Real-time Prescribing

Real-time prescription monitoring

It may seem a long time coming, but WA is edging towards a mandatory real-time monitoring service.

The WA Department of Health is slowly progressing towards a realtime prescription management system which will connect with other states and territories with the objective of reducing problematic prescription usage and prescribing practices of schedule eight (S8) pharmaceuticals.

WA currently utilises the Prescription Monitoring Program (PMP) for S8 prescriptions, which is a monthly reporting system that provides prescribers retrospective notice of problematic prescribing for a drug dependent and oversupplied person, long after the pharmaceuticals have been dispensed.

As the PMP system produces monthly reports, there is inherent latency in providing clinicians with information they need to make informed, in-the-moment prescribing choices, as notices could be sent long after a prescription has been dispensed.

With increasing overdoses and accidental deaths from controlled pharmaceuticals over the past 20 years in Australia, particularly S8 opioids, real-time prescription monitoring is considered a viable harm reduction strategy.

Tasmania was the first state to implement RTPM with the Drugs and Poisons Information System Online Remote Access system (DORA) in use since 2012. The Australian Capital Territory began using the DORA system in 2019. Whilst using the DORA system is voluntary in both states, prescribers

James Knox reports.

who use it can see how and when S4 and S8 opioids and other controlled S8 pharmaceuticals are being prescribed.

Victoria implemented its own RTPM system, SafeScript, in 2019 which differs from the DORA systems as it is mandatory for all prescribers and dispensers.

National action It is expected that in 2020, WA will be joined by South Australia, Queensland and New South Wales in planning and implementing RTPM systems.

Each of these systems will connect to the national data exchange (NDE), a federally funded, Australia-wide system providing state and territory interconnectivity and interoperability for prescribers and pharmacists with real-time prescribing information.

The NDE, rolled out in December 2018, is the primary architectural component for the Electronic Recording and Reporting of Controlled Drugs (ERRCD) system, the national RTPM system, based on the Tasmanian DORA model.

The ERRCD system has been made available to each state and territory by the Commonwealth since 2013 yet the ACT is the only state to take up the offer so far.

Both Dora and SafeScript were developed independently to the ERRCD and national data exchange, funded by the individual states, with the Victorian system costing a reported $30m. In 2018, the COAG Health Council agreed to a federated RTPM model, releasing a communique at the time saying: “The minsters agreed to… a federated model with jurisdictions committed to progressing development and adaptation of systems to connect to and interface with Commonwealth systems to achieve a national solution.”

WA’s RTPM system will connect to the NDE, yet nationalised data sharing of prescription information comes with a multitude of state and territory agreements, along with legislative and policy changes in WA.

How close is WA to having a functional RTPM system? How will it be implemented? And what will this mean for prescribers and dispensers? Medical Forum spoke with the WA Department of Health and WA’s Chief Pharmacist Neil Keen for the answers. Towards real-time The Prescription Monitoring Program (PMP) in WA is far from perfect with notices being sent to prescribers up to three months after a script has been dispensed to potentially drug dependent and oversupplied persons, highlighting the need for RTPM in the state. The program only monitors S8s, whereas other systems scrutinise S4 opioids, such as Tramadol, as well.

The WA Department of Health (WADoH) has decided to connect to the NDE rather than having a purely state and territory-based system as in Tasmania, Victoria and the ACT. This means data sharing

agreements need to be formed with each state and territory based on the Medicines and Poisons Act 2014 (WA), prior to the system being rolled out.

WA currently has no formal data sharing agreements with other jurisdictions, but it is hoping these will be completed in 2020. WADoH does, however, occasionally receive or make requests with health departments in other states and territories regarding individual patients and these are dealt with on a case-by-case basis.

The WA RTPM system will be based on SafeScript currently in use in Victoria, and will be mandatory for prescribers and dispensers and will be designed integrate into an envisioned national system.

“The new RPTM system is expected to improve the current process in that the information will always be up to date, will be accessible to practitioners 24/7 and available via secure electronic channels on the clinician’s own computer,” Neil Keen told Medical Forum.

The current system Although the WADoH hopes to roll out RTPM in 2020, the current system is what prescribers and dispensers rely on and depending when the data sharing agreements and legislative changes happen, it could be in place for some time yet.

“PMP is considered generally effective, within the limitations of the technology in use,” Mr Keen said.

“Each year the Health Department responds to tens of thousands of calls and provides patient dosing histories to medical practitioners across WA. The records are continuously monitored, and people believed to be oversupplied or doctor shopping are identified, and their cases managed.”

The PMP has two clear functions: Ensuring compliance with the Medicines and Poisons Regulations (2016) and the Schedule 8 Medicines Prescribing Code, and identifying patients that have been flagged as drug dependent or oversupplied.

These are the medicine types and dose thresholds that require prior authorisation: opioids in any combination, where the total dose is more than 90mg morphine equivalents per day*; immediate release opioids where the dose is more than 45mg morphine equivalents per day*; all injectable preparations*; methadone*; alprazolam or flunitrazepam; S8 medicines not registered with the TGA.

* Specialists can prescribe these for up to 30 days without prior authorisation from the department.

While prior approval is required for patients under 18 years, recorded as oversupplied or drug dependent or with a history of substance abuse within the previous five years.

For a patient to be classified as drug dependent, a medical practitioner diagnoses them, then reports the case to the WADoH. The patient can choose to accept the diagnosis or dispute the report with the department, which will then review the case.

Whereas an oversupplied person can be identified via a health professional’s report, prescription monitoring conducted by the department, or from police reports. Excessive S8 prescriptions from multiple doctors over three- and six-month periods is the type of behaviour identified as oversupplied. For clinicians with patients on longterm S8 prescriptions below the approved thresholds, the WADoH says it “undertakes both routine and ad hoc monitoring of Schedule 8 dispensing records… [and] uses a risk-based approach to monitoring”.

If a prescription is considered problematic by the WADoH, it may request the patient to be referred for specialist appraisal if there is no specialist support for the prescribing regimen.

It says:

“The advice to the general practitioner is that the patient be referred to an appropriate specialist relevant to the diagnosed condition.

“In certain circumstances the department may request a non-pain specialist such as a rheumatologist to also refer the patient to a pain specialist for a second opinion.”

As for the support structure for patients identified as drug dependent and/or oversupplied, WADoH advised they could be referred on to Next Step Drug and Alcohol Services.