the pharmacist enters in Pharmacom what he sells to the customer (what the patient is using) and not the prescription from the doctor, because probably the patient didn’t buy all of the prescription: “They (the local pharmacy) deliver medication and they (the local pharmacy) can see when the patient has to come back for more. Sometimes they discuss that with the patient (are you still using the medication). If the patient doesn’t say anything, then the pharmacy doesn’t know. It’s a problem. We only see what was dispensed. It could be another prescription but then it can be that the pharmacy has called the physician to say “this is not the right prescription or it’s not good in combination with other medication, we have to change it”. Then they enter it in the system. So we only see what is delivered not what is prescribed.” Results 57 The hospital pharmacist from Woerden answered that all kinds of medications could become available on the medication history of patients but it depends on the pharmacy. The pharmacies try to record everything they know about medication, also the homeopathic medication and the medication like the paracetamol which is not prescribed by a doctor. Furthermore stated that the medication list usually are not complete so they always have to ask the patients (together with the medication history) what is really used by the patient and then make a complete list of what’s really used at that moment. When the researcher ask him if there are exceptions (if patients don’t want that some information became available in the system, e.g. medication for AIDS) the interviewed answered that in the hospital they don’t have exceptions, they try to record everything they can about the patient’s medication. He also stated “Can a patient ask to leave out information or ask to make it not visible to anyone else? No, in the near future we want to arrange that but at this point we can’t make exceptions at that level. But, of course, for privacy reasons we need to arrange that kind of option.” Following the answer to this question the interviewed took the opportunity to explain how the distribution system from the hospital pharmacy functioned: the physician asks the patient what kind of medication he’s using and compare with the list from the community pharmacy. Then he’s going to put that information (new information) in the electronic prescription system of the hospital and the distribution system from the hospital pharmacy would recognize that (medication checked signals) and have access to that information. “This is the automated way of medication checks. If there’s an interaction between two different drugs or there’s a dose that’s too much for this patient or the patient has problems with his kidneys and he needs another dose, that’s how we check all the patients’ medication.” Regarding to this question, in particularly about exceptions, the Program Manager from Breda confirmed that the patient can requests some information to be deleted from the system: “When a patient wants some information to be erased, we have to delete it. It is the right of patients.” For that the patient has to sign a paper declaring that he wants the information deleted. The family doctor from Etten-Leur answered that he doesn’t have access to medicines not subject to medical prescription: “Even when the patient is buying medicine in the pharmacy, which is not prescribed, it’s not in the system. It is maybe possible that the pharmacy can see what they sold to the patient in their own system, but we, the doctors can’t see that, we only see the 58 Results prescribed medication.” The same for homeopathic medicine, just in the cases that it was prescribed. Regarding exceptions, the researcher gave the example from Massachusetts, where physicians had access to patient’s medication history in the emergency, but the patient’s history was incomplete caused by the Massachusetts restrictions on the display of mental health and HIV. The family doctor explained that in their system (Medicom) doctors can make a private prescription and the pharmacy can see the prescription but another doctor can’t see. He also said that he don’t know if the pharmacist can do the same in Pharmacom (system from the pharmacy). The community pharmacist from Etten-Leur mentioned: “(…)most of the time people don’t like it when the doctor can see what they buy in the pharmacy (not prescribed), so I check all the medication that the patient buys but in the system the doctor just can see what was prescribed by him. But when I see that the medication that the patient wants to buy can interact with the medication prescribed by the doctor, I can call to the doctor.” Usually the pharmacy register some medications that are not prescribed by the doctor: “We have six groups of medication which we have to put in the system before we sell that. (…) I can give you some examples: high doses of ibuprofen, some medication to lose weight, medication for nausea, etc. So there are six large groups of medication that we need to register in the system.” He also mentioned: “In the Netherlands we have drugs in 3 types and you can see the code in every pack of the medication: UR, which means that it is only with a prescription; UAD, which means only pharmacy and drugstores and there is UA, which means only in pharmacies. Medication which is only sold in a pharmacy we always have to put in the system. Most of the times this medication [UA] is safe to use and you don’t need the prescription from the doctor but sometimes we need to check. So you have medication that you can buy everywhere, medication that you just can buy with a prescription and medication that you just can buy in a pharmacy. For example, when you have medication with the code UA you can buy that here in the pharmacy but first I need to check the system for more information about the patient. And before I can sell that kind of medication I have a list of questions that I should ask to the patient.” About homeopathic medication, they can sell in the pharmacy, but they don’t put in the system. The main reason is that homeopathic drugs are not medication according to the Dutch law. All the medication in the Dutch law Results 59 has a RVG-number – Register for pre-packed medication, and homeopathic drugs don’t have a code. The NBD manager (New Business Development Manager) from Janssen-Cilag (Tilburg) also pronounced about this subject and referred that all the medication prescribed is available in the system are there are no exceptions (e.g. HIV medication). Furthermore he stated: “But what you see is that patients with HIV are going to specialized pharmacies. Often they don’t go to their own pharmacist to get their HIV products(…) Nowadays HIV medication is becoming very complex (…) And that’s why some pharmacies are now becoming more or less experts and really specialized in HIV medication and that’s why patients are willing to travel for an half an hour or more to a specialized pharmacist.” 4.2.12. For how long the medication history is kept? • How many years; • The last year; • Months The hospital pharmacist from Breda answered that they need to keep the history for 15 years by law (also for local pharmacies). Besides mentioned that when they did not have an electronic database, it was by paper and they also had to keep that for fifteen years: “We still have the same software from last century. So we have about 30 years of information.” What they put it in their computer system is not the original prescription. This one is still on paper in the hospital, because there is the signature of the physician. And because they don’t scan (they enter in their system) the original prescriptions are on paper and it’s why they have to keep those papers. But this will be different with the new system EPIC: “Then it’s all in one system and we don’t have paper anymore.” The hospital pharmacist from Woerden, the program manager from Breda and the family doctor from Etten-Leur gave the same answer: 15 years by law. The community pharmacist from Etten-Leur answered that they need to preserve all the recipes for 15 years: “So if I need to see some recipe I need to be able to find it in the system because it’s almost impossible to find it in the archive.” 60 Results 4.2.13. Which information is available regarding medication history (e.g. internal prescription)? The medication history contain information, such as: internal prescription (e.g. medications prescribed and administered in the emergency); or medications dispensed to the patient in the hospital (e.g. in ambulatory surgery, the patient often takes with him medication dispensed by the hospital). The hospital pharmacist from Breda answered that the history of medication does not contain that kind of information because patients don’t get anything from this hospital. Furthermore she stated: “I don’t agree with that, I think it’s better to give medication for one or two days to the patient, so that he doesn’t have a problem when he gets out hospital and first needs to go to the local pharmacy to get the medication.” So, the patient is going home the technicians will fax the medication list of the patient to his own community pharmacy and then the patient can get his medication over there. The hospital pharmacist from Woerden responded that the history of medication does not contain more information like internal prescription. The history of the medication or the list of the medication which is in the community pharmacies does not have the internal prescription. Contrary to what happens in the hospital in Breda, the interviewed said that in the hospital in Woerden they give for 2 or 3 days medication to overcome the lack of time. But the medication list does not contain this information. The program manager from Breda answered that all the medication prescribed by the doctor and also medication that patients buy over the counter will be in the system, because they want to have a total overview. But she’s talking about the system that they are implementing in the hospital – the EPIC system; she’s not talking about the medication history which can be seen throughout the community pharmacies. Furthermore she stated that the system (in the community pharmacies) allows seeing medications prescribed by the physician and dispensed by the pharmacy. The family doctor from Etten-Leur stated that the medication history does not contain information, like medications prescribed and administered in the emergency or in ambulatory surgery: “(…) it’s because you don’t have any connection with the hospitals.” But, for example in the emergency, sometimes the emergency physician sends the report from the emergency episode to give to the family doctor and then the family doctor put in their system (e.g. new Results 61 medication or new allergies). It is the same when the patient is going to see a specialist: “Normally it works in that way. With a simple control visit it doesn’t happen all the time because sometimes it’s not necessary, but when he’s doing some really new examinations you get a letter and also going electronically, by email. If the patient has an appointment with a specialist in the hospital I receive a message in the system (in Medicom) with a report of that appointment. I can see the name of the doctor that saw the patient, what time and in what day, what’s the history, etc. When I receive that message about the patient I read what happened and make a conclusion and then I put that in the file of the patient (in Medicom). When I receive the report or message in paper takes more time but we also put that information in the system.” 4.2.14. Which information is available regarding the medication history? In this question the researcher presented some options to the interviewees, such as: Local of Prescription; Date of Prescription; Name of doctor who prescribed; Specialty of the doctor who prescribed; Telephone number of the physician who prescribed; Date of dispensing of medications at the pharmacy; Designation of the medicinal (Paracetamol/Codeinefosfaat Sandoz); Dosage (paracetamol 500mg, codeinefosfaat-hemihydraat 20mg); Pharmaceutical form (oral); Amount of tablets; Posology; Medication allergies and others. The hospital pharmacist from Breda mentioned that they can see the medication in use and the medication history, in the following information’s: date of prescription (the date when the medication started); name of the doctor who prescribed (they see the specialty of the doctor but not always the name); the specialty of the doctor who prescribed; the pharmacy who delivered; date of dispending; the dosage; the pharmaceutical form; the amount (how much medication is delivered and how often the patient has to take it); Posology (Indications, if they are put in) and Medication allergies. About the medication allergies she also stated: “Medication allergies it’s the most difficult part for all pharmacy departments. For example, the patient says that he is allergic to a certain medication because he had diarrhea when he was using this medication. In reality it might not have been an allergy, and the patient was just sick. But if the pharmacy has entered this allergy in his system we have a problem when the patient needs this medication. You can’t give the 62 Results medication because it can give an allergic reaction, when probably it is not! So, that’s very difficult to get the right information about allergy.” They also can see the Contraindications, for example if a patient get some medication because he has hypertension, but this patient has also some other problems for which he’s not allowed to have that medication - That’s contraindication. The hospital pharmacist from Woerden answered: specialty of the doctor who prescribes; name of the doctor who prescribed; date of prescription; designation of the medication; pharmaceutical form and posology. Note that the date of prescription and date of dispensing are the same in the hospital pharmacy but in the community pharmacy that can be different. Related with the amount of tablets the pharmacist stated: “Amount of tablets that depend. When we prescribe at an outpatient treatment then we have an amount of tablets but inside the hospital we only have a period of time and we don’t have the amount. You can calculate it but we don’t enter it in our system. We only enter a period. When it starts and when it ends.” He also mentioned the contraindications like the other hospital pharmacist. The family doctor from Etten-Leur answered that the information that is available regarding the medication history is: Date of Prescription; code of the primary doctor (not the name); Specialty of the doctor who prescribed the medication (not the name); Date of dispensing of the medications at the pharmacy; Designation of the medicine; Dosage; Pharmaceutical form; Amount of tablets; Posology and Medication allergies. The community pharmacist from Etten-Leur answered: Location Prescription (e.g. name of the hospital where the doctor works); Date of Prescription; Name of doctor who prescribed; Specialty of the doctor who prescribed; telephone number and address of the physician who prescribed; Designation of the medication, Dosage, Pharmaceutical form, Amount of tablets, Posology; patient name; patient address, birth date; patient identification; patient insurance number. 4.2.15. Other subjects: Information campaign in the Netherlands “If you go to the doctor, bring your medication list” The hospital pharmacists from Breda and from Woerden explained to the researcher the purpose of the campaign and in what way would be performed. In November 2011, there was an information campaign in the Results 63 whole of the Netherlands. Everywhere it was possible to see posters on the wall: “If you go to the doctor, bring your medication list”. It was a campaign organized by community pharmacists together with hospital pharmacists. The objective was that patients go to their pharmacy and bring their medication history when they visit the hospital. They asked for patients to pick up the responsibility of being aware of what they use for medication when they go to the hospital too; to be able to deliver the information. It’s also a responsibility for the patient and usually they don’t know their medication. They have to know what kind of medication they are using. And if they don’t know, because it’s too difficult to pronounce, they should write it down and have always the list with them. Patients should go to their local pharmacy and ask their medication list, but it is important that they check the medications that they are using to update the information. The community pharmacist from Etten-Leur also talked about this subject: “Last year (2010) we had a new law that obligates all the pharmacies to use software (like pharmacom) that can create a medication list for the patient. And we (pharmacists) tell to every patient when they go to the doctor “please take your medication list”, because the doctor (the specialist) doesn’t always have access to our system. The campaign is about that: when you go to the hospital, always go to your pharmacy and get your list of medication. We have a database of the patient’s medication and that’s our responsibility, but most important of all, the health of the patient is the responsibility of the patient himself. It is their responsibility and everybody needs to know why they are using the medication they use. When you talk with elderly people and you ask to them why they are taking that medication, they mostly don’t know!” The NBD manager (New Business Development Manager) from Janssen-Cilag (Tilburg) also pronounced about this subject and in his opinion maybe it is a good idea that patients should always have a list of the medication that they are using, but that will be very difficult, especially because older people have a huge list of medication. In his opinion “…the most appropriate way to have access to all the medication will be with a kind of a bank card. And every time you have new medication you just need to ask to put that information on that card.” 70 Results back to the practice and he put it in the system and then send it to the pharmacy. The pharmacy receives the prescription electronically. And at the end of the day, the patient can go to the pharmacy and pick up his prescribed medication and don’t need to go with the recipe (prescription) in his hand. 4.2.19. Other subjects: LSP – National Switch Point Notes: The National Switch Point (LSP – Landelijk Schakel Punt) was developed by NICTIZ; the National ICT Institute for Healthcare, together with the Dutch Health Ministry. Concerning the National Switch Point the hospital physicians (pediatricians) referred that the government want to make one access point in the Netherlands where all the medical data will go, but for it is not safe enough. They also stated that for politicians the security of the data is more important than having communication between the different systems. “It is not allowed in the Netherlands because medical data is secret and there probably will be no solutions for these safety and privacy issues in the next years. “ The hospital pharmacist from Breda referred that with the National Switch Point everyone in whole Netherlands got a letter asking if we want they information in that system. And patients can say “no I don’t”, then the patient is not in the system and no one can’t see anywhere what medication the patient is using. “ If you have an emergency problem, then no one knows what kind of medication you are taking. But, every person has this possibility to say “I don’t want to give my information”.” The hospital pharmacist also thinks that with the National Switch Point maybe more patients will say “I won’t… I’m not happy to have my information over there in the system…everyone can see it”. Furthermore she thinks when a regional system like in the Netherlands exists, no one ever thinks about it. She stated “Maybe it’s not so big, like a system for the whole country. It’s just a region and like that we don’t have the problems which the national database has. In all these years in which we get the information from the local pharmacies, only one patient was not happy that we had that information.” The Program manager from Breda also pronounced about this subject and explained the reason of LSP cancellation: “At first was a privacy issue, and NICTIZ didn’t get the right connection, so pharmacies, GP’s and hospitals didn’t want to join LSP. And then government ordered to the LSP that they had to make (built) their own customers… So hospitals, GP’s and pharmacies Results 71 said - we will pay for the service when it is ready and functioning - so in the end that´s why the program stopped.” In her opinion, working on the regional connection system, like they work in the Netherlands, it is not the solution. The Family doctor from Etten-Leur also talked about this issue and mentioned that: “In the policy there was a countrywide system that would make it possible for everybody, every doctor, to look in the system and the patients agree that he is looking. But the policy is canceled for now, after already having invested millions and millions of euros in that system. So now we are trying, with all the doctors, to do something. Maybe we’ll not go as far as originally planned in the policy, but we want to do something to make it easier to look in one system from everywhere in the Netherlands. That’s the LSP.” Likewise the community pharmacist from Etten-Leur talked about the LSP and mentioned that because the regional network OZIS is read-only, in the Netherlands for several years were trying to make a system which is not readonly but accessible for all pharmacies, all doctors, etc. “The National Switch Point is not ready because of privacy issues and because of another problem which is when you participate in the National Switch Point as doctor you need to put all the diseases in a specific way in the computer (with a code), because otherwise you cannot communicate properly with the other participants and that would be a problem.” Besides he mentioned: “(…) there is no uniformity. The danger of that system is when you access to the National Switch Point and you see the medication, the diseases, etc. from the patient and you think that is all the information, but it’s not! Most of the time there’s more, so I better know nothing than I just know a half of the information (and draw the wrong conclusions)! When I will think everything is there it’s very dangerous! And that is the problem with the doctors. They won’t tell you because they say that there is no problem but this is the biggest reason.” The NBD Manager (New Business Development Manager) from Janssen-Cilag (Tilburg) also pronounced itself about this subject stating that in the Netherlands they have 2 different systems: the system of the physicians and the system of the pharmacies. At this moment they are not connected. The Government wants to have an electronic patient record, the National Switch Point, and really make it into one system for all of the Netherlands, where everybody (healthcare professionals) is connected to. But in April 2011 the law which should make this possible, was declined. Currently the system is on hold and at this moment there is no effort anymore to solve the issue and really build one system. So at this moment we have one system for the pharmacy and one system for the healthcare professionals. 72 Results He also stated that NICTIZ is the the National IT Institute for Healthcare in the Netherlands and was the company that was behind the electronic patient record, which the Government canceled (2011). According the feedback from the interview transcription and the e-mail that the researcher sent asking about the current situation in the Netherlands (September 2012), the interviewed informed that the Ministry of Health has transferred the LSP to a separate organization called Vereniging van Zorgaanbieders voor Zorgcommunicatie (VZVZ) - Association of Healthcare providers for Healthcare Communications. In November 2012 the VZVZ will start a campaign towards patients to ask their permission to include the patient data in the LSP (by Opt-in). They are going to ask everyone to fill in a form (at their doctor, pharmacy, or online) to allow their information to be accessible for all healthcare professionals in the Netherlands. Discussion 73 5. Discussion This chapter discusses the results from the questionnaire applied to the Portuguese Public Hospitals as well as the results from the interviews carried out in the Netherlands. Moreover present the research limitations during this study, the main findings of this study and the main recommendations for a possible implementation of a project in this context in Portugal (bearing in mind the current scenario in the country). Through this study the researcher was able to get some answers about their investigation question: Accessibility in the Emergency Department to Patient’s Medication History. The major contributions were obtained both through the questionnaire conducted in Portuguese public hospitals as well as through the interviews carried out with health professionals in the Netherlands. Besides trying to get the opinion of physicians already with some or extensive experience working in the emergency department, was also considered important to understand the residents views which are still in a learning phase. Through the questionnaire was possible to obtain the following information: • The physicians that perform functions in the Emergency Department always ask about the patient medication history and they consider that is very important to have access to patient’s medication history. • However it is verified that one resident answer that rarely seeks for the patient’s medication history. Throughout the data collected from the questionnaire, the researcher found that it is a resident which studies the specialty of pediatrics. Most interesting is, when the researcher asks about the importance of having access to patient’s medication history in ED, the resident answered “very important”. The resident may have answered "rarely" to this question, because children are 74 Discussion accompanied by the child health consultations in health centers of the SNS – equivalent to NHS, and parents always bring the child’s heath book which contains very useful information about child's health. • ED Physicians strongly agree that the accessibility to patient’s medications history bring several benefits regarding the patients safety, in particularly they can have a faster characterization of the patient situation and provide the best adequate therapeutics. The physicians also agree that they could have another kind of benefits like: make a faster and better diagnosis; the decision about the therapeutic would be faster; they could make a better prognostic and that represents an economic benefit (to patients, to physicians and even to the hospital). • Regarding the information’s that physicians think should be able to access in a computer application with the patient’s medication history, the responses were (over 50%): Posology; Designation of the medicine; Dosage; Date of prescription; Patient name; Pharmaceutical form; Amount of tablets and Number of packages prescribed. The respondents considered that allergies and the adverse reactions to medicines also should be included in the computer application. About the types of medicines, physicians strongly agree that they should access to Medicines subject and not subject to medical prescription. In addition they give importance to have access to homeopathic medicines. • However there was a comment from a physician quite important for this study (which is consistent with the information obtained through the interviews in the Netherlands). Even when the physician can access the patient's medication history the problem is that patients do not fulfill the prescribed therapy. There will always be the necessity to interrogate the patient about the medication that he is currently taking. The interviews in the Netherlands allowed the researcher to get an overview of the functioning of the health system. The objective was to talk with all the stakeholders witch could be important for the study of the electronic medication record (community pharmacists, hospital pharmacists, physicians, family doctor and a pharmaceutical company). The interviews allowed collecting very important information, such as: • The researcher wanted to understand what kind of relationship exists between the family physician and the community pharmacy and the Discussion 75 systems in common use (e.g. how they communicate with each other) and understand the concept of family pharmacist. a. Physicians and the pharmacists organized together a system that records the used medication from patients. In 1999, the Ministry of Health and the Royal Dutch Society for Pharmacies (KNMP) made an agreement in which results the incorporation of the pharmacist care into the Dutch Medical Treatment Contracts Act (WGBO). Thus pharmacists need to access patient’s medication data for the patient’s safety. (Pirnejad, Bal, Stoop, & Berg, 2007) b. Usually pharmacists and GP’s use the same computer system for the medicine (e.g. in Etten-Leur, pharmacist use Pharmacom and GP’s use Medicom, this software is from Pharmapartners) - so family doctors can see the information from the pharmacists. c. The pharmacist can only see the medication and the contraindications, intolerance, and allergies. He cannot see anything about the medical history of the patient. d. GP’s can also see the medication that pharmacists sold to their patients (medication dispensed). e. Regarding chronic medication of patients - In the computer pharmacists can see exactly when the patient is almost out of the stock, so they can create a new package for patient and ask the GP for the authorization. So the patient doesn’t need to call to the doctor himself. Sometimes pharmacists have an authorization from some GP’s - they made a list of medicines which the pharmacy can always give to patients. f. In emergencies at night and in the weekends, pharmacies can look into OZIS – the regional network (includes all databases from the pharmacies). g. Patients have their own pharmacists – like a family pharmacy. It’s better to go to their own pharmacy, because pharmacists know everything about their medication - what they are using at the moment and what they have been using. Furthermore, bring many benefits: more protection against drug-related problems; prevents duplication of drugs and drug interactions. • The access to medication histories through pharmacies is local and in maximum regional. We can say that is “national”? It is not correct, but 76 Discussion it is possible to obtain information from a patient nationwide. For example, if a patient lives in the north of the Netherlands and he’s in a hospital in the south, physicians can call or send a fax to the pharmacy from the patient and ask his medication history. Even when we say regional, there’s always the problem and challenge to determine where a region starts and what areas it includes. For example, in Breda, they still have a big percentage of patients that are not connected to the system. • Physicians from hospitals (from all departments) can ask patient’s medication information to the community pharmacies via fax or e-mail. But how does a physician identify himself when he wants that information? Regarding this issue the researcher found different answers: the physicians answered that normally they don’t have to give their number of registration of healthcare professionals to the pharmacy to get the information; the community pharmacist answered that most of the times they need to send a fax with the signature of the patient. • Public and Private hospitals can ask patient’s medication information to pharmacies also by fax. But the community pharmacy stated that only if the physician sends a fax with the signature of the patient. • The researcher wanted to understand if the patient sign or not an informed consent. There were different answers regarding this issue, such as: It is not a written informed consent, it is an oral consent given by patients, but physicians have to document in the patients file “patient allows us to ask the pharmacist”; Before the patient visits the hospital pharmacy, we already have the information and at that moment we ask “are we allowed using that information?”, etc. There is only one case where the patient signs a document: is when the physicians ask to the pharmacy the patient medication history, because they need to send a fax with the signature of the patient. • Hospital pharmacists and community pharmacists don’t have access to each other’s database, but some hospital pharmacists have an agreement with the community pharmacists and they can view the patient’s medication data. For example in Breda, they have a pharmaceutical service point but just from the local pharmacies in Breda, where they can access to Pharmacom. That service point is located on a few places in the hospital and only the pharmacy technicians can see that information. If they don’t have an agreement Discussion 77 with the community pharmacists, they can look into OZIS. It’s an Open Care Information System, a database which can be used by different software systems, and it is read-only. • When the hospital pharmacist can view Pharmacom, they can print a list of medication from the Community pharmacy. For example, when a patient is going to the hospital (e.g. for a surgery) the technician from the hospital pharmacy get a pre-operative screening of medication using the list of the community pharmacy. Then he asks (or the physician) the patient what kind of medication he is using and checks the list to know exactly what medication the patient is using. So, it is always necessary to check with the patient the medication from the list. • In November 2011, there was an information campaign in the whole of the Netherlands. Everywhere it was possible to see posters on the wall: “If you go to the doctor, bring your medication list”. It was organized by community pharmacists together with hospital pharmacists. The objective was that patients go to their pharmacy and bring their medication history when they visit the hospital. Also important is they check all the medications that they are using to update the information. • Patients can ask a medication list to the community pharmacist. They also can ask to the family doctor, but usually, they ask to the pharmacy. Pharmacists developed specific lists for specific situations, but usually patients can ask the standard list, which contains the name of the pharmacy, the contra-indications, and intolerances, allergies, the doctor which made the prescription, etc. Another example: when patients are going in holidays, the pharmacies have a specific list (they have this list in Dutch and in English). • Regarding the kinds of medications that become available on the medication history of patients, usually it is only the medication prescribed and dispensed by the pharmacist. But they always make an effort to record everything they know about medication, also the homeopathic medication and the medication like paracetamol which is not prescribed by a doctor. • The history of medication also does not contain internal prescriptions (e.g. medications administrated in an emergency episode) and medications dispensed to the patient in the hospital (e.g. when the hospital give for 2 or 3 days medication to overcome the lack of time) • Hospital and community pharmacists need to keep the medication history for 15 years by law. 78 Discussion • Regarding the information that is available from medication history, they can see the medication in use and the medication history: date of prescription (the date when the medication started); name of the doctor who prescribed (they see the specialty of the doctor but not always the name); the specialty of the doctor who prescribed; the pharmacy who delivered; date of dispending; the dosage; the pharmaceutical form; the amount (how much medication is delivered and how often the patient has to take it); Posology (Indications, if they are put in); medication allergies and contraindications. • Regarding the LSP – National Switch Point, the objective from the government is to have an electronic patient record, one system for all of the Netherlands, where everybody (healthcare professionals) is connected to. At present, the Ministry of Health has transferred the LSP from NICTIZ to a separate organization called Vereniging van Zorgaanbieders voor Zorgcommunicatie (VZVZ) - Association of Healthcare providers for Healthcare Communications. In November 2012 the VZVZ will start a campaign towards patients to ask their permission to include the patient data in the LSP. Patients should give their authorization until January 1, 2013, otherwise their data are not including on the LSP (but patients may also authorize after that. 5.1 Main Findings Throughout the questionnaire, the interviews and literature review about other countries, the main findings are:  Physicians consider that is very important to have access to patient’s medication history and this information is essential for patient’s diagnosis and treatment.  The accessibility to patient’s medication history through the community pharmacist (medication prescribed by the doctor and medication dispensed by the pharmacy) is essential to have an overview of the history of medication of patients, and can prevent duplication of drugs, drug interactions and could even detect drugrelated problems.  Relating to medication history, it is important that all the medication (prescribed and not prescribed by a physician) should be accessible. In Discussion 79 countries which already have access to medication history, there is always a concern to record all the data for increased patient safety.  The involvement of pharmacists is crucial: pharmacist is the last health professional to be in contact with the patient before he takes the medication prescribed by the physician. It is the pharmacist who provides all the information and counseling to patients, from drug interactions, contraindications and adverse reactions to the selection of the most appropriate drug.  In some countries (e.g. Netherlands) campaigns are performed for sensitization of patients. The major objective is “If you go to the doctor, bring your medication list”; because patients should know the medication that they are taking. For such, pharmacies have developed standard lists of medication. Patients should go to their pharmacy (and here we are talking about the concept of family pharmacy) and ask for their current medication list. At this moment it is essential that they check their medication to keep this list updated.  Even in countries which have systems that allow access to medication history, there is always the need to verify the medication that patients are actually taking.  Relating with privacy issues, patients are the owners of their own medication history, but it’s not very well regulated at this point. Patients should sign an informed consent but in reality they don’t sign. For example, in the Netherlands, they are going to start a campaign to inform patients about the LSP (National Switch Point), and how they may authorize the provision of their medical records to be accessible for all healthcare professionals. 5.2 Main Recomendations Through the questionnaire conducted in Portuguese public hospitals and the interviews carried out in the Netherlands, the researcher is able to make some recommendations. When we think about create a new system, it is important that it will be as complete as possible. Otherwise we run the risk that users will not use. Using an expression of an interviewee from the Netherlands “I better know nothing than I just know a half of the information”. 86 Appendix 87 Appendix Appendix I List of Portuguese Public Hospitals with more detail 1 Total Region Abbreviation Name of the Hospital Notes 1 North ULSM Unidade Local de Saúde de Matosinhos, EPE - Hospital Pedro Hispano The ULSM consists of the following units of care: Cluster Health Centers of Matosinhos - ACES; Hospital Pedro Hispano - HPH and Convalescent Unit. 2 North HSJ Hospital de São João, EPE Hospital de São João and Hospital Nossa Senhora da Conceição de Valongo merged at Centro Hospitalar de São João (CHSJ, EPE). 3 North ULS Unidade Local de Saúde do Nordeste Unidade Hospitalar Bragança Unidade Hospitalar Macedo de Cavaleiros Unidade Hospitalar Mirandela 4 North CHTMAD Centro Hospitalar de Trás-os-Montes e Alto Douro, EPE O CHTMAD, E.P.E was created on 28/02/07, by fusing the Centro Hospitalar de Vila Real/Peso da Régua, E.P.E and the Hospital Distrital de Chaves e o Hospital Distrital de Lamego 5 North CHAA Centro Hospitalar do Alto Ave, EPE Fusion of Hospital da Senhora da Oliveira and S. José de Fafe. 6 North ULSAM Unidade Local de Saúde do Alto Minho, EPE Hospital de Santa Luzia Hospital do Conde de Bertiandos 7 North CHP Centro Hospitalar do Porto, EPE 8 North CHVNG/E Centro Hospitalar de Vila Nova de Gaia/Espinho 9 North CHTS Centro Hospitalar do Tâmega e Sousa, EPE Padre Américo S. Gonçalo 10 North HSMM Hospital Santa Maria Maior, EPE (Barcelos) 2 Total Region Abbreviation Name of the Hospital Notes 11 North CHMA Centro Hospitalar do Médio Ave, EPE Unidade de Santo Tirso Unidade de Famalicão 12 North CHPVVC Centro Hospitalar Póvoa de Varzim-Vila do Conde Unidade da Póvoa de Varzim Unidade de Vila do Conde 13 North HB Hospital Braga The Hospital de Braga is a hospital unit is integrated into the NHS, under a Public Private Partnership celebrated through a management contract signed by the Northern Regional Health Authority, representing the Ministry of Health. 14 Center HIP Hospital Infante D. Pedro - Aveiro The Centro Hospitalar do Baixo Vouga, EPE was created on 01.04.2011 by merger of Hospital Infante D. Pedro E. P. E., Hospital Visconde Salreu from Estarreja and the Hospital Distrital de Águeda of Aveiro (DecreeLaw n. º 30/2011 of 2 March). However, the request for disclosure of the questionnaire was done for each individual Board. The Hospital Estarreja was not considered because he has no ED since 2009. 15 Center HDA Hospital Distrital de Águeda 16 Center HDFF Hospital Distrital da Figueira da Foz, EPE 17 Center CHCB Centro Hospitalar Cova da Beira, EPE 18 Center CHEDV Centro Hospitalar de Entre o Douro e Vouga, E.P.E. Hospital de São Sebastião Hospital de São João da Madeira Hospital São Miguel 3 Total Region Abbreviation Name of the Hospital Notes 19 Center CHLP Centro Hospitalar Leiria-Pombal 20 Center CHTV Centro Hospitalar Tondela-Viseu, EPE Hospital de São Teotónio (Viseu) Hospital Cândido de Figueiredo (Tondela) 21 Center CHUC Centro Hospitalar e Universitário de Coimbra 22 Center ULSCB Unidade Local de Saúde (ULS) de Castelo Branco, E.P.E. 23 Center ULSGuarda Unidade Local de Saúde da Guarda, E. P. E. Hospital Nossa Senhora da Assunção - Seia Hospital Sousa Martins - Guarda 24 Lisboa and Vale do Tejo HFF Hospital Professor Doutor Fernando Fonseca, EPE 25 Lisboa and Vale do Tejo CHLC Centro Hospitalar de Lisboa Central, EPE Hospital de S. José Hospital de Santo António dos Capuchos Hospital de Santa Marta Hospital Dona Estefânia 26 Lisboa and Vale do Tejo CHLO Centro Hospitalar de Lisboa Ocidental, E.P.E. Hospital de Egas Moniz Hospital de Santa Cruz Hospital de S. Francisco Xavier 4 Total Region Abbreviation Name of the Hospital Notes 27 Lisboa and Vale do Tejo CHLN Centro Hospitalar Lisboa Norte Hospital de Santa Maria Hospital de Pulido Valente 28 Lisboa and Vale do Tejo CHMT Centro Hospitalar do Médio Tejo, EPE Unidade de Abrantes - Hospital Doutor Manoel Constâncio Unidade de Tomar - Hospital Nossa Senhora da Graça Unidade de Torres Novas - Hospital Rainha Santa Isabel 29 Lisboa and Vale do Tejo HGO Hospital Garcia de Orta, EPE 30 Lisboa and Vale do Tejo CHBM Centro Hospitalar Barreiro Montijo, EPE Hospital de Nossa Senhora do Rosário - Hospital Distrital do Barreiro Hospital Distrital do Montijo 31 Lisboa and Vale do Tejo HDS Hospital Distrital de Santarém, EPE 32 Lisboa and Vale do Tejo CHS Centro Hospitalar de Setúbal, E.P.E. Hospital de São Bernardo Hospital Ortopédico Sant’Iago do Outão 33 Lisboa and Vale do Tejo CHON Centro Hospitalar do Oeste Norte Centro Hospitalar Caldas da Rainha (Hospital Distrital Caldas da Rainha; Hospital Termal Rainha D. Leonor ) Hospital São Pedro Gonçalves Telmo - Peniche Hospital Bernardino Lopes de Oliveira - Alcobaça 34 Lisboa and Vale do Tejo HRS Hospital de Reynaldo dos Santos - Vila Franca de Xira 5 Total Region Abbreviation Name of the Hospital Notes 35 Lisboa and Vale do Tejo HBeatrizAngelo Hospital Beatriz Ângelo The Hospital Beatriz Angelo is a new public hospital, built in the National Health Service. 36 Alentejo ULSBA Unidade Local de Saúde do Baixo Alentejo, EPE Hospital José Joaquim Fernandes (Beja) Hospital de São Paulo (Serpa) 37 Alentejo ULSNA Unidade Local de Saúde do Norte Alentejano, E.P.E. Hospital Dr. José Maria Grande de Portalegre Hospital de Santa Luzia de Elvas 38 Alentejo HESE Hospital do Espírito Santo de Évora, EPE 39 Alentejo HLA Hospital do Litoral Alentejano, EPE 40 Algarve CHBA Centro Hospitalar do Barlavento Algarvio, EPE - Unidade Hospitalar de Portimão (sede) The CHBA is formed by two hospital units: Portimão and Lagos. The questionnaire was made available only to Portimão. 41 Algarve HDF Hospital de Faro, EPE Authorized Authorized but outside the deadline ( July 31, 2012) Not authorized Appendix II Formal requirement for questionnaire authorization Ana Margarida David da Silva Rua Aurélia de Sousa, n.º 59, 1.º Frt. 4000-099 Porto Contacto: 964134466 E-mail: [email protected] Exmo. Senhor Presidente do Conselho de Administração da …….. Porto, dia… de …… de 2012 Assunto: “Acessibilidade nos Serviços de Urgência ao Histórico de Medicamentos dos Doentes”. Questionário de opinião no âmbito da investigação para Tese de Mestrado em Informática Médica, a desenvolver na Faculdade de Medicina e Faculdade de Ciências da Universidade do Porto. Diversos estudos têm demonstrado que a morbilidade e mortalidade associada aos medicamentos são muito elevadas. Os erros de medicação, em especial nos Serviços de Urgência/Emergência, constituem um dos problemas que tem preocupado as autoridades sanitárias de alguns países desenvolvidos, e que os levou a repensar e redesenhar os seus processos clínicos, para melhorar o atendimento e segurança dos doentes. A maioria dos erros de medicação e de intervenções inapropriadas é imputável a uma história incompleta da medicação, no momento da admissão do doente nos Serviços de Urgência/Emergência. No seguimento do acima exposto, venho solicitar a V. Exa. permissão e apoio na divulgação pelos profissionais médicos do Serviço de Urgência de …………., de um questionário de opinião cujo preenchimento se afigura essencial para o sucesso da tese acima identificada. Neste sentido venho requerer que: a. O questionário acima mencionado seja disponibilizado a todos os profissionais médicos do Serviço de Urgência (médicos de clínica geral e médicos especialistas, incluindo internos do ano comum e internos complementares) b. O questionário seja disponibilizado via online pelos V. Serviços, enviando o respectivo link para o e-mail dos mesmos. c. Me seja facultado o número total de profissionais a quem será dado acesso o questionário. Informo que todos os dados serão tratados de forma completamente anónima. No final do estudo será enviado um resumo dos resultados obtidos. Em anexo envio declaração comprovativa de frequência de Mestrado em Informática Médica, Proposta de Tese, Questionário a disponibilizar aos profissionais de saúde e pequeno texto explicativo do objectivo de preenchimento do questionário a agregar ao link disponibilizado. Estando certa que o tema desta investigação será de maior interesse para a V. Instituição, aguardo a melhor apreciação por parte de V. Exa. Atentamente, _________________________________ Accessibility in the Emergency Department to patient’s medication history David, Margarida Master in Medical Informatics – Faculty of Medicine, University of Porto Keywords - Drug Prescriptions; Electronic Prescribing ; Medical History Taking ; Community Pharmacy Services; Medication Errors; Drug Interactions I. INTRODUCTION Medication errors are a major concern in the Emergency Department in all countries. The most part of the hospital medication prescribing errors are attributable to incomplete medical histories at the moment a patient is admitted in the ED.1 The process of keeping a medication history begins when the physician asks the patients (if the patient can respond) what kind of prescribed medication they are taking. The collected data is often inaccurate because the patient rarely knows the exact names and doses of their current and recent prescriptions, or they just describe the color and characteristics of the pill or medication box. An accurate medication history gives more knowledge of the drugs that the patient takes or has taken, and prevents duplication of drugs, drug interactions and could even detect drug-related problems.2 Many organizations in many countries have already begun to redesign their clinical processes to improve the patient’s care and safety. One strategy to minimize the possible problems with medication is having electronic access to the patient’s medication history, through databases from national community pharmacies. In this way, physicians have knowledge about what, when and how much medication was dispensed from the pharmacy to the patient. For example, in Ontario, one of the provinces of Canada, the Ministry of Health and Long-Term Care provided most Ontario hospital ED’s with electronic access to the medication history of patients, through the Ontario Drug Benefit program (ODB). The physicians from the ED’s are allowed to access a patient’s medication history in real-time. The major objective of this system is to help healthcare providers to quickly identify and prevent drug reactions, and provide more informed emergency care. 3 In Portugal the scenario is quite different. All Portuguese pharmacies are equipped with computer networks and specific software which is properly accredited.4 One of the pharmacies’ software applications used in Portugal allows the pharmacies, to consult the medication history of their customers. All the data is centralized in the ANF – Portuguese National Association of Pharmacies, in a non-word mark, a barcode. The ANF only has access to the customers’ barcode, without any possibility of identification.5,6 . None of the health organizations or physicians has access to the patients’ medication histories in Portugal. Recently the Portuguese government introduced the requirement of the electronic prescription. This will create a better communication between professionals from different institutions, since there is one uniform format of information that is exchanged. It will also decrease the risk of errors in prescriptions. II. AIM To develop an application that allows the ED’s in the public Portuguese hospitals real-time access of patients’ medication histories. Subsequently a pilot project will be implemented in an ED. III. METHODS A literature review will be done to understand the operational aspects of the existing applications in other countries. Besides this, a questionnaire will be sent to all the ED’s of the public portuguese hospitals. With the questionnaire it will be possible to measure the importance of access to patients’ medication histories in the reduction of medication errors and inappropriate interventions. Also crucial to this study will be the interviews which will be held with several Portuguese health institutions, like: ANF - National Pharmacy Association, ACSS - Central Health Administration System, ARS - Regional Health Administration and others. IV. EXPECTED RESULTS After a thorough research on existing applications in other countries, and the development of an application suitable for Portugal, the expectation is the implementation of a pilot project in one ED. The results of this pilot project will be compared with the situation before the implementation of the application. This will be thoroughly evaluated and validated, using the most appropriate methods of statistical analysis. REFERENCES [1] Tam VC, Knowles SR, Cornish PL, et al. Frequency, type and clinical importance of medication history errors at admission to hospital: a systematic review. CMAJ. 2005;173(5):510-515. [2] FitzGerald RJ. Medication errors: the importance of an accurate drug history. Br J Clin Pharmacol. 2009;67(6):671-675. [3] Paterson JM, Suleiman A, Hux JE, Bell C. How complete are drug history profiles that are based on public drug benefit claims? Can J Clin Pharmacol. 2008;15(1):e108-116. [4] Deliberação n.º 292/2005, February 17 2005; (DR II.ª Série, n.º 46, 07/02/05) [5] Deliberação n.º 292/2005, February 17 2005; (DR II.ª Série, n.º 46, 07/02/05) [6] CNPD – Comissão Nacional de Protecção de Dados; Autorização n.º 172/2007 , February 5 2007 Appendix V Question List (interviews in the Netherlands) Question list 1. By what way do pharmacies allow access to a patient’s medication history? a. Via telephone b. Via fax c. Via email d. Via software application accessed in real time e. Other 2. If the access to medication histories is through a computer application: a. All pharmacies use the same software? b. Is there an institution in the Netherlands that certifies the software used in the pharmacies? 3. The access to medication histories through pharmacies is: a. National b. Regional c. Local 4. Patients signed informed consent form? With whom (pharmacies?) 5. How does a physician identify himself when he wants to access information from the patient's medication history: a. Number of registration of healthcare professionals)( N BIG-nummer ) b. Name c. Other 6. By what way can the patient’s medication history be accessed? a. Health number b. Number of civil identification c. Full name d. Date of birth e. Address f. Other 7. Who can access the patient information? a. Pharmacies b. Physicians (specify functions which they perform in the hospital) c. Nurses d. Patients e. Other 8. If the patient has access to your medication history, how can obtain it? a. Identification (Citizen Service Number (BSN)? b. To who can request this information? 9. Institutions in which information can be accessed: a. Public hospitals b. Private hospitals 10. Which departments in a hospital are allowed to access information from patient’s medication histories: a. Emergency department b. Intensive care c. Internment d. External consultation (include here family doctor) e. Surgery f. Others 11. What kinds of medications become available on the medication history of patients: a. Prescribed by a doctor b. Medicines not subject to medical prescription c. Homeopathic medicines d. Are there exceptions? (e.g. HIV drugs) 12. For how long the medication history is kept: a. Years (how many) b. The last year c. Months d. Other 13. The medication history is accessed through pharmacies (medications dispensed by the pharmacy). The history of medication does not contain more information, like: a. Internal Prescription – e.g. medications prescribed and administered in the emergency b. Medications dispensed to the patient in the hospital - e.g. in ambulatory surgery, the patient often takes with him medication dispensed by the hospital 14. Which information is available regarding the medication history? a. Location Prescription b. Date of Prescription c. Name of doctor who prescribed d. Specialty of the doctor who prescribed e. Telephone number of the physician who prescribed f. Date of dispensing of medications at the pharmacy g. Designation of the medicinal (Omschrijving/beschrijving van het medicament) (Paracetamol/Codeinefosfaat Sandoz) h. Dosage (dosering) (paracetamol 500mg, codeinefosfaat-hemihydraat 20mg) i. Pharmaceutical form (toedieningsvorm) (voor oral gebruik) j. Amount of tablets (aantal tabletten) (30 tabletten) k. Posology (dosering)(3 a 4 daags 1 tablet) l. Medication allergies (medicijnallergieën) m. Other Other subjects: a. Family doctor and family pharmacist b. E-prescribing in the Netherlands c. Electronic Health Record (electronic medication record (EMD) and electronic general practitioner’s summary file to be used by locum GP’s). d. Institutions involved with implementing of e-prescribing and Electronic Health Record (Nictiz – national IT institute for healthcare; Ministry of Health; others) Appendix VI Interviews transcriptions from the Netherlands 1 Interview with Dr. Marc Jonkers & Dr. Anthon Hulsmann - Pediatricians Amphia Ziekenhuis, Breda November 7, 2011 MJ: Marc Jonkers AH: Anthon Hulsmann M: Margarida David B: Bart Wouters (interpreter) Notes: 1. The interview was tape-recorded with the authorization of the interviewees and the interpreter. 2. Before the interview started, we had the opportunity to visit the Pediatrics Department through a guided tour. M: I´m writing a thesis for my master and the subject is to design an informatic application to have access to patient medication history in Portugal, especially in the emergency department. This is why I would like to understand the reality of this subject in other countries. MJ: In the Netherlands, the electronic prescribing is going to start in the next summer (2012). M: So at present you prescribe by hand? MJ: Yes, right now we write the recipe by hand. The GP’s (General Practitioners) are much more developed in this sense; they prescribe electronically since many years. M: Ok, I thought it was an obligation by law in the Netherlands. In Portugal we started with electronic prescribing in last august (2011). MJ: And it’s by law? M: Yes. It is a phase of transition and so we still have some exceptions. For example, for the doctors who make house calls, they write the recipe by hand. They are not obligated to prescribe electronically. MJ: In the Netherlands it is not an obligation to prescribe electronically, not by law. In reality, the family doctors prescribe mainly electronically, by e-prescribing. We are not using it yet but we plan to do that next summer (2012). B: Family doctors all do that? MJ: Yes, nearly all the GP’s do that, but they can still prescribe by hand. For example, my wife is a family doctor and she prescribes by hand when she’s doing house visits but when she comes back to her officer she will put all those prescriptions in the computer. So the record is complete. There are hospitals in the Netherlands that prescribe electronically already, but here we don’t do that yet. The GP’s prescribe electronically and they have two different programs, one of them is Medicom. Medicom is from Pharmapartners. B: And a system like this is going to be use in the entire hospital or just in the Child Department? 2 MJ: No, it’s in the whole hospital. We have one system but there are different modules for each department. B: Yes, because they need their own specific layout… MJ: Yes, it’s right. AH: But one of the problems is that the layout of the patients who are admitted in the hospital is completely different from the layout for patients who are outpatients. The process is more or less the same. So that’s typical… MJ: Yes, you have different buttons, you have different layouts and the layout changes after you click the button. Now we are going to install the software EPIC in the whole hospital. EPIC is from the United States and they are marktleader in that business. That system is being used in more than 160 hospitals in the United States and they just started in Europe. They are now in three hospitals in Europe and those are three Dutch hospitals. One is in Haarlem and another is the Lukas Andreas Hospital in Amsterdam we are the third one. And they want to expand to more hospitals in Europe after they have developed the software for the Dutch hospitals. M: About my question list… MJ: Yes, we can start…But because we don’t prescribe electronically yet, it is a bit premature for us to answer some questions… M: That’s ok. First of all, I would like to confirm if in the Emergency Department the physicians can call to the pharmacy to ask the medication that the patient is using? MJ: Yes, that’s correct. We can call to the pharmacy but it depends on the fact if the medication is prescribed by the General Practitioner. They have the communication between the family doctor and the local pharmacy, in the cities. If the family doctor is entering the medication in the computer the pharmacy can see it as well, so they can see both. But in the hospital we cannot look directly in their system to see the medication that the patient is using, just if we call to the pharmacy during the daytime. So the pharmacy keeps track on the medication and the GP’s do too, but we don’t. Our hospital enters the medication in the computer and the medication that is written by hand is entered in the computer by the pharmacy assistants. Every morning they go hospital ward and they enter all the hand written prescriptions they find there in the computer. So we can see what the patient is using. But it is only for tracking and not for prescribing. M: But you are talking about the medication that is administered here in the hospital? But if you need to know the medication the patient is using you need to call to the pharmacy, is that? MJ: Yes, if it is prescribed medication from the family doctor it is not available in our system. There’s no communication between the two systems. M: And if the patient is here in this hospital (Breda), but is living Amsterdam for example. You can call to a pharmacy in Amsterdam? MJ: Yes, we can call to the pharmacy. But there’s no electronically communication yet. There is a political debate on the subject that we can see the patient’s medical records from other hospitals but it is not 3 allowed by the politicians yet because it is not safe. The security of the data is more important than having communication between the different systems. They want to make one access point in the Netherlands where all the medical data will go, but for now it is not safe enough. We are thinking now about communicating by an electronically standard. We have an electronic medical record like this and it can communicate with the hospital in Amsterdam, for example. So, it will be direct communication instead of all the data going to one point… M: You talking about the National Switch Point? MJ: Yes and the National Switch Point is not safe so we do direct communication. M: But do you think they are not going to make that through the National Switch Point in the Netherlands? MJ: No, the National Switch Point is not going to start in the next years, we think. The doctors they want to have this, of course, but the politicians don’t consider it safe enough. AH: It is not allowed in the Netherlands because medical data is secret and there probably will be no solutions for these safety and privacy issues in the next years. M: I was reading about the patients’ rights regarding to the National Switch Point…about the informed consent that the patient should sign…like he has the right to delete information from his file, or choose which physicians can see his file… MJ: If you send medication to another organization then you need informed consent of course. That is one of the problems on safety. You have to give consent actively when the medication is sending somewhere else, and they are really afraid to do that. But if a patient, for example from Amsterdam, is knocking on the Emergency door here, saying “please help”, at this moment we don’t have information on his medical record. So I think is probably better, if you are part of the team who treats patients, you can directly contact electronically the medical records in the hospital of Amsterdam. In this scenario we are one team so the patient doesn’t have to give informed consent in that Emergency visit because everything is one team of treatment. If the patient comes to the hospital we can ask if we can see his medical records in Amsterdam. He then will give permission at that time and we contact electronically the hospital in Amsterdam. Like this we don’t need the National Switch Point. M: But right now you’re not working in that way? That is in the future? MJ: No, we are not working like that now. But with the EPIC system it is possible to communicate between the hospitals. They are using that in the United States. M: Yes, I understand, but for that you need to have the EPIC in all of the hospitals in the Netherlands… MJ: Or you need a standard. If you have a standard way of communicating you can read the data from all the hospitals. And EPIC can read and can deliver the standard. M: To conclude, you can ask the medication history from a patient through phone, fax or e-mail (question number 1). MJ: Yes, that’s correct. 4 M: If the access to medication histories is through a computer application, do all pharmacies in the Netherlands use the same software? (Question number 2) MJ: I’m maybe not the right person to answer that question; I think it is better if you ask this to a pharmacist. What I know is that Medicom is communicating directly with the GP’s. For us (pediatricians) it is important that our system can communicate with the systems of the pharmacies and the family doctors. M: We already talked about the question number 3 (The access to medication histories through pharmacies is national, local or regional?). For example, if a patient is here in the hospital but he’s from Amsterdam, and you need to know the medication that he’s using you can call… MJ: Yes, but it is only in daytime, it is only in office hours. M: And at night? MJ: We can call to the hospitals, it’s what we do. Because we cannot reach the pharmacy. M: But if you call to the hospitals you can have access to the medication history? MJ: Only the medication that is prescribed in the hospital. Not the medication from outpatients. We don’t have communication between hospitals and local pharmacies yet. M: We already talked about the informed consent which the patient should give (question number 4) but it was not completely clear to me. If you are allowed to call to a pharmacy to ask the patients medication history, the patient should give the informed consent before that. MJ: Yes, in reality we ask the patients if we can call to the pharmacy. And we only call to the pharmacy if they approve. It is not a written informed consent, it is an oral consent. M: So the patients don’t sign anything? MJ: No. M: Never? AH: We have to document in the patients file “patient allows us to ask the pharmacist”. We have to write that down. That is approved by law. M: Do you need to identify yourself when you call to a pharmacy? MJ: Usually I say that I’m a doctor from the Amphia Hospital and that I need to know the medication. So it’s not really very safe. M: I thought that you need to give the BIG number… MJ: No, we don’t use that in reality. Normally we don’t have to give the BIG number to the pharmacy to get some information. The information which we want to know is not really top secret. We ask the pharmacy, for example, what kind of antibiotics the patient got recently because the patient’s really doesn’t know what kind of medication they are using. 6 B: It’s the other way around! RV: This discussion is all over the Netherlands. They are discussing the idea but it’s not working when you have to ask to patient in advance every time. The patients think that we get the information from the community pharmacy and that we give the information back. They find this normal. M: Well, but the patient just needs to authorize one time. And if he then decides that he doesn’t want his medical information available he just need inform that. RV: Yes, we already discussed this often, but we think that this is a job for the community pharmacy. The community pharmacy has a different and closer relationship with the patient; we (pharmacy hospital) don’t have that. B: That’s a difference here in the Netherlands. In Portugal you don’t have a thing like a family pharmacy, like a family doctor. You have many pharmacies in the city and you can go there with your recipe and you’ll be served but it’s not that you have one pharmacy where you normally always go to and your name is in their system, etc. It’s different. RV: Here in the Netherlands you can also go to another pharmacy. It’s possible, but most people go to their own pharmacy. It’s better to go to your own pharmacy, because they know everything about your medication, so what you are and what you have been using. Otherwise you have to tell that at the other pharmacy and then they need to see if you have some problems with different medication. B: But, in this region (Breda), because they all use Pharmacom, so they can see. RV: Yes. If you go to another pharmacy than your family pharmacy to get some sleep medication, for example, and you don’t tell that other pharmacy that you normally get your medication from the other (your family) pharmacy, they will give you the medication. Only when all the pharmacies are closed, at night or during the weekend, patients have to go to the one pharmacy that is on duty. There they can see the medication from all patients from the region, because they can look in all the pharmacy databases in that region and get the information. They call this the OZIS connection. All the pharmacies using Pharmacom are connected with each other. If you want to have information about a certain patient you enter a date of birth and a name. Then you search for all the different databases of the pharmacies and you’ll get the information. But the problem is that this information is not always very correct, because every pharmacist who works with Pharmacom has his own way of entering the medication and dosages in this system, it can give wrong or confusing information. You have to be very careful with that. In the end they will stop OZIS because the LSP… B: The National Switch point. RV: The National Switch point will take over that part. In a few years… M: To conclude, just the technician and the pharmacist can access the medication history of patients. RV: Through Pharmacom. M: By what way can the patient’s medication history be accessed in Pharmacom? 7 RV: With date of Birth and with a name you can find the patient. First, we have to know to which pharmacy the patient goes, and in which city, then you enter the date of birth and you get some names and then you choose the name of the patient. B: And the technician how does a technician identify himself in this system? RV: They have a login code. But the problem is that all the technicians here in the hospital pharmacy use the same password. Because we can’t add or change anything in the system and it’s only for the pharmacy department. It’s only to look for the medication. It’s impossible to have different passwords, because we have so many technicians. M: But the Pharmacom should give a different user and a different password. RV: I think for our objective, just to look into the system, one is really enough. The computer is located in the pharmacy and it’s only accessible by the pharmacy. So, there’s no one else, besides the pharmacy technician and the pharmacist who can get access to the computer. M: So the answer to the question 7 (who can access the patient information) is pharmacists and pharmacy technicians. RV: Yes. But it’s only about Pharmacom and other outside information. It is different situation if you’re talking about the medication inside the hospital. Pharmacom is only to look outside the hospital and get information of the patients who are coming into the hospital, but inside we have another system. B: So, that’s EPIC. RV: EPIC is the new software but for the pharmacy now we still have Centrasys, that’s our software and we will be using for a little while longer, because the logistics have to be in Centrasys, our system, because EPIC is not ready for that yet. They are building a logistic system in EPIC. M: You need to look to Pharmacom to have the list of the medication from outside the hostpital and in Centrasys to see the internal prescriptions? RV: Yes, that’s right. Everything the physicians prescribe for patients inside the hospital we enter in our own system. So, if you want to know something about medication inside the hospital then everyone can see the information, the nurses, the physicians, etc. M: And then, the information that you’re going to see in the pharmacy, you’re going to put in your system here in hospital? RV: Yes. The physician writes the prescription on paper and we enter it in our system. Like normally you go to the community pharmacy, you have a prescription and you give it and they enter it in the system and you get your medication. And that’s the same we are doing here. So, I don’t know if you only want to focus on the Pharmacom, because that’s the outside pharmacy system and Centrasys is inside (hospital) pharmacy system. So it’s quite different. B: No. It’s about the process of e-prescribing the medication. You do it inside as well as outside. And it’s good to know the difference between looking outside through Pharmacom and the communication inside of this hospital through Centrasys, and later on EPIC. 8 RV: And EPIC will be also for prescribing to outside patients. There’s no connection between EPIC and the community pharmacy, so we will still have to print. When you’re prescribing by computer you will have all medication and interactions between medications. But you still have to get make a print and the patients still need to take it to their local pharmacy. M: And then they enter it in the system? RV: Yes, they enter it in their system and they check it again. M: This is why it’s going to be easier when the electronic prescription is ready. RV: Yes. It would be nice and we are going to investigate if it’s possible to get an interface between Pharmacom and EPIC. It would be nice if EPIC could send information to the Pharmacom system. M: So, and can the patient have access to his medication history? RV: The patient? M: Here in the hospital or in the pharmacy outside? RV: If he wants, he can ask, because the patient is the owner of his own medical file. So he can ask if he want to see it and then he gets a medication list of what he’s using or what is entered in the system. Here in hospital they have never asked, because they get the medication from our department and we make a list so the nurse can see which medication and which time the patient have to have this medication. But some patients, who can take medication by themselves, they don’t have to ask the nurse, but they get the medication and they can take it by themselves. Sometimes we give them a list so they know what they have to take. But that’s not very often. M: So, and talking a little about types of medications that you can see. For example, if you want to see the medication history from Pharmacom, you just know the medication that was prescribed by the doctor or you can see another kind of medication? For example, if I’m going to the pharmacy to buy a paracetamol. RV: It depends. If the pharmacy put it in the system, then we can see. Otherwise, we don’t.. I think most of the pharmacies don’t enter this information in their system. So, when we have patients here for their pre-operative screening, we ask what kind of medication the patient is using through the pharmacy and we always ask which “over the counter products” they are using. B: Like a normal painkillers or things like that, for which you don’t need a recipe? RV: Yes. We always ask because I don’t think the community pharmacy enter it in the system. M: Do you think this is important information? RV: Yes, it’s important. We always ask about the medication. Sometimes we see the patient takes a lot of paracetamol and sometimes too much. A patient might think it’s not so important but it’s important that you do not take too much paracetamol. M: And the same for the homeopathic products? 9 RV: Yes. We also ask that. It has to be really important medication, and then we enter it in our system. When a patient uses four times a day one gram paracetamol, we put it in our system. There is no prescription that the patient has taken it and we want to know that the patient has taken it. But we skip the homeopathic medicine. M: Sometimes you have some homeopathic medications which are not very good for the patient… RV: Homeopathic we are not interested in and they don’t get it here in the hospital. So, if they want to use that, they have to get it from their own pharmacy. We don’t order that. M: And you can see all the medications in the system? RV: When the physician has prescribed something, we enter it in our system and we can see everything. M: Because, for example, in Massachusetts they can’t see the drugs for AIDS. RV: In our system as we are working now, every patient who is coming in hospital and gets medication and the medication is dispensed by the pharmacy department, we enter it in our system. If they, the doctors, don’t give the information to us, then we don’t know and we can’t enter it in our system. B: Of course. It depends on the co-operation of every one. RV: And we also want to enter medication patients are using by themselves in our system, because we want to know all the medication they are using. Otherwise we can’t see the possible interactions between the medication and it’s very important to see those. So we enter as much information as possible in the system. M: So, for the law… there are no exceptions? RV: In our hospital and in our pharmacy we do not have any exceptions. M: In the Netherlands? RV: I don’t know. Sometimes, in the system of a hospital, you may not put in the medication if the patient requests that. But, in all years that I’m working in the hospital pharmacy, I’ve never had such a case. But with the National Switch Point everyone in whole Netherlands got a letter asking if we want our information in that system. B: I had that letter. RV: And you can say “no I don’t”, then you are not in the system and they can’t see anywhere what medication you are using. If you have an emergency problem, then no one knows what kind of medication you are taking. But, every person has this possibility to say “I don’t want to give my information”. I think with the National Switch Point maybe more patients will say “I won’t… I’m not happy to have my information over there in the system…everyone can see it”. When you have regional system, I think, no one ever thinks about it. B: No. It’s just… it’s there. 10 RV: It’s there and it’s easy. Maybe it’s not so big, like a system for the whole country. It’s just a region and like that we don’t have the problems which the national database has. In all these years in which we get the information from the local pharmacies, only one patient was not happy that we had that information. M: And for how long is the medication history kept? RV: 15 years by law. For 15 years we have to keep the history. When we did not have an electronic database, it was by paper and we also had to keep that for fifteen years. This in case when someone wants to know something. M: But this is in the hospital? RV: No. It’s for pharmacies, for prescriptions. The prescriptions have to be held 15 years. B: Also for local pharmacies? RV: Yes. We still have the same software from last century. So we have about 30 years of information. It’s no problem. B: If you want you could look back 30 years? RV: Yes. I don’t know how things will be when we switch to EPIC. We have to have a tool to look in Centrasys when it’s necessary, but we also have all the papers. Because what we put it in our computer system is not the original prescription. The original prescription is still on paper here, because there is the signature of the physician. So we have to keep those papers for 15 years. M: So you don’t scan? RV: No. We don’t scan. Our technicians enter it in our system, but the original prescriptions are on the paper… B: The original papers need to be kept for 15 years by law? RV: Yes. Because it’s not the original prescription in our database. It’s what we put in. It will be different with EPIC. Then it’s all in one system and we don’t have paper anymore, I hope. M: Which information is available regarding the medication history? (Question number 14) RV: What we see in Pharmacom is…what the technician has entered in the system of the local pharmacy and that’s the day when the medication started, the dosage. Also I think the physician; the pharmacy who delivered it. Also we can see the label they are printing. The contraindications, the allergies… M: Posology? RV: Indications, if they are put in. Location of prescription, yes. But there’s not the location but the person of the prescription. M: Name of the doctor who prescribed? 11 RV: Specialist or general practitioner, like that. Is it a doctor from here, from hospital or is it their own family doctor. I think those are the two things. M: Maybe the specialty of the doctor who prescribed the medication? RV: Yes. I don’t think we always see the name of the doctor. We see the specialty of the doctor but not always the name. The date of prescription is the date when the medication started. The prescription is maybe written a week ago but the patient is getting his medication today. Date of dispending. The phone number I don’t see. Maybe it’s in there but I can’t remember I’ve see this information. We see what kind of medication it is. The dosage we see. Also the pharmaceutical form. We also see the amount, how much medication is delivered and how often the patient has to take it. We see medication allergies. And, I think, indications and contraindications when they enter it in the system. B: You see contra indications? RV: Contraindications. For example if a patient get some medication because he has hypertension, but this patient has also some other problems for which he’s not allowed to have that medication. That’s contraindication. Special medication which is not allowed to be given to this patient or otherwise he gets in trouble. We can also see in allergy… we can see which allergy was reported by the physician or by the patient. B: But those are not medication allergies? RV: They’re medication allergies. One of the most difficult things to arrange is allergies. For example, the patient says that he is allergic to a certain medication because he had diarrhea when he was using this medication. In reality it might not have been an allergy, and the patient was just sick. But if the pharmacy has entered this allergy in his system we have a problem when the patient needs this medication. You can’t give the medication because it can give an allergic reaction, when probably it is not! So, that’s very difficult to get the right information about allergy. It’s the most difficult part for all pharmacy departments. M: In the Netherlands you have public and private hospitals. Can the private hospitals access Pharmacom? RV: We have in the Netherlands ZBC’s (Zelfstandige Behandel Centra’s – Independent Treatment Centers) they offer mostly only special surgery likes knee or plastic surgery, those kinds of things. It’s not a community hospital. We have arranged connection with Pharmacom, because we have good connections with our community pharmacies, but I think the private hospitals don’t have that connection. Probably they need to ask to the patients when they are coming to their hospital. B: The patient needs to bring his own information. RV: Yes, a medication list. I don’t think they have access to Pharmacom, but I’m not sure; I don’t know how they work. We have here in Breda the Medinova Hospital. That’s a hospital for orthopedic surgery. B: And that’s a private clinic? RV: Yes, but they also need to have an arrangement (agreement) with the insurance company. We also have connections with them, because if something happens over there, the patients can’t stay there and they need to come to a real hospital. M: For example, does a dentist have access to Pharmacom? 12 RV: I think they can ask the community pharmacy about that. But you should ask that to the community pharmacy. They will know. Because we only look in our hospital. B: But with dentists, like family doctors, you have a personal relation. You have your own dentist, your own family doctor and your own pharmacy. So, probably they are connected and they can see. But that’s indeed a question you need to ask the community pharmacy. RV: I think they can ask the community pharmacy. The dentist will ask the community pharmacy. And now in a few weeks they have all the posters and everything to say “when you go to the dentist or the physician or to the pharmacy always bring your medication list with you”. That’s now a campaign we are doing here. I think it’s also a responsibility for the patient. If you ask something about their medication, patients usually don’t know. They have to know what kind of medication they are using. And if they don’t know, because it’s too difficult to pronounce, they should write it down and have always the list with them. I don’t have a list with me. My mother was staying in the hospital this year and she didn’t have it. I thought “I’m a pharmacist and she’s doesn’t have the list” and last time I said to my parents “you have to go to the pharmacy and get your list”. M: So that campaign is to explain how you should make the list? RV: No. You have to go to the pharmacy and then you have to discuss your medication. You get a list from the community pharmacy and that is what you always have to have with you. B: You can go to your local pharmacy and ask that list and they can print that for you, because they have the history of your whole life in their computer. RV: And at that time, they check it with you, because when a physician here has stopped certain medication, I don’t think the pharmacy knows. The pharmacy doesn’t know. No one tells a pharmacist that the patient stopped using a certain medication. Only the patient knows it has stopped. So when the patient is going to the pharmacy, and he wants to have a list, they check all the medication that he’s using and update this and enter the right information. M: But for example, you have a prescription and you go to the pharmacy to buy the medications. But you can choose, well, I don’t want this medication… RV: Well, I know. We see it every day. That’s why when the pharmacist makes a list together with the patient, the patient needs to say which medication he’s using and how much. And then it’s the real list. We know, because we see here during the pre-operative screening: “I don’t use all because I only take half the medication, because otherwise I get sleepy” or whatever. But we write down that he only takes one instead of two pills. Then the information is going to the physician (the patient doesn’t take the right amount). But we are not going to give him two tablets when he’s here, because he’s used to one. We have to give the patient the medication he’s really using and it can be different of what is prescribed. That’s very difficult to get right. M: So the pharmacist enters in Pharmacom what he sells to the customer? Not the prescription, because probably the patient didn’t buy all of the prescription… RV: Yes, what the patient is using. They deliver medication and they can see when the patient has to come back for more. Sometimes they discuss that with the patient (are you still using the medication). If the patient doesn’t say anything, then the pharmacy doesn’t know. It’s a problem. But when we use the 13 National Switch Point, we don’t know anything, because we think the patient is using what is delivered. I know that is not the real situation. M: This is why you should know what the pharmacy dispenses to the customer. RV: Yes, that’s what we know. We know what the pharmacy dispensed. M: Not what was exactly the prescription but what was dispensed to the… RV: No. We only see what was dispensed. It could be another prescription but then it can be that the pharmacy has called the physician to say “this is not the right prescription or it’s not good in combination with other medication, we have to change it”. Then they enter it in the system. So we only see what is delivered not what is prescribed. We are talking about Pharmacom. Here we see what the physician prescribed and then, sometimes we have to call to say “That’s not good, we have to change the prescription”. M: Question number 13: The history of medication contains information, like medication dispensed to the patient in the hospital. For example, in ambulatory surgery, the patient often takes medication dispensed by the hospital with him (e.g. for the next 2 days). You write that in the process of the patient? RV: They don’t get anything here from the hospital. I’m not so happy with it… If I could change it, I would, because I think it’s better to give medication for one or two days to the patient, so that he doesn’t have a problem when he gets out hospital and first needs to go to the local pharmacy to get the medication. But here, on this location, we have an external pharmacy. When your own pharmacy is closed, you can get the medication there. And besides that we have a service point here, with pharmacy technicians. When a patient is going home the technicians will fax the medication list of the patient to his own community pharmacy. And then the patient can get his medication over there. So the patient is not taking his own prescription to the pharmacy. We fax it to the pharmacy. M: Always? RV: Almost always. It depends on the department. But it’s easier to give the prescriptions here to the service point. Then they can check if everything is ok and if the home medication still has to be continued. And sometimes we split some medication, because we don’t have that medication. And then when he goes back home, he has to use the medication he was using at home. And that’s what the department service point is doing. And fax it to the community pharmacy so they can already enter it in their system and prepare everything for the patient for when he’s coming there. And they can even deliver at home, if it’s necessary. It’s also possible. The community pharmacy can deliver at home. M: Thank you for your time and cooperation with the research for my study. I will make a transcript of the interview and would like, if possible, to get your feedback. Do you agree with that? RV: Of course. M: Can I have your contact information to send you the transcript by e-mail? RV: Yes, I will give you my card. M/B: Thank you once again. 1 Interview with Dr. Renier van Dinter – NBD Manager, Janssen-Cilag Tillburg, province of North Barbant November 7, 2011 RD: Renier van Dinter M: Margarida David B: Bart Wouters (interpreter) Notes: The interview was tape-recorded with the authorization of the interviewee and the interpreter. M: I’m writing a thesis for my master and the subject is to design an informatic application to have access to patient medication history in Portugal, especially in the emergency department. It’s why I would like to understand the reality of this subject in other countries. And because I know that in the Netherlands you have access to some information of medication I decided to start here. Can you tell what your function in Janssen is? RD: I’m working now for 17 year for Janssen and I have been doing a lot of different things here. First I was a sales representative, visiting the GP’s and the specialists, then I became a marketing product manager, where I was responsible for a couple of projects in the company and now I’m the new business development manager for Europe so I’m trying to look at different products that are being developed by other companies and if those products are interesting for us we try to make a deal or an agreement or negotiation so that we, as Janssen which is part of Johnson & Johnson, can sell the products of ourselves. So buying products from other companies is the most important part for my job at this moment. I have a special focus for the medium sized countries which is Europe without the five biggest countries. So I’m more specialized in the central and eastern European countries, the Nordics, the Netherlands and the Alpine cluster Switzerland and Austria. M: I would like to understand what the role of the pharmaceutical companies is in the medication history of the patient’s…the connection with the doctors, pharmacies, hospitals, etc…. RD: At this moment I’m working at a kind of innovation project where we look at how can we raise compliance and solve compliance issues by creating a platform, an (electronic) dashboard, which is for the patients of course, so the patients have a platform at home online which is built up with data which comes directly from pharmacies and healthcare professionals. So connecting both the data that is available from the pharmacist and healthcare professional and fill the platform towards the patient. So all the medication is on the platform and also there’s a loop between these 3 parties. So, if a patient has side effects he automatically enters that into the platform and then automatically a notification is going to the pharmacy and the pharmacist can act upon that. So, for example, he can call the patient, tell him that it is a side effect but that the patient should wait 2 or 3 days and keep on using the same medication in the same dose and after 2 or 3 days this kind of side effects will go away or, for example, this is a serious side effect and it has to be reported and the pharmacist has to change the medication for the patient. It’s the interaction between the 2 or 3 parts in the system. That’s something that I’m currently working on… B: But is it going to be national? RD: We are building the case for Janssen Europe and some countries are more advanced than other countries for such kind of innovation, so it is very small, but it is already available in the Netherlands, I think that 30% of the pharmacies in the Netherlands are using this at this moment. We want to build it in the Netherlands and we want to expand it in several countries in Europe. 2 M: I already know that the physicians can see the patient medication history through the community pharmacies. That’s correct? RD: In the Netherlands we have 2 different systems: we have the system of the physicians and the system of the pharmacies. At this moment they are not connected. The Government wants to have an electronic patient record, the National Switch Point, and really make it into one system for all of the Netherlands, where everybody (healthcare professionals) is connected to. But in April from this year (2011) the law which should make this possible, has been declined. Currently the system is on hold and at this moment there is no effort anymore to solve the issue and really build one system. So at this moment we have one system for the pharmacy and one system for the healthcare professionals. B: But just on local and regional level the physicians and pharmacists connect. We already talked with a pharmacist from Amphia Hospital and she said that on regional bases we can access the electronic medication files from the pharmacies in the region. RD: The pharmacies? Yes, but not the healthcare professionals. M: The healthcare professional can call to the pharmacy or ask by fax and the pharmacy can send the list of the medication. RD: The list of the medication…but the reason behind the two systems is that the healthcare professionals don’t want to include the indication in the system, for which you get the prescription. Because if the pharmacist want to know the indication, then you, as a physician, can be scared that the pharmacy will take over the rights of the physician (and tell to the patient “so this is the indication so you should have this product”). The physician wants to have the rights, the power, and the control to decide which product should be prescribed. And that’s the reason why the systems are not connected. When there already is connection between the systems it’s always without the indications. And for the next year, 2012, they are trying to overcome the first hurdle and include, I think, for 5 or 10 disease areas also the indication into the pharmacy system. That’s a transition and it’s a pilot. So let’s see if the pharmacies will use it. So it’s very important to understand that we have two different systems: one system for healthcare professionals, for the physicians, and one system for the pharmacies. And several hospital pharmacists can look into the regional pharmacy database. M: Yes, with the Pharmacom system. RD: Yes, for instance. B: So you have Pharmacom system for the pharmacists and Medicom system for the medical professionals. RD: But it’s just one system. Besides Pharmacom and Medicom you have also other providers. M: About the first question (By what way do pharmacies allow access to a patient’s medication history?)… RD: What way do pharmacies allow access to a patient’s medication history? Every pharmacy has a computer and in the computer they have all the patient medication histories. It’s online and real-time accessible. The physicians have their own system.