Electronic prescriptions in the Czech Republic

What is an ePrescription?

Since January 2018, the Czech Republic has required doctors to issue all prescriptions in electronic format only. An ePrescription is a medical prescription in electronic form. In the Czech model, it is stored in a so-called Central Repository of Electronic Prescriptions (CREP, “CÚER” in Czech). Each ePrescription has a unique identifier in the form of a 12-digit code, with a bar code that a pharmacist can scan. If the pharmacist finds a prescribed medicine in the CREP, they can provide it to the patient. Information on how and when to take the drug is also registered in the CREP.

The ePrescription identifier can be submitted in four ways:

  • paper note

  • text message (SMS)

  • e-mail

  • mobile phone or tablet application

The method used depends only on the agreement between doctor and patient. An ePrescriptions has no stamp or doctor’s signature – this is replaced by an electronic signature in the form of a personal qualified certificate.

Description of target users and groups

The obligation to issue ePrescriptions applies to all prescribing doctors, including groups such as laboratory technicians, hygienists, epidemiologists, and doctors on maternity leave.

No medical facilities are exempt from the obligation to use electronic prescriptions, regardless of their size or specialist activity. The obligation also applies to health facilities directly managed by government ministries.

The Ministry of Health, in agreement with the Czech Medical Chamber (CMC), issued a decree setting out exceptional situations where it is possible to use a traditional paper prescription – for example, if access to the electronic system is not possible.

Policy context

The legal obligation to create medical prescriptions only in electronic form, the so-called electronic prescription, was introduced on 1 January 2018.

E-prescriptions are the second action within the National eHealth Strategy for the period 2016–2020, which has been approved by the Czech government. Within this action, Phase I (a gradual move to full-scale electronic prescriptions) was nearing completion at the time of writing (February 2018). The implementation of Phase II, which covers electronic access to medical records, had begun and is due to be complete by 2021.

A working ePrescription system is a prerequisite for the Czech Republic to be involved in the European Commission Connecting Europe Facility (CEF) Telecom call (November 2015) to finance the creation of a European infrastructure for cross-border electronic transfer of patient data.

The Commission considers the development of eHealth (the integration of information and communication technologies into health services) to be a major factor supporting the improvement of the quality, efficiency, and performance of health services. One aspect is the portability of health data between member states.

Technology solution and implementation

In accordance with the Czech Pharmaceuticals Act, the State Institute for Drug Control (SIDC) operates data repositories to collect and process electronically prescribed medicinal products. These databases include the Central Repository of Electronic Prescriptions (CREP) and the Register for Medicinal Products with Limitations (RMPL). To implement ePrescriptions, SIDC developed a new dedicated information system. This new system must meet various safety and technical criteria, including compliance with the Czech Republic’s Cyber Security Act and Public Information System Requirements. These should ensure that the ePrescription system is secure and guarantees high availability, even at high loads.

Healthcare facilities must meet three requirements to handle ePrescriptions:

  1. Electronic signatures (qualified personal certificates) backed by one of three certificate authorities: eIdentity, PostSignum, or First Certification Authority.

  2. Ability to send requests to the central repository and access the medical facility for auxiliary functions of the central repository.

  3. Medical software that supports ePrescriptions. Examples are AMICUS, MEDICUS, PC DOKTOR, PC DENT, and TURBOASISTENT SQ ambulatory programs.

Main results, benefits, and impacts

Advantages of electronic prescriptions include:

  • Higher patient safety in drug delivery, by eliminating the possibility of mistakes or fraud in identifying the patient.

  • ePrescriptions cannot be faked (estimates suggest 450,000 forged paper prescriptions per year).

  • There is no risk that an ePrescription will be filled out incompletely.

  • Information is transferred seamlessly to the patient’s medical record.

  • Reduced administrative burden for doctors and pharmacists.

  • An ePrescription can include more items than a paper prescription.

  • The doctor can check whether the patient actually took the medicine in the pharmacy, and also verify the batch code in cases of suspected contamination.

  • ePrescriptions can be sent to the patient without the need to see a doctor, which is convenient for repeat prescriptions in chronic illnesses.

  • Easier availability of medical information to patients and their lawyers.

  • Permanent record of the costs of treatment.

  • Simpler communication between doctors, pharmacists, pharmacy offices and health insurance companies makes it easier to answer questions and resolve disputes.

  • Patients will find it easier to change their healthcare providers if they want to cut costs or find better care.

  • No risk of lost prescriptions.

  • ePrescriptions are expected to reduce the volume of medicines prescribed by making the process more transparent and harder to circumvent.

  • Increasing the effectiveness of controls by health insurance companies.

  • Patients can track all their ePrescriptions via a website and a mobile application.

The official mobile app is available for Android and iOS. To use it, the patient needs to have set up credentials via the Czech National Identity Authority (NIA).

Criticism

The President of the Czech Medical Chamber, Milan Kubek, is demanding that the obligation to make all prescriptions electronic be abolished, so that traditional paper prescriptions can still be issued. According to Kubek, electronic prescriptions do not work, nobody needs them, and instead of reducing the administrative burden they complicate matters and cause healthcare costs to rise.

Administrative burden

Many other Czech doctors also criticise the whole system of electronic prescriptions. They complain that ePrescriptions create extra work. Dentists also disagree with the obligation to prescribe electronically, given the low number of prescriptions they write. Many doctors, especially elderly ones, were not ready by the time the new law came into force. Concerns have arisen that some physicians (up to 2% of general practitioners serving the adult population) may close their practices as a result. This would be a problem, especially in small towns where there is only one doctor.

The need for a computer with a high-quality barcode printer and a reliable Internet connection is also an issue, especially since the government does not guarantee the right to high-speed broadband across the Czech Republic. Poorly printed barcodes that cannot be read by pharmacists’ scanners hinder the release of drugs to patients. Additionally, hospitals need to adapt their outpatient information systems to work with ePrescriptions.

Unresolved problems

Physicians also point out that ePrescriptions will not be able to completely prevent false prescriptions.

Also not yet solved is the issue of how to handle doctors working in temporary positions or in more than one healthcare facility (for example, when working on call or part time in a hospital). This is because the security certificate belongs to the computer used to issue the prescription, not to the individual doctor. This will bring operational complications, especially for GPs.

A clear negative is the collection of personal data about patients in the SIDC central repository. It is not clear who owns the registry, and at the moment a patient does not have the right to refuse permission for their personal data to be stored. If a patient rejects an electronic prescription, do they have the right to request a non-electronic one?

Costs

The National Audit Office (SAO) describes the whole ePrescription project as overpriced and complains that the cost of administering one ePrescription is many times higher than the equivalent paper prescription. The current ePrescription solution was inadequately prepared and remains incomplete, the SAO says.

The total cost of introducing ePrescriptions has been over half a billion Czech crowns in nine years: SIDC puts the costs at CZK 418 854 210. The Central Electronic Depot itself cost about CZK 318 million. However, according to medical doctor Jan Bruthans of Charles University, this figure does not include other costs that the system will have to meet. According to Bruthans, the total cost of deploying and operating the ePrescription system over the project’s 10-year life will total CZK 839 million.

At the end of January 2018, the Czech parliament approved the new system for a year. Doctors who do not comply with the law face a fine of up to CZK 2 million in principle, though at present (February 2018) there is no penalty for writing a paper prescription. Nonetheless, many doctors and a number of politicians have protested and demanded postponement of the ePrescription law.

The Association of General Practitioners (AGP) insists that electronic prescriptions should be made optional again, so that ePrescriptions can coexist with paper prescriptions – at least, the AGP says, until ePrescriptions meet all the criteria they are supposed to.

Sources

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