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DESPITE repeated calls by many health bodies and coroners, we are still hampered by the absence of a national system of real-time electronic reporting and recording of controlled drugs.
Tasmania is the only state to have introduced a real-time electronic reporting and recording of controlled drugs (ERRCD) system. Although the system is often talked about on the mainland, I have been struck by how few people know how it works in detail.
I recently visited the Pharmaceutical Services Branch (PSB) of the Tasmanian Department of Health and Human Services to explore their system — Drugs and Poisons Information System Online Remote Access (DORA) — which the PSB told me had successfully delivered a reduction in inappropriate prescriptions and dispensing of drugs of dependence (DOD).
As doctors, we are often asked to prescribe DOD to patients we have limited information about. In making a decision about prescribing, we need to consider our clinical, ethical and legal responsibilities. We are well aware that failure to do so may lead to adverse consequences, not the least of which is potential harm to patients.
For all medications, and especially for DOD, having current and accurate information about the drugs prescribed and dispensed to patients is crucial in assisting clinical decision making. But this is sometimes easier said than done.
Although limited, this information can currently be accessed by tools such as the personally controlled electronic health record (PCEHR), the Prescription Shopping Programme and the Pharmaceutical Benefits Scheme (PBS) authority system.
Real-time reporting and monitoring has the potential to solve a lot of problems. My visit to Tasmania showed DORA has a number of useful features.
Once registered with the system, a GP can log into an online portal and see what opioids and other restricted drugs (dexamphetamine, lisdexamfetamine, methylphenidate, flunitrazepam and alprazolam), and in what quantity, have been dispensed to a particular patient. This information is available at any time.
Usage of and access to this information is monitored, with unauthorised access prohibited by federal and Tasmanian privacy laws.
Registered GPs can see if a patient has previously been declared drug dependent or a drug seeker as defined by the Tasmanian Poisons Act , if they have been treated on the Tasmanian Opioid Pharmacotherapy Program for their dependence, and if the PSB has distributed a circular about the patient on behalf of a medical practitioner. DORA users receive an alert if accessing files of patients identified as being at high risk of misuse or diversion.
When a pharmacist dispenses a script for a DOD the information is automatically transferred to DORA. The information is seen and monitored in real time (albeit in business hours) by the PSB. The pharmacist has access to the same online portal as doctors.
When required, the PSB can call a pharmacist to stop dispensing the drug. It is also able to call the prescribing doctor to inform them of the patient’s prescribing history and to seek further information on the reasons why the drug has been prescribed.
DORA monitors all dispensing of monitored drugs, whether dispensed as a private prescription or on the PBS.
A surprising realisation from my trip to Tasmania was that DORA is just one tool (albeit a powerful one) used to assist doctors to prescribe safely, effectively and lawfully.
Another method of monitoring, regulating and educating GPs on the use of opioids and other restricted drugs is the PSB’s regular meetings with a clinician panel comprising pain specialists, addiction specialists and GPs, to discuss applications to prescribe to drug-dependent and non-drug-dependent patients. Expert advice is facilitated at a local level when required.
The power of this system is in ensuring patient safety cannot be overstated. I was amazed by its ability to allow real-time monitoring and collaboration between the PSB, pharmacists and doctors.
Critics have claimed that what has been achieved in Tasmania is too difficult and expensive to roll out nationally. Yet what I witnessed in Tasmania was nothing short of inspiring.
Working together to anticipate and stop a problem, before it even becomes a problem, is surely in everyone’s best interests.
For the sake of doctors, pharmacists and especially patients, ERRCD should be introduced nationally as a matter of urgency.
Dr Walid Jammal is Senior Medical Advisor-Advocacy at Avant Mutual Group.
As a practitioner I would certaily like some more factual information about the DORA system in order to make an informed decision. I would like to know:
1. Is DORA a separate system or is it seamlessly integrated with desktop software – both GP desktop and pharmacy desktop?
2. How is authentication done – are users (GPs and pharmacists) required to have yet another username/password?
3. Who keeps permissions up to date and how do they do this?
4. How do prescriptions records get into the system and what is the mechanism by which hospital and GP prescriptons end up in the central server in real time?
5. What is the time delay from when a doctor starts to try and check to see if he has a doctor shopper in front of him at the time of the consultation to when he has the information in hand to discuss with the patient?
6. Has my desktop vendor evaluated DORA and do they think they can work with it in a way which will give me a streamlined solution that will help me?
7. Will DORA be available through my software vendor or some other Third party and what will it cost me to instal?
Dr Walid Jammal states that “critics have claimed that what has been achieved in Tasmania is too difficult and expensive to roll out nationally”.
What do these critics mean?, Who are they?; What are their credentials?; In what way is it too difficult to roll out nationally?; What is the dollar value of ‘too expensive”?; Where are the costings?; What are these critics really saying?
If Coroners had more power to drive through change instead of making recommendations for bureaucrats to thumb their noses at we would have Real Time Prescription Monitoring in Australia today. It is not that difficult and it is not that expensive; but without competent leadership no progress will be made.
If the public sector is so incapable of embracing innovative solutions and driving change then perhaps Coroners need to become more forceful in recommending the private sector be engaged to deliver RTPM, integrated with the eScript Exchanges already serving all doctors and pharmacists throughout Australia.
Let us not forget that more deaths occur in Australia from prescription drug overdose than from motor vehicle accidents.