Electronic Medication and Prescribing in Aotearoa New Zealand

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What is the current state of play with digital medications in New Zealand? Please help me to flesh this out; this is a wiki so feel free to edit it directly if you are feeling brave. Alternatively, any replies with useful info or corrections would be greatly appreciated!

Overview

Electronic Medicines Management (eMM) is the application of digital technology to the process of pharmacologic medical treatment. This includes several components:

  1. Prescription
  2. Dispensing
  3. Administration
  4. Compliance
  5. Monitoring

Terminology

The best acronym I can find to cover the breadth is electronic Medicines Management (eMM). This gives an excellent NZ-centric overview of the terminology:

https://www.hqsc.govt.nz/our-programmes/medication-safety/projects/electronic-medicines-management/

Benefit vs Risk

Unfortunately, evidence of definite clinical benefit is elusive. While legibility issues are essentially solved by eMM, communication significantly improved, and decision support possible, these are balanced by workflow challenges and new hazards related to the use of digital technology. Here is the most recent systematic review on the topic:

The New Zealand Electronic Prescription System (NZePS)

The MoH website gives a good overview of the NZePS with up to date utilisation data, but the term ā€˜scanningā€™ reveals that the process is not yet maturely digitised:
https://www.health.govt.nz/our-work/digital-health/other-digital-health-initiatives/emedicines/new-zealand-eprescription-service

Primary Care

Longstanding ability to print prescriptions from a primary care EHR. However, the workflow was all paper and fax from there. As of late 2020, there is widespread availability (but not necessarily utilisation) of the New Zealand ePrescription Service (NZePS). If the NZePS is used, there is no need for a written signature on community prescriptions.

The NZePS is currently implemented in Medtech, MyPractice, Indici, and Medimap.

The current issues facing Primary Care:

Current situation re COVID waiver

At the time of the first NZ COVID-19 lockdown, the need for a written signature was temporarily waived. This has been extended until 2021-06-20T12:00:00Z. Full details are here:
https://www.health.govt.nz/system/files/documents/pages/approval-to-issue-cd-eprescriptions-updated-3-aug2020.pdf

Secondary Care

DHBs

I note that with reference to the National Medication Chart 2021, the Health Quality & Safety Commission NZ states the following:

The Commissionā€™s preference is for electronic prescribing systems, with paper-based charts intended as an interim stop-gap allowing DHBs time to implement electronic prescribing.

My understanding is that at present MedChart (by DXC) is used (at least in part) by the following DHBs:

  1. Southern (first trialled in 2010)
  2. Canterbury
  3. South Canterbury
  4. Waitemata
  5. Counties Manukau Health (2019)
  6. Taranaki

Other products:

  1. Orionsā€™s SMT handles outpatient prescribing in the South Island, but does not integrate with MedChart.
  2. Inidici is being used by some DHBs for outpatient prescribing (often in parallel with MedChart for inpatient prescribing)
  3. Mosaiq is widely used (but not necessarily loved) for chemotherapy.
  4. Medimap is used by some DHBs for Addiction Services medication.

And now Better Meds (previously OPENeP) is making inroads in the Middle of the NI:

Private Hospitals

Iā€™m not sure of any who are currently using eMM.

Iā€™ve heard that Mercy Ascot (Auckland) are currently working towards implementing the TrakCare Medication Management (InterSystems).

Aged Residential Care

The HQSC are also keen on us digitising medications in ARC, but acknowledge the difficulties in achieving this:
https://www.hqsc.govt.nz/our-programmes/medication-safety/projects/national-medication-chart/aged-residential-care-arc-medication-chart/

The following are used in the ARC sector:

  1. Toniq 1chart
    • not currently NZePS compliant but apparently working towards it.
  2. Medi Map. From their website, apparently in 2019 ā€œMedi-Map usage in aged care in NZ passes 65% of all facilitiesā€

Pharmacy

Electronic pharmacy management is a key component of eMM, with many potential benefits to being digital. However, the workflows are complex and effective data flow (especially to and from prescribers) remains challenging.

Hospital Pharmacy

The pharmacy management system used in (possibly 100%) DHB hospitals is ePharmacy (vendor: DXC transitioning to Dedalus).

ePharmacy integration with other applications

MedChart and ePharmacy, despite sharing the same vendor, have limited integration:

Auto-resolution integration between ePharmacy and automated dispensing cabinets (ADCs) such as Pyxis is possible.

Community Pharmacy

Electronic pharmacy management is widespread in the community, but many pharmacy workflows include paper steps. These are the software products utilised in NZ:

  1. Toniq (NZ based vendor, used by approximately 80% of community pharmacies)
  2. RXOne
  3. LOTS

This is a typical community pharmacy workflow (hybrid electronic / paper):

90% of our prescriptions are NZePS that are either email directly from the surgery, or arrive via Toniq inbox, we then print these and scan for dispensing.

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Replacement for Orion Soprano Medical Templates
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Toniq is used out in Residential Aged Care a lot I believe

https://toniq.nz/products/1chart/

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Where I am working (in aged residential care), we use MediMap.

https://medimap.co.nz/

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Yeah Canterbury ARCs are split between toniq and Medi-map.
Canterbury first went live in 2014 with MedChart.
ā€œat least in partā€ is right re MedChart e.g. ADHB has it in some geriatrics wards through to CDHB in >90% of inpatient wards

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I understand Waitemata DHB is using Indici for outpatient prescribing.

I have a powerpoint for our region which I can email you of some of the landscape but it has roadmap detail so Iā€™m not sure how much is able to be widely shared.

Regards,

David

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That would be great, thank you David.

I would ensure that only content that spoke to the present state would be shared. Perhaps best sent to me as a personal message then rather than posted here eh?

Thank you all!

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Medi-Map is in over 65% of ARC facilities, it has e-prescribing with NZePS integration.

Some DHBā€™s use Medi-Map Addiction Services for OST medication and script management.

GP, district nurses and/ or hospice are also using Medi-Map in some regionā€™s for palliative and complex patients.

GP and Specialists (DHB and private) sharing care though Medi-Map medication management in several other scenarios . This include Paediatric respite and supported living with psychiatrist involvement.

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As noted from other responders - Medi-Map is used in a large proportion of ARC (Aged Care) facilities. We work with 80 independent aged care providers throughout NZ and all have either Medi-Map or 1Chart in place with Medi-Map having the majority uptake. The below is a summary of how this came to be which I sought frm the Pharmacist Director of Medi-Map:

Medi-map summary

Dear Nathan

I think there is quite a lack of information here so I can fill in many of the gaps- here is a summary as an FYI for you- I can speak at any stage if helpful

ā€¢ Medi-Map is a full eMAR solution operating in NZ and Australia ā€“ Established in 2014 with exemptions from the MoH for eSignatures
ā€¢ Medi-Map is used in more than 70% of Aged care sites in NZ, rehab and mental health units, community care and is currently rolling out an Addiction Services module to manage Opiate Substitution therapy management. Currently there are around 60,000 patients whose medicine is managed electronically in Medi-Map
ā€¢ MediMap has full NZePS certification and signature exempt status for non-Controlled Drugs (CDā€™s are on a single print page for signature ā€“ no triplicates) There is no faxing or emailing of scripts required as Medi-Map can publish eScripts to a patients pharmacy in real time in system electronically. eScripts are pushed to the correct pharmacy without needing to be printed.
ā€¢ Medi-Map has around 4000+ prescribers in NZ using the system, more than 40% of all pharmacyā€™s as a completely integrated solution in addition to the care facilities- Essentially a Single Source of Truth for all medicine activity ā€“ being charting, supply, administration and resupply
ā€¢ Currently Addiction Services is rolling out Medi-Map with 3 DHBā€™s in implementation now and 4 in discussion. There are around 20,000 clients NZ wide.

Medi-Map has been around for a while now and expanding its functionality and services ā€“ all related to medicine management. As an example we are releasing a Vaccination module in Q2, have an IV in the home module for Q1 2022, releasing an Integrated CD register, have a IMI and Clozapine management solution for mental health patients for release in Q3, are releasing a FHIR Integration Platform in Q2 and have completed integration into one GP PMS system with Medtech and My Practice integration being released in Q2/3

Please contact me at any stage if you would like more information but I can assure you, Aged Care Medicine Management is most certainly digitised and integrated across other systems. The biggest barrier we face is antiquated DHB solutions and trying to integrate for data flow to and from these solutions. As an example Medchart and the Alcidion currently have no mechanism to be able to connect using a FHIR API for data to be drawn from Medi-Map or pushed back on discharge ā€“ after 4 years of discussion

Kind Regards
Greg Garratt CEO
Christchurch, New Zealand Adelaide, Australia
www.medimap.co.nz www.medimap.com.au
P: 0800 298363 M: +64 21 470424 P: 1800 431420

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Apparently Indici has been implemented in a few places for outpatient prescribing. Can anyone elaborate on this? @lara?

@richard.medlicott - can you help me flesh out the lie of the land in Primary Care at the mo?

@Kat.Azer and your pharmacy colleagues - can you help out from the pharmacy perspective?

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In the South Island prescriptions on discharge (and in some cases within Outpatient) are created within SMT. They are generally printed and handed to the patient however during COVID we did some work to allow electronic delivery to pharmacies (via ERMS) to deal with the telehealth use cases. This was done under the temporary waiver put in place by the DG of MoH and I believe is still valid.

The plan is to move away from the temporary setup and to something that submits to NZePS for discharge/OP scripts. Worth noting that MoH still indicate that the full script (either on paper or PDF) needs to arrive at the pharmacy to allow for dispensing, so NZePS submission isnā€™t the whole story.

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From a pharmacy perspective - I would say 90% of our prescriptions are NZePS that are either email directly from the surgery, or arrive via Toniq inbox, we then print these and scan for dispensing.
I believe MoH wants to move to completely paperless processes, and eliminate the printing (sustainability) or thatā€™s what I have heard.

I still think there are inefficiencies in this process:

ā€œFor instance, a Swedish study compared the number of times pharmacists had to contact the doctor to clarify information from new e-prescriptions, compared with computer-generated or faxed prescriptions.

The study found e-prescriptions were nearly eight times more likely to have issues about the dosage or how to take the medication. The authors believed this may be due to some electronic systems misinterpreting common shorthand doctors useā€

Prescribers select wrong meds, enter wrong quantities, wrong doses - I think perhaps that a critical step in prescriber education was missing when NZePS was introduced. This diluted the efficiency that NZePS was intending to create for the dispensing process!

In terms of EMR - the shared platform that integrates what is prescribed with what is dispensed in the South Island is HealthOne - the problem is, you are only permitted to access this if you actually dispense a prescription otherwise youā€™ll be audited - I feel this defeats the purpose! (Thatā€™s another story)

Also, a number of surgeries still resistant to adopting NZePS, and specialist practitioners have not adopted it yete.g. specialists, dentists, midwives.

Did I answer your question?

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Perhaps shouldā€™ve mentioned Toniq has ~80% market share of pharmacies. Other dispensing softwares are RXOne and LOTS.

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Thanks Gavin! Good to know, Iā€™ve incorporated it into the wiki

Thank you Kat; yup, you painted a clear picture of the state of the situation in community pharmacy. Iā€™ve summarised it in the wiki, and included a bit on the latest evidence.

This is a gaping hole in my knowledge (and therefore the wiki). Can any of the hospital @pharmacists out there help out with the current digital reality for you?

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Thanks Simon! Are you able to flesh that out a bit more? For instance, how well ePharmacy interoperates with MedChart and the products of other vendors, how effectively digitised it is, handling of outpatient services and the NZePS, etc.

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There is limited data flow FROM MedChart TO ePharmacy (ie new and edited prescriptions can be configured to appear in the dispensing worklist). There is no flow of information from ePharmacy to MedChart (ie MedChart has no idea of stock inventory or imprest, or if a medicaiton has been dispensed). A closed loop medication management solution that should include two way communication between ePharmacy and MedChart has been discussed for several years. At CDHB we are still printing paper dispensing worksheets from MedChart for dispensing by ePharmacy and have yet to realise a paper-lite intergration between these two systems (despite both being DXC products they were acquired by them (previously CSC) so were not initially developed with the intention of being fully integrated/complimentary applications).

As for other products - I believe the Midlands project team who are piloting Better Meds are in the process of engaging with DXC around ePharmacy integration now.

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Hey Nathan, as Olivia has laid out thereā€™s a lot potential MedChart integration that has not quite made it over the line yet but expected in the future (which keeps getting further away). Such as paper-lite dispensing between MedChart and ePharmacy, or end-to-end NZePS connectivity. Iā€™ll add a wee bit more about auto-resolution between ePharmacy and Automated Dispensing Cabinets (ADCs) eg Pyxis but it will be vague as its not something I have any experience in, CMDHB are involved in this.

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Yes, eMM is OKish from the GP end - we are really waiting for the legislative changes to get rid of the need to print and post CDs at all. We also have the issue where some pharmacies will dispense from a script sent via e-script while waiting for hard copy, and some wait for posted script to arrive. VERY frustrating.

System not setup for paperless at pharmacy end. Lots of work to do.

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Yes I can relate to your frustration, lots of progress to be made, but thinking of where we were weā€™ve come a long way!
I do believe the intention is for pharmacy to go paperless, it is working progress!

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This has been our local experience, which has defeated the purpose of trying to get NZePS to work. We tried, but the hassle of ā€˜print-to-PDFā€™, then email to pharmacy, to then learn they have to print out anyway for the barcode . . .and, I got nervous about all these script PDFs being emailed around, stored who-knows-where! . . . so weā€™ve abandoned. The print-to-PDF-> save-file-as ā†’ attach-to-email ā†’ delete email with attachment (hope this is done on other end), was so many extra clicks there was no way I was going to convince my tech-frustrated colleagues to follow thru with that work-around!

The NZePS process must consider full work-flow from script generation to dispensing, before comment can be made about efficiencies, etc.

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Hi Nathan, let us know what youā€™re needing to know. Iā€™m sure thereā€™s a few of us who can add detail :grinning_face_with_smiling_eyes:

Youā€™ll find each DHB is operating with a unique combination of software. Maturity & uptake differs across the country.

  • Indici is used in outpatient eprescribing in the northern NZ region DHBs
  • MedChart is used for inpatient eprescribing at some DHBs
  • Private hospitals will operate differently again. I understand Mercy has eprescribing with TrakCare.
  • Iā€™m not sure if anyone is doing closed loop prescribing, those Iā€™d be interested if they are
  • Pyxis machines are used in some DHBs
  • DHB dispensing involves a mix of dispensing systems.
  • I canā€™t comment on reporting & monitoring capacities

Hope this information helps.