Health secretary Jeremy Hunt stated that he would like the Department of Health and NHS England to look strategically at how pharmacists’ role could be developed through electronic record sharing, in a letter he wrote to Oliver Colvile, vice-chairman of the All-Party Pharmacy Group (
PJ 2013:291;514). In the letter, he further stated: “When a patient gives their permission it should be possible for a pharmacist to access a GP record in order to give the best possible advice.”
It is clear that there is now a will, at the highest level, to enable pharmacists to access patient records. Under current arrangements in community pharmacy, there is no model for independent pharmacist prescribers (IPPs)to conduct clinics or write NHS prescriptions for patients with any chronic condition. This is despite pharmacists, particularly IPPs, being best placed to manage the medication of patients with chronic conditions such as pain, diabetes and asthma.
There are examples where sharing patients’ records with pharmacists has worked successfully in the community. The recent Royal Pharmaceutical Society commission report “Now or never — shaping pharmacy for the future” referred to a community pharmacy pain medicines management clinic, which I set up in 2011, as an example of an innovative service.
Model for clinic approved
In 2009, I became an IPP with a specialism in musculoskeletal and neuropathic pain. In 2010, I identified a need in my area to support local GPs and help keep chronic pain patients in the community and out of secondary care. I designed a model for a community pharmacy medicines management clinic to provide a patient-centred service in my pharmacy, which would enable me to use my extended skills as an IPP. Excellent communication with the local GPs, including access to their patients’ records, underpinned this model.
While researching the design of this model, Paula Wilkinson, chief pharmacist at Mid-Essex primary care trust, informed me that district nurses used a laptop with limited access to patients’ records on their home visits. Ms Wilkinson suggested this would be ideal for my model and I used this method in my proposal to the local primary care trust. With Ms Wilkinson’s support, the proposal was accepted in April 2010 and Mid-Essex PCT funding was secured for a pilot project which started in November 2011.
In my clinic, I was able to share full access to selected patients’ records with their GP using a laptop preloaded with SystmOne software in my consultation room. I was also able to use SystmOne software to issue NHS prescriptions.
Access to records using SystmOne
“SystmOne software” is a software package used by many GPs in my area, allowing shared access and easier communication between the IPP in the pain clinic and the patient’s GP. SystmOne software contains a variety of individual “modules” that are ideal for a clinician working remotely and can be tailored to suit different locations, patient groups and evaluation outcomes.
In line with current legislation and guidance, the software and the data contained within it were kept on a PCT laptop PC and secured in a locked pharmacy consultation room with a Kensington lock. The machine had a secure mobile broadband connection using a dongle and connection with the PCT network was via a VPN token making this consultation room effectively a “satellite surgery”.
The participating GP practice referred selected patients to the community pharmacy pain medicines management clinic using an electronic “share” (essentially an email with each patient’s details). When the “share” was accepted for each patient, the IPP was able to access their full patient record from the NHS spine, make appropriate prescription issues, additions and notes and return records to the spine from a remote location such as a pharmacy consultation room. In this way GPs could clearly see what treatment the IPP has prescribed to their patients, just by accessing their records in surgery.
The clinic laptop gives access not only to NHS patient records but to a variety of modules used to capture other necessary data and record it on the patient’s record during each consultation.
Delivering the service
The clinic was set up as a ‘”community unit’ and used a unique data template, which was designed specifically for this project, to capture and record consultations and other data such as verbal analogue pain scores. The screenshots show how the data capture template can be used for collecting verbal analogue pain data and indicating where on the body the pain is.
| Screenshot of the module allowing the collection of verbal analogue pain data|
|Screenshot of the module that allows patients to indicate where the pain is|
The “goal setting and monitoring” module was used to record each patient’s goal at the initial consultation and this became a focus at subsequent consultations for monitoring progress. It also provided each patient with an end point to treatment and once patients achieved their goals they were discharged. Goals were chosen by the patients themselves and were as simple as “being able to walk children to school”, “hanging out washing without pain” or “to be headache free on waking after six months”. The importance of the goal to the patient was recorded, along with details of an agreed action plan set at each consultation.
Improving patient care
Having access to the full patient record meant that my prescribing choices were better informed and helped optimise the medicines issued to each patient. For example, kidney function was reduced in six of the patients who presented at my clinic. The only way I knew this was because I had full access to their records that showed they had varying degrees of chronic kidney disease. I would not have known this without full access and this informed my choices of their preferred pain relief.
Evaluating the service
Evaluation of the clinic would have been far more difficult without access to patient records. Although the data were anonymised, full access meant I could extract prescribed item information from each patient’s record during the trial. From this I was able to compare the data with the patient medication records (PMRs) from the pharmacy for the same period and prepare a log of all the items issued by the IPP to each patient during the trial. Using these sources of information, a table was constructed to review IPP prescribing versus GP prescribing to see if the community pharmacy clinic does save GP time through reduced appointments.
Some 249 prescription items were issued to the 21 patients over the six-month period. Of these, only 17 (7 per cent) were issued at a GP appointment. Of the remaining items issued, 132 (57 per cent) were issued by the IPP, with the remaining 100 items (40 per cent) being issued by repeat template. This clearly shows this type of clinic saves GP time.
I ran 18 clinics, undertook 116 consultations, and issued 132 items at an average value of £16.80 per consultation.
Only 43 per cent of clinic patients were regulars at my pharmacy before the pilot (a regular is defined as a patient who collected at least one item/month for the previous six months). However, 74 per cent of all items I issued were dispensed at my pharmacy by a locum pharmacist while I ran the clinic and 43 per cent of all items issued to patients during the pilot were issued by repeat template.
The five patients who were issued with highest number of items represented 56 per cent of the total items issued and the four patients who were issued with the highest total value of medication accounted for 54 per cent of the total cost of items issued during the pilot.
This model for delivering specialised healthcare to selected patients with chronic pain in a community pharmacy was extremely well received by the participating patients, as evidenced by the results of the patient experience questionnaire. It was underpinned by the use of integrated software with full access to the patients’ records.
PMRs make accuracy checks difficult
There are many occasions when a patient presents at a pharmacy and asks for advice relating to their medication. Currently, the pharmacist is limited in their response by only being able to refer to PMRs at that pharmacy.
Many patients have their medicines dispensed at many different pharmacies, for example where they live, where they work or near relatives’ homes. This makes a comprehensive record of a patient’s medication difficult at one pharmacy, as each pharmacy PMR system is separate.
The most common request is for over-the-counter medicines. Currently the advice given to patients is limited by their responses to a series of questions asked by the pharmacist or healthcare assistant and by checking their PMR in the pharmacy. Often with elderly patients or young children a representative gives information on their behalf and there is even more cause for concern about the supporting information provided by a third party.
This uncertainty about the accuracy of information provided to a pharmacist to make an informed decision would be eliminated if the pharmacist had access to the patients’ records and ensure the correct medication at the correct dose would be optimised to each patient’s condition.
All contractors could get the benefits
Evaluation of this pain medicines management clinic has demonstrated that it is possible for an IPP successfully to manage chronic pain patients in a community pharmacy using appropriate IT systems that allow access and transfer of necessary patient data, resulting in safe and efficient care. The IPP could not operate this model as effectively without full access to patient records.
Having access to full patient records reduced the potential for harm to my patients, made my prescribing choices better informed and helped optimise the medicines issued to each patient. The model also helped improve my existing relationship with my local GP.
All pharmacy contractors could gain the same benefits if they had similar access to patients’ records.
A full report of the project and its evaluation is available on request from the author.