Dispensing in EPS Release 2
Dispensing in EPS Release 2
The service has been modelled where possible on existing dispensing practice; however Release 2 will introduce additional steps in the dispensing process.
The legal basis for electronic prescriptions
In preparation for the roll-out of Release 2 of the Electronic Prescription Service, changes were made to the relevant legislation to enable the prescribing and dispensing of electronic prescriptions.
An electronic message becomes a legal electronic prescription where the prescription has been created in electronic form, is signed with an electronic signature and is then transferred to the dispensing site as an electronic communication. It is not yet possible to issue an electronic prescription for a drug specified in Schedule 1, 2 or 3 of the Misuse of Drugs Regulations 2005 and prescribers remain free to continue to issue paper prescriptions.
The NHS (Pharmaceutical and Local Pharmaceutical Services) Regulations 2013 are clear that for an electronic prescription to be dispensed as an NHS prescription, it must be sent via the NHS Electronic Prescription Service and no other messaging system.
The NHS (General Medical Service Contracts) Regulations 2004 put in place controls around which patients can be issued with electronic prescriptions. Initially, it will only be possible to issue an electronic NHS prescription where the patient has nominated their dispensing site. It is possible that at a much later stage in the deployment of EPS Release 2, there will be further regulatory change to enable electronic prescriptions to be issued where the patient does not want to nominate a pharmacy.
Scope of the Service
It is currently not permitted to issue an electronic prescription for a Controlled Drug specified in Schedule 1, 2 or 3 of the Misuse of Drugs Regulations, however this may change in the future. And there will be occasions where a product cannot be prescribed electronically for technical reasons. For example, this could occur if the product is not listed on the NHS Dictionary of Medicines & Devices or if the prescribing system is not able to issue a prescription for the item because the supplier hasn’t ‘mapped’ the appropriate codes. This is likely to affect less commonly prescribed items including products to be specially manufactured or extemporaneously dispensed products.
Retrieving Electronic Prescriptions
There are only two ways to access an electronic prescription:
Where a prescription is flagged to be sent to a patient’s nominated pharmacy, the pharmacy system is able to periodically ‘pull down’ the message to the local pharmacy system. To minimise network traffic, this will normally be done once daily, over night or first thing in the morning as part of the system start-up process. Pharmacy staff will also be able to initiate a system check for any nominated prescriptions waiting to be pulled down, on an ad hoc basis when necessary. For example, a pharmacy may wish to check for any nominated prescriptions before placing an order with a supplier to ensure that any necessary stock is ordered in time for the patient visiting the pharmacy.
By scanning the barcode on the prescription token or manually inputting the prescription identifier, the electronic prescription can be pulled down to the local pharmacy system.
Note, only Release 2 enabled pharmacy systems will be capable of retrieving an electronic prescription. Release 1 dispensing systems will not be capable of scanning barcodes on Release 2 prescription/ dispensing tokens.
If a pharmacy scans the barcode on a token but the electronic prescription is not available to be ‘pulled down’, the system will send back a ‘reject message’ providing pharmacy staff with a reason why their request has been rejected. Rejection reasons include that the ‘prescription has been cancelled’, the ‘prescription has expired’, the ‘prescription is with another dispenser’, the ‘prescription has been dispensed or marked as not dispensed’ or ‘prescription cannot be found – contact prescriber’. There are a number of reasons why a prescription may not be found on the system, for example, the prescription may have been removed under the EPS housekeeping rules or the prescription may not have arrived at the Spine.
All messages sent via the EPS service are classified as ‘immediate’ or ‘routine’. These classifications are used to prioritise certain prescription flows and don’t relate to the clinical importance of the prescription. On issuing the prescription, the prescriber has the flexibility to classify the prescription.
Acute prescriptions and those which arise from face to face consultations default to ‘immediate’, as the patient is then more likely to be going directly to a pharmacy. Prescriptions that are issued where the patient is not present, for example repeat prescriptions, should normally be classified as ‘routine’. However, service levels require that both immediate and routine messages are sent from the prescribing system to the Spine in a matter of seconds.
Paper copies that are printed to accompany electronic prescriptions are known as ‘tokens’. These are simply paper copies of the prescription details contained within the electronic prescription and should never be used to dispense prescription items without the corresponding electronic prescription. The barcode on the token can be scanned to retrieve the electronic prescription from the spine. There are two types of token: the prescription token and the dispensing token.
Prescription tokens are printed on prescription form FP10SS by the prescriber. Standard text will be printed automatically in the signature box to prevent the prescriber from signing the prescription token.
Prescription tokens will be issued in different situations depending on the stage of rollout of Release 2. For the time being, electronic NHS prescriptions can only be issued where they are being sent to a patient’s nominated pharmacy. The prescriber:
Has the option to provide a token to the patient where they have nominated a dispensing site, for example where the patient requests a copy of the prescribed information or if the prescriber believes it is helpful to provide this to the patient for example to signal the end of a consultation.
But must provide a token to the patient when authorising a repeatable prescription (repeat dispensing).
Where an electronic prescription is being sent to a patient’s nominated dispensing contractor and the prescriber chooses to give the patient a prescription token, the right hand side of the token will include the name and address of the patient’s nominated dispensing contractor. This will help to ensure that the patient always knows who they have nominated.
If the patient brings their prescription token to their nominated pharmacy, the barcode can be scanned to ‘pull down’ the electronic prescription, supporting efficient processes within the pharmacy. If the patient goes to a pharmacy other than their nominated pharmacy, if the prescription has not already been pulled down to their nominated pharmacy’s local system, the prescription can still be accessed.
There are two scenarios where pharmacy staff will be required to print a Dispensing Token:
Where a prescription has been sent to a patient’s nominated pharmacy but that pharmacy is unable to fulfil the order, for example because they are out of stock of an item, if the patient wishes to go to another pharmacy, the electronic prescription would have to be released back to the Spine by the nominated pharmacy and a dispensing token printed so that the patient can access the electronic prescription at another Release 2 enabled pharmacy. In the same way as with paper prescriptions, all items on the prescription would have to be returned to the spine in this scenario so that they can be accessed by another pharmacy, not just the out of stock item.
Where the patient has nominated a pharmacy and is not age exempt with the patient’s date of birth contained within the electronic prescription, a dispensing token will normally need to be printed to collect the patient’s exemption declaration or where the patient pays for their prescription charge. If the patient has been given a prescription token by the prescriber, this can alternatively be used to collect the exemption declaration.
Dispensing tokens may also be printed in other scenarios, for example if this is requested by the patient or to support the communication of supplementary clinical information to the patient. Tokens contain patient identifiable information so care should be taken in how they are disposed of.
NHS England Area Teams are responsible for providing community pharmacies with Form FP10DT, free of charge, to use to print the token. This form is white in colour and is in the same style as other NHS prescriptions. As the dispensing token will not be signed by a prescriber, it is not a legal prescription and therefore Form FP10DT does not need to be stored securely. It will be important for LPCs to discuss local arrangements for the distribution of the forms with NHS England Area Teams to ensure that arrangements are efficient and manageable.
Tokens used to collect the patient’s exemption declaration will be required to be sent to NHS Prescription Services each month for audit purposes.
Supplementary Clinical Information
The right hand side of a paper prescription form is used by prescribers in different ways. It may be used to communicate review dates for patients, be used as an order form for repeat medication and is often also used to promote the prescriber’s practice for example clinic opening and closing times as well as advertising particular services such as ‘flu clinics.
In Release 2 of the Electronic Prescription Service, there will be occasions where there is no paper document flow between the prescriber and the patient so this supplementary information must be passed on to patients via alternative routes.
It is mandatory for community pharmacies to pass on non-routine information relevant to the clinical care of the patient including:
Patient or medication-specific instructions for example instructions for the patient to arrange an appointment with the prescriber for a blood test or guidance on a change to the patient’s medication regimen;
The patient’s review date if within 4 weeks; and
When the last repeat prescription authorised by the prescriber is dispensed
Pharmacy staff will also be required to provide the following information to the patient, at the patient’s request:
A full list of the patient’s ‘repeat’ medication (as received in the electronic prescription message);
The patient’s review date (where greater than 4 weeks); and
Information on the number of times the medication can be reordered from the prescriber without a review.
Pharmacy contractors have the choice of how this information is passed on to the patient, for example printing the information on the right hand side of the dispensing token or in an alternative paper format such as on a dispensing label. Alternatively it could be passed on verbally to the patient.
The relevant patient information will be communicated to pharmacies electronically as part of the electronic prescription message and pharmacy systems will support pharmacies with printing this information. Suppliers have a degree of flexibility over how systems alert pharmacy staff to the availability of this information and when and how the system can be used to print the information. This is therefore a key area for pharmacists to discuss with their system suppliers to ensure solutions being put in place meet the needs of pharmacy staff.
Pharmacy staff will not be required to pass on non-clinical information linked to the services offered by another provider for example practice hours or an advert for a flu clinic.
While the prescription is being prepared and is awaiting collection, there is no requirement to update the prescription status on the Spine.
It is for a pharmacy contractor to determine how the accuracy check in the dispensing process is undertaken including when dispensing electronic prescriptions received via EPS Release 2. Options include:
Checking against the prescribed information on screen: Different pharmacy systems will display the prescribed information in different ways on screen. Systems will record both the prescribed information (from the electronic prescription) and the dispensed information (as entered by the user where different from the prescribed item). It will be important for system suppliers to make it very clear to the user when they are viewing prescribed information and when they are viewing dispensed information.
Checking against the prescription or dispensing token: System suppliers have been mandated to print specific information from the electronic prescription message on to the dispensing token without any of this information being edited. This will be assessed by the HSCIC as part of the clinical safety checks in the Common Assurance process.
Checking against dispensing labels: As dispensing labels may be edited, for example, the dosage instructions changed, there may be a risk to patient safety if an accuracy check is undertaken against dispensing labels. System suppliers may develop other solutions to support accuracy checking for example, printing the electronic prescription information but not on a dispensing token, for example creating a pick list on a smaller slip of paper such as a till receipt to minimise waste.
Dispensing Notification and Reimbursement Claim
After the medication has been issued to the patient a ‘dispense notification’ message should be sent to the Spine. This does not need to be done immediately after issue; staff can choose a convenient time that fits in with the pharmacy’s business processes. Also, there is some flexibility in how local systems support pharmacists with this process, for example one option is for pharmacy systems to generate a bar-code to include on the bag label which can be scanned at the point of issue to the patient to automatically update the system.
To complete the dispensing process, each prescription item must be marked as either ‘dispensed’ or ‘not dispensed’ (if all prescription items on a prescription have the same status it is possible to mark the entire prescription as opposed to marking individual items). There are also two intermediate statuses that can be used, ‘with dispenser – partial’ and ‘with dispenser – owing’, where part of the prescribed quantity has been dispensed and where none of the prescribed quantity has been dispensed but is likely to be dispensed at a later date. The Spine should be updated after each dispensing event, that is, each time a product is issued to the patient. There is no need to update the spine whilst the prescription is being prepared for collection.
Pharmacy staff also need to submit a ‘reimbursement claim’ message to the Pricing Authority which includes endorsement information and information on the prescription charge status of the prescription. This can be done either at the same time as sending the ‘dispensed notification message’ or separately at a later date. More information can be found in the endorsing and submission section.
|What If? Scenario 1: An electronic NHS prescription has been pulled down by a patient’s nominated pharmacy but the patient has presented in another pharmacy with an urgent need for their medication.|
|This is not a desirable situation. In collecting consent for nomination, it should be clearly explained to patients that once a prescription has been sent to their nominated pharmacy, they should go to that pharmacy as going elsewhere may lead to delays in their care.In exceptional circumstances, to support patient care, where a message has been pulled down to a pharmacy, as long as the prescription has not been marked as ‘dispensed’, it can be returned to the Spine using the pharmacy system. Another pharmacy will require the prescription’s unique identification number to ‘pull down’ the prescription. If the patient has been given a ‘prescription token’ by the prescriber, this can be scanned to retrieve the electronic prescription. Alternatively, the prescription identifier could be provided by the original nominated pharmacy, for example by the pharmacy printing and faxing a copy of the dispensing token. The prescription identifier (an 18 character code for nominated prescriptions in Release 2) could also be passed on verbally for keying in to the pharmacy system.It is PSNC’s position that once a pharmacy contractor has retrieved a nominated prescription and prepared it in good faith, ready for collection by the patient, it should not be mandatory for him to return it to the spine if this means that he will be denied appropriate payment. PSNC is in discussion with the Department of Health on this issue.Note, Release 1 enabled dispensing systems will not be capable of retrieving electronic prescriptions generated by a Release 2 system (either from scanning the barcode or entering the 18 character code on the prescription token).|
|What If? Scenario 2: An electronic NHS prescription has been pulled down by a patient’s nominated pharmacy but the nominated pharmacy is out of stock of a product and the patient needs their medicine urgently|
|The electronic NHS prescription can be returned to the spine using the pharmacy system. The pharmacy is able to generate a ‘dispensing’ token (see page 12) which the patient can take to any other Release 2 enabled pharmacy to have dispensed.It will not be possible for a Release 1 enabled pharmacy to access a dispensing token generated by a Release 2 system, therefore whilst Release 2 is being rolled out, it may be necessary to consider other contingency measures in this situation, for example referring the patient to the GP so that a paper prescription can be issued that can be taken to any pharmacy.As with paper prescriptions, all items on an electronic prescription need to be dispensed by the same pharmacy. It is not possible for some items to be dispensed at one pharmacy and some at another.|
Frequently Asked Questions
Q. Can a prescriber issue an FP10MDA Instalment Dispensing prescription electronically via the Electronic Prescription Service?
A. In England, only Schedule 2 Controlled Drugs plus Buprenorphine, Buprenorphine/Naloxone (Suboxone) and Diazepam can be prescribed in instalments on Form FP10MDA. Schedule 2 and 3 Controlled Drugs are currently outside of the scope of the Electronic Prescription Service however as a result of the Shipman Inquiry, consideration is currently being given to allowing the electronic transmission of prescriptions for Schedule 2 & 3 Controlled Drugs in the future.
Although there is no FP10MDA concept in the Electronic Prescription Service, prescribers could use the repeat dispensing arrangements to authorise multiple dispensing of diazepam to a patient. Schedule 2 and 3 Controlled Drugs cannot be prescribed within the NHS repeat dispensing arrangements.
Q. Will I continue to receive paper prescriptions as well as electronic prescriptions?
A. Yes. The mix of paper versus electronic prescriptions will vary greatly depending on the location of a pharmacy and patient preferences. Initially only patients who have nominated a dispensing site will be able to receive their prescriptions electronically. There will also be occasions where the prescriber cannot issue an electronic prescription, for example if the prescription is issued during a home visit and the prescriber does not have access to the service or where a particular product cannot be prescribed electronically.
Q. Can a nurse prescriber working in a GP practice, issue prescriptions via the EPS Service?
A. Yes, all types of nurse prescriber (community practitioner nurse prescriber, independent nurse prescriber and supplementary nurse prescriber) linked to GP Practices can issue prescriptions via the Electronic Prescription Service as long as they have the correct roles and GP Practice locations registered on their smartcard. When an electronic prescription is received, the prescriber type will be indicated on screen.
Q. My NHS England Area Team has provided me with dispensing tokens. The form is coded FP10DT0407. I’ve noticed that Box H states ‘gets income support (IS)’ whereas the normal FP10s state ‘gets income support (IS) or income related employment and support allowance (ESA)’. How should a person claiming income related employment and support allowance’ (ESA) complete the back of the FP10DT0407 form?
A. The FP10DT0407 dispensing tokens were originally produced in 2007 and the reverse of the form was correct at that time. A new form was developed in June 2008 (FP10DT0608) to reflect changed to the exemption arrangements.
The old version of the dispensing token will remain in circulation until the forms are used up. People who are included in an award of income-related Employment and Support Allowance and who need to complete an exemption declaration on an old form should tick box H “*gets Income Support” to claim free prescriptions.
Q. Will I need a specific printer for printing tokens?
A. Your pharmacy system supplier will be able to provide guidance on hardware requirements. As a minimum a 600dpi mono laser printer is required. This must be able to handle the size and weight of the prescription token stationery. Dual bin printers are recommended.
Q. The prescriber has signed the token; does this make it a legal NHS prescription?
A. No. If the prescriber has signed the prescription token, it cannot be treated as a legal NHS prescription as the form is not approved for this use by the NHS. A contractor would be reimbursed for dispensing against the electronic prescription, not the token. To minimise the risk of a prescriber signing the token, the signature box on the token will be over-written by the prescribing system to state that the token should not be used as a prescription.
Q. Does the barcode contain any patient sensitive information?
A. No. the barcode does not contain any personal information about the patient but does contain a unique reference number for the prescription. By scanning the barcode or manually inputting the prescription identifier, the electronic prescription message can be pulled down to the local pharmacy system. In Release 1, the prescription identifier code was 32 characters. In Release 2, the prescription identifier code will be 32 characters for non-nominated prescriptions and will be shortened to 18 characters for nominated prescriptions sent electronically. Release 1 systems will not be capable of scanning barcodes on Release 2 prescription/dispensing tokens or manually inputting the 18 character prescription ID to retrieve the electronic prescription.
Q. My pharmacy system is configured to automatically print tokens when a legal NHS electronic prescription is received; this is regardless of whether the token is required to collect the patient’s exemption declaration or not. What should I do with the waste tokens?
A. It is possible that some pharmacy systems will be configured to automatically print tokens for all nominated prescriptions, for example, so that the token can be used to support accuracy checking following the preparation of prescribed products. Tokens contain patient identifiable information so care should be taken in how they are disposed off, for example the waste paper should be shredded within the pharmacy. Ifthe token is handed to the patient, after dispensing, as a reference of what was prescribed, the patient should be reminded that they cannot take the token to another pharmacy to have it dispensed.
Q. I am having problems scanning the barcoded forms that are being issued by a particular local prescriber. What should I do?
A. Pharmacies may experience problems scanning barcodes that have been poorly printed, for example if the prescriber’s printer toner is running out or if the prescriber is using the ‘economy setting’ on their printer. Pharmacy contractors should alert the prescriber to this.
Q. How will a patient order their repeat prescriptions in future?
A. Arrangements for ordering repeat prescriptions are agreed locally, for example some practices currently accept repeat prescription requests by phone, email, fax or through online ordering systems, others require patients to submit a paper request. This will not change.
Where prescribers require patients to submit a written request for repeat medication, patients will be able to request a printed list of their repeat medication from a Release 2 enabled pharmacy. This information will be provided to pharmacies in the electronic prescription message received from the prescriber. There is some flexibility over how system suppliers will configure systems to generate this information, for example automatically for nominated prescriptions or on demand. The impact of this task on workload within pharmacies will be monitored closely during the initial implementation of Release 2 of the Service. To minimise the number of occasions that a patient has to order repeat prescriptions, the NHS repeat dispensing arrangements are encourages.
The Department of Health information strategy – The power of information- set the target that by 2015, all general practices will be expected to make electronic ordering of repeat prescriptions available to patients.
Q. Can a prescription/dispensing token be processed by a Release 1 system?
A. No. Release 1 dispensing systems will not be capable of scanning barcodes on Release 2 prescription/dispensing tokens.
Q. Can dispensing tokens be reprinted?
A. Yes. Dispensing tokens can be re-printed, for example if there was a problem with the printer whilst printing the initial copy. The re-print will be an exact copy of the original.
Q. I have received an EPS Release 2 electronic prescription however when I try to dispense this, an alert is coming up in my system to indicate that there is “no dm+d mapping”. What does this mean and what should I do?
A. The NHS Dictionary of Medicines and Devices (dm+d) provides a unique code for each medicine and device and is the key to supporting interoperability between pharmacy and GP clinical systems. System suppliers use a variety of drug databases in their systems. Where a supplier has not adopted the NHS dm+d as their core database, they must ‘map’ the codes of the individual products on their database with the dm+d codes.
Where an electronic prescription has been received for an item but the individual pharmacy system supplier has not mapped that item on their drug database with the dm+d code, the system will flag that there is a problem dispensing the product (this alert is worded in different ways in different systems). If this occurs, it is important to contact the supplier’s helpdesk to report the problem. It may be necessary to request a paper prescription as an interim measure until the supplier can arrange for an update to their PMR system database.
It is essential that mapping is accurate. If whilst dispensing a prescription via the service, a pharmacist identifies an incorrect map, for example if the information printed on the token is different from prescribing information shown on the screen, the pharmacist should report it to their system supplier immediately. The incident should also be reported to the National Patient safety Agency (NPSA) using their online reporting form.
Q. I have received an electronic prescription but only two of the four items requested are in stock. Can I dispense the items in stock and push the electronic prescription back to the Spine for the patient to get the other two items dispensed at another EPS R2 enabled pharmacy?
A. No, it is not possible to split the dispensing of items on an electronic prescription form between different pharmacies. This is the same as the arrangements for paper prescriptions. If the patient requires all medicines urgently and is not willing to accept an owing note, an option is to return the electronic prescription to the Spine and provide the patient with a dispensing token so that their electronic prescription can be accessed at another EPS R2 enabled pharmacy.
Q. I have recently upgraded to EPS Release 2 and submitted a dispense notification message in error. Can this be recalled?
A. The EPS central infrastructure supports the recall of dispense notification messages as long as a reimbursement claim message has not been submitted. However, not all pharmacy system suppliers have built this functionality into local systems. If your system does not support recalling dispense notification messages, we would recommend making a development request to your supplier for this functionality to be added.
Q. I have received an electronic prescription from the prescriber and the dosage instructions are not clear, can I manually amend this so that the dispensing label carries the correct instructions?
A. Yes. Pharmacy system suppliers may design their systems differently but will have the flexibility to allow the dosage instructions to be amended and corrected as necessary by pharmacy staff.
Q. In EPS Release 2, will a prescriber be able to cancel a prescription that has already been dispensed by a pharmacist?
A. Release 2 of the Electronic Prescription Service will support the cancellation of electronic prescriptions.
It will not be possible for a prescription to be electronically cancelled by a prescriber, where it has the following status: ‘With Dispenser’, ‘With Dispenser – Active’, ‘Dispensed’ or ‘Claimed’. Where a prescription cannot be electronically cancelled, a prescriber can follow manual processes, as now, and call the pharmacist to explain that there is a problem with the prescription. To facilitate this, the prescribing system will provide information to the prescriber on which dispensing site has pulled down the prescription.
Q. In my EPS Release 1 enabled system, the system presents me with the quantity and unit of measure prescribed and asks me to confirm, amend or re-key this information. This is laborious. Will I continue to have to do this in Release 2?
A. No, pharmacists shouldn’t be required to continue to do this in Release 2. To resolve this problem, systems suppliers have been asked to comply with certain standards in the way the quantity of medication and units of measure are expressed in systems. The way systems express this information will be assessed as part of the common assurance process.
Q. I have pulled-down a nominated prescription but do not have the item in stock. The patient wishes to change their nomination settings anyway to a neighbouring pharmacy. If I push the prescription back to the spine and change the nomination settings – will my neighbouring pharmacy be able to access the electronic NHS prescription?
A. No, when the prescription is returned to the spine it will no longer be flagged as a nominated prescription therefore the prescription ID is required by the other pharmacy to pull the prescription down. A dispensing token should be printed for the patient to take to the other pharmacy.
Q. Can electronic prescriptions be post dated?
A. Yes. Prescribers are able to post date electronic prescriptions, however, the prescription will be held on the local prescribing system until the date on the prescription. It will not be available for the dispenser to retrieve in advance of the date on the prescription. Prescribers should consider if repeat dispensing would be more appropriate.