Questions/Answers

A better rationalization of access to medication, reduced prescription costs and adequate monitoring of the entire prescription and dispensing system were determining factors associated with the development of a project called "Paperless Prescription", or Electronic Medical Prescription (PEM), where the primary objective was to implement measures to reduce costs associated with the prescription of medicines and health products, promoting the rational use of the access to medicine by users. As an active measure in the fight against fraud associated with the prescription of medicines and health products, the Paperless Prescription is a project that implemented measures aimed at the progressive elimination of manual prescription and ensured the transition to the dematerialization of the prescription, dispensing and invoicing process . PEM is the computer application developed by SPMS since 2012 for the electronic prescription of medicines. This tool is available throughout the national health system. With the objective of providing a better service to the citizen, taking into account a better quality of service and greater convenience, a significant reduction in paper, improving the efficiency of the process in order to reduce costs and time in the administrative process of pharmacies and in the process of conference of invoices by the National Health Service (SNS), and with strong commitment in the fight against fraud, while providing a service with greater security, the dispensing process, together with the electronic prescription, allows access to the prescription by part of the pharmacies, to consult and send electronic invoicing, integrating all actors in a single process: users; prescribers; pharmacies and financiers. For that end, it was necessary to create the technical conditions for the necessary dematerialization of the medical prescription, through the centralized supply of a prescription system that offered all the guarantees of security, confidentiality and data integrity.

This initiative is a technologically challenging project, which brings greater security to the prescription and dispensing process and which is characterized as a transformation of a process that aims to create better conditions for the access to medication by physicians and users. The dematerialization of prescriptions is based on a more efficient and secure process for controlling the creation and dispensing of prescriptions, requiring authenticated electronic access through a qualified digital certificate. The RSP includes an “Access Code” provided only to the user, to validate the dispensation in the Pharmacy, ensuring greater effectiveness, efficiency and security to the circuit of prescription of medicines in the NHS.

This project fits into the SDG “Quality Health” (to ensure access to quality healthcare and promote well-being for everyone, at all ages). The main focus of this project was to ensure that the e-prescription model could be implemented throughout the national territory, ensuring that no health professional or user would be excluded from accessing the medicine. Furthermore, since this model allows dispensing to be carried out in any pharmacy in the country, it guarantees the same conditions in terms of access to dispensing by pharmacies and by all users.

It makes a difference by the innovation and benefits it brings to physicians, pharmacists, citizens and the health system in general, with great cost reduction and simplification of procedures. Through its anti-fraud mechanisms, it is possible to detect irregularities quickly, which has already made it possible to reduce cases of fraud by around 80%. It should be noted that the digital transformation process has reached a 97% dematerialization rate of prescriptions, that is, it encouraged the reduction of paper use, avoiding the printing of prescriptions, thereby having an economic impact of more than 2.3 million euros, from 2015 to 2017. Finally, the implementation of the measure has allowed a reduction of the need for users to travel to health units to obtain prescriptions, given the possibility of sending access to the prescription by SMS and/or email, or via the SNS 24 app or the SNS 24 Portal.

Before the electronic prescription materialized, there was no information on the prescription after the user left the health unit. The Ministry of Health only had revenue information at the monthly conference to calculate the value of the contributions. After the process was dematerialized, pharmacies started to centrally record the dispenses made, which are always linked to a previously issued prescription. In addition, the system made available to pharmacies applies, at the time of dispensing, the reimbursement rules applied at the time of the conference, guaranteeing to pharmacies the payment of state reimbursements in real time. In addition, the Paperless Prescription allowed a significant reduction in fraud associated with the prescription and dispensing of medicines, as, since there is a centralized register of prescription and dispensing, each prescribed medicine can only be dispensed once, making it impossible to copy prescriptions for undue reimbursed dispensation. The Portuguese health system changed with the implementation of the project, through the active collaboration of organizations and health professionals in pursuing the project's objectives that focus on creating value and health gains for users, and gains in efficiency and safety for health professionals and organizations.

This initiative is transversal to all users of the National Health System, and since the electronic prescription, before the implementation of the RSP, did not present differences for users of different genders, and the main objective of the RSP initiative was to provide a service associated with the prescription of medicines and health products to the entire universe of users, the promotion of gender inequality does not apply.

This initiative has the participation of the following target groups: health professionals, users and pharmacies. With regard to health professionals, it allows physicians to access privileged clinical information, namely on users' allergies and previous adverse reactions of patients, and can later verify their adherence to the prescribed therapy. For users, this new system brings advantages, as all the prescribed health products are included in a single prescription, which was not the case in the past. In the act of dispensing in pharmacies, the user may choose to dispense all the prescribed products or only part of them, making it possible to collect the rest in another establishment and/or on another day. For pharmacies, this initiative made it possible to improve the efficiency of the invoice verification process in order to reduce costs and time in the administrative process of pharmacies, ensuring access to the prescription by pharmacies/agreements, for consultation and delivery of the provision (electronic invoicing), integrating all actors in a single process: users, prescribers, pharmacies and funders.

Throughout 2015, all the necessary steps were taken to ensure: • The end of prescription through the SAM (former prescription system) and the availability of dematerialized dispensation in all community pharmacies; • Capacity for dematerialized invoicing and conference, either by creating the legal conditions for this purpose (Ordinance No. 223/2015) or by creating technical, technological and procedural conditions, with the institutions involved; • Review of the existing Legislation and Regulations, shown in: o Publication of Ordinance No. 223/2015 – Billing and Conference; o Publication of Ordinance No. 224/2015 – Prescription and Dispensation; o Publication of Dispatch 7979-P of SES – mandatory adoption of PEM within SNS institutions; o Publication of Technical Standards for Prescription, Technical Standards for Dispensing, Technical Standards for Prescription Software, Technical Standards for Dispensing Software and CCF Relationship Manual; o Provision of strong authentication and qualified digital signature with CC and COM. As a result of these steps, on September 25, 2015, at 9:47 am, the first fully dematerialized prescription was issued at the Centro Hospitalar de Setúbal, marking the beginning of the Paperless Prescription in Portugal. Also in this matter, a Protocol was signed with the Order of Doctors with the basic objectives of making PEM available, free of charge, to small private prescribers, outside RIS. Throughout 2016 and 2017, the following areas worked regularly: • Paperless Revenue Working Group (between January and July 2016); • Steering for Paperless Revenue (between March and August 2016); • Paperless Revenue Monitoring Committee (September 2016); • Functional and technical meetings with prescription and dispensing software providers (since January 2015); • Training and awareness-raising actions for prescribing physicians belonging to the Order of Doctors and the Order of Dentists (since January 2015).

For the intended objectives to be fully achieved, a whole set of other projects had to be implemented, thus providing the necessary adequacy of the information systems. This vision is continuous over time and the scope has been expanded in order to create a platform that supports legal, clinical and European guidelines. In addition, it was necessary to coordinate with health institutions in order to encourage the use of strong authentication by prescribers, thus ensuring the issuance of dematerialized electronic prescriptions, with resistance to change being the main obstacle to the generalization of the project.

This electronic model allows for the prescription of different medications, bringing benefits to the user, as all the prescribed health products are included in a single prescription. In the dispensation, the user can choose to dispense all or only part of the medication, being possible to collect the rest in another establishment and on another day. This model is more effective and efficient, as it combats fraud, enhancing security for users, doctors and pharmacies. It leads to effective savings for the State, through the elimination of paper, allowing control of the prescription circuit, requiring electronic authentication, and the identification of the user in the pharmacy.

This initiative was designed from the ground up at the national level and was not based on any existing initiative.

Not Applicable

No

This initiative has a lot of potential to be adapted, namely in European Union countries, such as Ireland, which presents a business model, related to the prescription and dispensing of medicines, very similar to that of Portugal. The fact that is translates into real savings for the State with the reduction only of circulating paper and with the reduction of the costs of medicine conference makes this initiative quite appealing to be implemented in other countries. In addition, as this initiative improves citizens' access to health by increasing the information available for this through digital platforms, not abolishing paper printing for the cases of users with lower levels of literacy, its implementation is undoubtedly an added value. It should be noted that, due to the legal dispositions of other member states, some adaptations may be necessary.

This initiative had the support of €135,428.75 by the FEDER with the aim of promoting the operation called “DRM-IEUP – Dematerialization of Medicines Prescription and Electronic Identification of NHS Users and Health Professionals” and consisted in funding the purchase of smartcard readers for authentication and digital signature. In addition, the entirety of the project had the involvement of the Ministry of Health and associated institutions, which together ensured the implementation of the project.

Approximately 80% cost reduction with prescription conference in pharmacies. Important economic impacts result from: • Decrease in drug fraud and increased transparency • Increased safety in prescriptions, both for physicians and citizens • Greater and better access to medicines • Increased information available to physicians about therapeutic adherence • Increasing the information available to the user through the personal area Portal do SNS24 and by making the same information available through the SNS24 App.

Si

Internally

As this is a national initiative in the area of health, it had the involvement of several government entities, such as the Central Administration of Health Systems, I.P. (ACSS), Infarmed, IP, the General Directorate of Health (DGS), the Ministry of Health, the Agency for Administrative Modernization (AMA), National Health Service Institutions, the National Association of Pharmacies (ANF), the Orders of Doctors and of Dentists, the Association of Pharmacists and providers of electronic medical dispensing software. SPMS, in the pursuit of its competences and as responsible for the digital transformation in health, has promoted, together with these entities, meetings to align the strategy and objectives, which take place at regular intervals, via digital platforms, in order to provide a better response to the needs of users and health professionals.

As this is a national initiative in the area of health, it had the involvement of several government entities, such as the Central Administration of Health Systems, I.P. (ACSS), Infarmed, IP, the General Directorate of Health (DGS), the Ministry of Health, the Agency for Administrative Modernization (AMA), National Health Service Institutions, the National Association of Pharmacies (ANF), the Orders of Doctors and Dentists, the Association of Pharmacists and providers of electronic medical dispensing software. Discussion of the project between the various institutions above mentioned was essential since the beginning of the project, as the first part of its implementation began without a legal basis for it. To this end, weekly meetings were held between the different organizations that supported not only the beginning of the project, but also laid the foundations, with technological and training resources, so that the impact on the units of the National Health Service was as small as possible. . Today, looking back, we know that the project's success was due in part to the collaboration of different organizations from the beginning.

The mandatory authentication of the prescriber using the Citizen's Card (CC) or the Order of Doctors Card resulted in some resistance on the part of health professionals. Although this need was reflected in the legislation, it was necessary to maintain permanent contact with health institutions and the provision of free card readers to encourage this authentication route. On the other hand, the user saw a change in the paradigm associated with dispensing medication, sometimes leading to a lack of understanding regarding access codes and the right to choose. To minimize this lack of information, awareness campaigns were carried out among users, in order to ensure general knowledge of the project. As the main lessons learned, we highlight the communication of the project to users, health professionals and NHS health institutions in general - this should have advanced before the project's implementation, in order to reduce resistance from all participants. The publication of legal documents that reinforce the necessary changes and the rules associated with the project was also considered extremely pertinent, as it clarifies, establishes limits and rules and reinforces the legitimacy of the necessary developments, demanding their compliance.