See discussions, stats, and author profiles for this publication at: https://www.researchgate.

net/publication/257787729

E-Prescription across Europe

Article  in  Health and Technology · September 2013

DOI: 10.1007/s12553-012-0037-0

CITATIONS READS

41 7,077

Some of the authors of this publication are also working on these related projects:

Medical Care Networks View project

All content following this page was uploaded by Patrick Kierkegaard on 20 March 2015.

The user has requested enhancement of the downloaded file.

Health Technol. (2013) 3:205–219
DOI 10.1007/s12553-012-0037-0

ORIGINAL PAPER

E-Prescription across Europe

Patrick Kierkegaard

Received: 17 October 2012 / Accepted: 10 December 2012 / Published online: 20 December 2012
# IUPESM and Springer-Verlag Berlin Heidelberg 2012

Abstract The use of electronic prescription has been des- 1 Introduction

ignated as an important strategic policy to improve health
care in Europe. The aim of the European Union is to have a The advent of new technologies is affecting the way health-
cross-border electronic healthcare system in Europe which care is delivered. New medical technologies are assisting in
will enable EU citizens to obtain e-Prescriptions anywhere developing new health care models that will benefit the
in Europe. Cross border e-Prescription presents a myriad of health sector and patients alike. Rapid and reliable ICTs
challenges. This paper examines the issues concerning the have become vital components in improving the quality of
EU eHealth interoperability policy, specifically with regards health care in Europe as they provide an important oppor-
to the cross-border use of e-Prescription. The research in- tunity in improving coordination across the entire healthcare
volved conducting a review of the most current literature delivery chain. New technologies can improve disease pre-
and government reports regarding e-Prescription implemen- vention, diagnosis and treatment, facilitate patient safety and
tation on a national level in several European countries. The improve health systems’ coordination, use of resources and
European Union is pushing for more cross border health sustainability and reduce waiting times and errors.
data exchange. Despite favourable attitudes towards cross The use technology in health has led to different applica-
border e-Prescriptions, multiple perceived barriers impede tions in various programs, such as tele-medicine, e-
its incorporation in clinical practice. There are varying inter- Prescription and e-consultation. They have significantly
pretations and implementations of data protection and con- changed the way health care is provided. Tele-medicine
fidentiality laws in the 27 member states. Infrastructures are implies “medical care at a distance without physical contact
not in place to support the system and stakeholders in some or without the presence of the patient1”[1] or medicine/ med-
jurisdictions are reluctant to embrace e-health due to the ical act delivered at a geographic distance by electronic
high cost and the lack of security of the systems. The study means, and include the use of teleradiology, video conferenc-
concludes that member states have varying degrees of health ing, high-resolution cameras, or tele-robotics. E-consultation
care policy, privacy enforcement and laws concerning data is the use of electronic computing and communication tech-
protection, telecommunication services and digital signature nologies in medical consultation processes and is complimen-
with regards to e-Prescription. Interoperability of different tary to existing practices. It allows patients to have real-time
systems is only a partial solution. Security and enforcement webcam and email consultations with doctors. E-Prescription
of privacy must also be equally enforced. is a simple tool to generate prescriptions electronically. It is
generally understood as a prescriber’s ability to electronically
Keywords E-Prescription . E-health . Health portal . Cross send an accurate, error-free and understandable prescription
border . Privacy . Data protection . Security directly to a pharmacy from the point-of-care. E-Prescription
is also used by nurses to administer medicines and by phar-
macies to review orders and manage the supply of medicines.

P. Kierkegaard (*)
Department of Computer Science, University of Copenhagen,
1
Copenhagen, Denmark Definition used by Daniel Mart of the Comité Permanent des Méde-
e-mail: patrick.kierkegaard@diku.dk cins Européens/Standing Committee of European Doctors (CPME)
206 Health Technol. (2013) 3:205–219

To promote the use of tele-medicine and e-Prescription, use by doctors, healthcare providers and patients. This
several countries have enacted laws and implemented policies would include a centralised patient summary and a cross
to make them widely available. For example, in the US, there border e-Prescription system. In order to reap these benefits,
are 6 states (Florida, Maryland, New Mexico, Ohio, Pennsyl- eHealth tools and solutions need to be interoperable. Howev-
vania, Vermont) mandating payment for tele-medicine provid- er, centralised access to a patient’s health record and e-
ed services. Governments across the world are providing Prescription present a myriad of challenges. This paper exam-
incentives for implementing e-prescriptions, and at the same ines the issues concerning the EU eHealth interoperability
time penalizing non-compliance. One such attempt is the US policy, specifically with regards to the cross-border use of
implementation of American Recovery and Reinvestment Act e-Prescription.
(ARRA) in 2009, which received federal funding worth US
$19 billion for the modernization of HIT infrastructure in the
US. ARRA is expected to assist federal government in saving 2 EU health strategy: legal basis
an estimated US$22 billion in medical and drug costs over the
next decade [2, 3]. In addition, the adoption of e-prescribing Article 152 of the EC Treaty says that a “high level of
under the ARRA is expected to increase to about 70 to 75 % of human health protection shall be ensured in the definition
the total prescribers over the next 5 to 6 years [3]. and implementation of all Community policies and activities”.
The United States and Europe constitute the two major The European Commission has been investing in eHealth
markets for e-Prescription systems globally. Of the two, research for over 20 years. Since 2004, it has set targeted
Europe represents the largest market for e-Prescription policy initiatives aimed at fostering widespread adoption of
systems. eHealth technologies across the EU. The Action Plan for a
In Europe, Denmark is the leading country in terms of European eHealth Area focused on the implementation and
telehealth. The e-Journalen provides patients and health care deployment aspects of eHealth systems in Europe. The main
professionals digital access to information on diagnoses, objective of this eHealth Action Plan is to enable easy and
treatments and notes from Electronic Health Record (EHR) equal access to quality healthcare for all citizens in any place
systems in all public hospitals. In 2011, the system contained and at any time in the European Union. This objective consists
health data on more than 85 % of the Danish population and of developing on-line systems which requires interoperability
1.2 million entries [4]. Denmark is the only country in Europe among healthcare services at any geographical level. It advo-
which has a health portal that allows patients to have access to cates the development of interoperability approaches for pa-
their medication profiles and to re-order certain repeat tient identifiers, medical data messaging and electronic health
medications themselves. records. The ultimate goal is to enable access to the patient’s
E-health is a major agenda in EU policy. The European electronic health record and emergency data from any place in
Union is committed to delivering top quality health-care by Europe even outside a citizen’s country of origin or residence
improving cross border cooperation among member states. whenever this is required.
The EU has enacted the Cross Border Health Directive, In 2010, the flagship initiatives Digital Agenda for Europe
which enables EU residents to receive health services within and Innovation Union were launched as part of the EU’s
the EU borders. The EU Directive on the application of “Europe 2020” strategy for smart, sustainable and inclusive
patients’ rights in cross-border healthcare (2011/24/EU) growth. The EU’s Digital Agenda focuses on ICTs capability
aims to establish rules for facilitating access to safe and to reduce energy consumption, support ageing citizens’ lives,
high-quality cross border healthcare in the Union, to ensure revolutionises health services and deliver better public serv-
patient mobility and to promote cooperation on healthcare ices. The Digital Agenda for Europe includes a number of
between Member States [5]. It applies to patients who targeted eHealth actions and goals as part of a wider strategy
decide to seek healthcare in a Member State other than the towards sustainable healthcare and ICT-based support for
Member State of affiliation. dignified and independent living. The Innovation Union
The eHealth Action Plan and the Digital Agenda for strategy introduces the concept of a pilot European Innovation
Europe set the headline targets for making well connected Partnership on active and healthy ageing. Under the Innova-
eHealth services a reality in EU Member States. To these tion program, the adoption of electronic medical prescriptions
extents, a series of key EU policies to promote eHealth is part of this wider European health policy, which also
interoperability are currently being implemented. The EU promotes generic medication.
is developing ICT infrastructures that would enable secure The European Patients Smart Open Services project
access to patient health information among different Euro- (epSOS) is a European large scale pilot launched in 2008
pean healthcare systems. Interoperability can be defined as as part of the Innovation strategy. It involves 27 beneficia-
the capability for independent and heterogeneous health ries out of 12 EU-member states, including ministries of
information systems to exchange health-related data for health, national competence centres and industry. The
Health Technol. (2013) 3:205–219 207

project aims at developing, testing and validating technical having further elements in their prescriptions, as long as this
specifications to ensure interoperability of patient summa- does not prevent prescriptions from other Member States
ries and cross-border use of electronic prescriptions. This that contain the common list of elements from being recog-
facilitates the usage of the data for patients seeking health- nised. The recognition of prescriptions should also apply for
care abroad. It aims at improving the quality of healthcare medical devices that are legally placed on the market in the
for citizens when travelling to another European country. Member State where the device will be dispensed.
The services developed in the course of the epSOS project The recognition of prescriptions from other member
are tested in a pilot operation phase. For the first time states, however, does not affect the national law of govern-
European patients will have the opportunity to use cross- ing, prescribing and dispensing if the national law does not
border E-Prescription services if they require prescribed contravene the EU law (including generic and substitution)
drugs in participating epSOS pilot countries. and the rules of the reimbursement of medicinal products.
Article 11 of the recently passed EU Directive 2011/24/EU However, the pharmacists can also refuse for ethical reasons
of the European Parliament and of the Council of 9 March to dispense a product that was prescribed in another member
2011 on the application of patients’ rights in cross-border state if the latter has also the same right to refuse to dispense
healthcare provides for the recognition of prescriptions issued the same prescription. The recognition of prescriptions from
in another member state for dispensation in any member state other Member States should not affect any professional or
of the European Union. Table 1 highlights Article 11 of EU ethical duty that would require pharmacists to refuse to
Directive 2011/24/EU. dispense the prescription
The Directive thus provides for the right for a patient to Finally, the reimbursement of medicinal products is not
receive any medicinal product authorised for marketing in affected by the rules on mutual recognition of prescriptions,
the Member State of treatment, even if the medical product but covered by the general rules on reimbursement of cross-
is not authorised for marketing in the Member State of border healthcare. Thus, nothing should oblige a Member State
affiliation, provided that it is an indispensable part of obtain- of affiliation to reimburse an insured person for a medicinal
ing effective treatment in another Member State. Thus, product prescribed in the Member State of treatment, where
where medical products are authorised within a Member that medicinal product is not among the benefits provided to
State and have been prescribed in that Member State by a that insured person by the statutory social security system or
member of a regulated health profession for an individual national health system in the Member State of affiliation.
named patient, it should, in principle, be possible for such In order to implement the recognition of prescriptions in
prescriptions to be medically recognised and for the medic- the European Union, the Directive gives the European Com-
inal products to be dispensed in another Member State in mission the following rights:
which the medicinal products are authorised. The imple-
mentation of the principle of recognition must be facilitated (a) measures enabling a health professional to verify the
by the adoption of measures necessary for safeguarding the authenticity of the prescription and whether the prescrip-
safety of a patient, and avoiding the misuse or confusion of tion was issued in another Member State by a member of
medicinal products. These measures include the adoption of a regulated health profession who is legally entitled to do
a non-exhaustive list of elements to be included in prescrip- so through developing a non-exhaustive list of elements
tions. Nothing in the Directive prevents Member States from to be included in the prescriptions and which must be
clearly identifiable in all prescription formats, including
elements to facilitate, if needed, contact between the
Table 1 Article 11, EU Directive 2011/24/EU prescribing party and the dispensing party in order to
Article 11 contribute to a complete understanding of the treatment,
in due respect of data protection;
Recognition of prescriptions issued in another Member State (b) Guidelines supporting the Member States in developing
1. If a medicinal product is authorised to be marketed on their territory, the interoperability of e-Prescriptions;
in accordance with Directive 2001/83/EC or Regulation (EC) No (c) Measures to facilitate the correct identification of me-
726/2004, Member States shall ensure that prescriptions issued for
such a product in another Member State for a named patient can be
dicinal products or medical devices prescribed in one
dispensed on their territory in compliance with their national legis- Member State and dispensed in another, including
lation in force, and that any restrictions on recognition of individual measures to address patient safety concerns in relation
prescriptions are prohibited unless such restrictions are: to their substitution in cross border healthcare where
(a) limited to what is necessary and proportionate to safeguard human the legislation of the dispensing Member State permits
health, and non-discriminatory; or
such substitution. The Commission shall consider, inter
(b) based on legitimate and justified doubts about the authenticity,
alia, using the International Non-proprietary Name and
content or comprehensibility of an individual prescription.
the dosage of medicinal products;
208 Health Technol. (2013) 3:205–219

(d) measures to facilitate the comprehensibility of the in- Table 2 shows that there is increasing acceptance of e-
formation to patients concerning the prescription and prescribing in Europe According to a report on the technology
the instructions included on the use of the product, by market research firm Frost & Sullivan, system sales should
including an indication of active substance and dosage. more than triple in the next 6 years. According to the analysis,
the European market for e-Prescription systems, including
In adopting measures or guidelines, the Commission integrated and stand-alone e-Prescription systems, was worth
must give regard to the proportionality of any costs of $95.4 million in 2008 and should reach $449.7 million by
compliance with, as well as the likely benefits of, the measures 2015 [7]. It is however expected to be higher - reaching
or guidelines. Since the continuity of cross-border healthcare $508.38 million by the year 2017, according to a new report
depends on transfer of personal data concerning patients’ by companiesandmarkets.com [8].
health from one Member State to another, the fundamental However, there is still resistance from some of the EU
rights of the individuals with regards to the processing of their prescribers to adopt the technology of e-Prescription. A study
personal data must be safeguarded. The right to the protection conducted in 2011 by the Turku City Health Care compared
of personal data is a fundamental right recognised by Article the use of e-Prescriptions in 2002 and 2011 [9]. The study
8 of the Charter of Fundamental Rights of the European found that five countries were using e-Prescriptions as a part
Union. Directive 95/46/EC of the European Parliament and of their daily practice, but only Denmark and Sweden reported
of the Council of 24 October 1995 on the protection of nationwide use. These countries were the same that used e-
individuals with regard to the processing of personal data Prescriptions nationally already in 2002. Pilots presented in
and on the free movement of such data establishes the right 2002 have not yet advanced into daily practice. Nationwide
for individuals to have access to their personal data use of e-Prescriptions is not more common than in 2002.
concerning their health, for example the data in their medical In 2010 only a few European Union countries had imple-
records containing such information as diagnosis, examina- mented a fully functional primary care e-Prescription ser-
tion results, assessments by treating physicians and any treat- vice. However, the majority (16) reported it as an element of
ment or interventions provided shall apply in the context of their national eHealth strategy plan. Countries that have
cross-border healthcare covered by this Directive. adopted fully operational E-Prescription office practise are
Denmark, Estonia, Iceland, and Sweden which means that
the entire prescribing sequence, from issuing one in a Gen-
3 E-Prescription in the EU eral Practitioner (GP) to transfer and dispensation, is done
electronically. Pilots on e-Prescription can currently be
From 2006 to 2010, European member states have reported found in the Czech Republic, Finland, Italy and Poland
considerable increase in national health activities. E- [6]. The following section looks at the status of e-
prescribing is defined in the EU e-Health Strategy report Prescription in the European Union.
as “the electronic capture and then transfer of prescription
by a healthcare provider to a pharmacy for retrieval of the 3.1 A look at the e-Prescription in EU member states
medicine by the patient and the recording of dispensation in
the patient’s record. The Final Strategy Report on E-Health The Scandinavian countries are leading Europe in deploying
reported that only a few countries have implemented a fully e-Prescription. Electronic prescriptions are widely used only
operational national system and these are mainly in primary in three European countries: Denmark (97 %), Sweden
care and excludes medications dispensed in hospitals. Up till (81 %) and the Netherlands (71 %) [10]. Other countries
now, patients rarely have access to their own medication which use the prescription process routinely are Estonia,
profiles or are able to reorder certain repeat medications Iceland, England and Scotland.
themselves, e.g. via the web [6]. Table 2 shows the state
of e-prescribing in the European Union in 2010. 3.1.1 EU leaders

Denmark Electronic prescribing networks linking physi-

Table 2 State of E-Prescribing in the European Union 2010 cians and pharmacies have been in place in Denmark since
the late 1990s. The Danish Medicines Agency is responsible
E-capture E-transfer E-dispensation
for the system which handles electronic prescriptions issued
Currently available 15 9 7 by the doctor. All prescriptions are stored in a secure system
Planned for near future 5 8 6
that can be accessed by the patient as well as prescribers and
Unavailable 12 15 19
pharmacies. The electronic prescription gives the doctor, the
patient and the pharmacy an overview of all the medicine
Source: eHealth Strategies study, 2010 [6] that has been prescribed to the patient. This means that the
Health Technol. (2013) 3:205–219 209

pharmacy can advise patients on a highly professional basis, have access to the prescription. The patients can then get
because the pharmacy staff can see precisely what medicine their medication dispensed at any convenient time and phar-
the patient has received previously. macy throughout Sweden [11]. The patient has, with a secure
The doctor can indicate on the electronic prescription the digital signature, full access to the register on the internet [12].
name of the pharmacy where the medicine can be collected In a study conducted by Bengt Åstrand [12, 13], he attributed
and the pharmacy has the possibility of having it ready when the success of e-Prescription on the following prerequisites:
the patient arrives. The patient can also contact the pharma-
cy in advance to ask them to prepare the medicine via his & The early shared learning experiments in different
medicine profile. If the patient does not know which phar- organisations;
macy he wants to pick up the medicine, the prescription is & The high penetration of electronic healthcare records in
simply stored electronically and the patient can choose any primary care;
pharmacy in Denmark. & The determination by strong and enduring national/re-
Apoteket.dk is the health portal created by the Danish gional stakeholders, expressed as shared local/regional
Pharmacy Association. Patient can buy medicine online for implementation teams;
delivery or pickup at their local pharmacy. It also provides & The confidence in a secure handling, with a virtual
an automatic call service via sms when patients are private network for communication, with secure identi-
reminded when their medicines are due to be taken. fication for personal integrity;
From a rather slow start with less than 4,000 documents & The national registers allowing secure identification of
in the first year (1994), by 2011, 85 % of the country’s total drugs, prescribers, pharmacists, and prescriptions;
prescriptions were sent electronically. Medcom recently re- Standardisation of terminology, nomenclature, and com-
leased statistics for the digital exchange of health data in munication protocols;
Denmark [4] indicating that the exchange of health care & The low degree of detailed regulations, giving high
documents is now almost fully electronic with more than responsibility to stakeholders, beneficial for the entre-
60 million messages sent: preneurial development of the new technology;
& The new legislation allowing national databases, inde-
& Doctors sent on average 1312543 EDI-messages per. pendent of reimbursement form, but with a high degree
month of patient consent and transparency;
& In 2011 Specialist doctors sent on average 52840 EDI- & The high public penetration rate for mobile phones,
messages per. month personal computers, and the internet;
& In 2011 Hospitals sent on average 95144 EDI-messages & The high degree of public and professional acceptance.
per. month
& In 2011, After hours medical assistance (Lægevagt) sent More than 2 million e-prescriptions are transmitted each
on average 52536 EDI-messages per. month month in Sweden [11, 14].
& Prescription renewals sent by Pharmacies to the Munici-
palities were on average 61625 EDI-messages per. Month Netherlands The implementation of the nationwide EHCR
was initiated by the National IT Institute for Healthcare in
Sweden E-prescribing began in 1981 in Jönköping. The the Netherlands (NICTIZ), which was created in 2002.
development of e-Prescriptions in Sweden increased rapidly NICTIZ initiated the legal framework for the exchange of
in 2000 as a result of collaboration between the National patient information and for communication between GPs
Corporation of Swedish Pharmacies (Apoteket AB) and and other health providers (in terms of the national infra-
regional healthcare bodies. structure, electronic messages, and safety). It also coordi-
A national mailbox for e-Prescriptions allows the patient nates the implementation of health IT projects and provides
to have access to valid prescriptions at any pharmacy with a level of national support, including training, a helpdesk,
the presentation of valid identification. Patients may also and maintenance of Web-patient portals [15]. On January,
store their prescriptions in a national online repository, with 2012 the Netherlands implemented a new law that requires
no need for paper prescriptions and with the introduction of prescriptions to be transferred electronically to the pharma-
new services, like mail order prescription drugs. The Na- cy [16]. Prof. Dr van der Wal, the Inspector General of the
tional Pharmacy Register was also implemented in 2005 in Dutch Healthcare Inspectorate announced that the switch to
which all dispensed drugs are stored for the duration of an electronic prescription was due to the numerous errors
15 months. With the patients’ consent, doctors and pharma- being made in the dispensation of the medicines. He said:
cists may retrieve information from the database for reasons
of optimising their patients’ medical therapy. Only the pre- It is very risky to prescribe drugs without the help of
scribing physicians and Apoteket AB’s pharmacy personnel an automated system that instantly signals drug
210 Health Technol. (2013) 3:205–219

interactions and possible allergic reactions. This is prescriptions and medications’ side-effects will be made avail-
unnecessarily dangerous and no longer justified [17]. able. In 2012 eMedication will be rolled and initial medical
findings will be saved in electronic health records, while by
The announcement received initial mixed reaction from 2015, most of the medical findings will have been included
health care givers with specialists, giving consultation to there. Documents and medical findings such as laboratory and
patients in an ambulatory setting or day care, expressing radiological results, discharge letters, and medication data
reluctance to use electronic devices to enter patient data. The should be saved, if they are required for the treatment and
mobility of the specialists, running from one consultation care of patients. The data must be updated and relevant, so
room to another, hinders them from sitting down behind a they will be deleted after a certain period of time (6 months or
workstation. It is easier for specialists to write a written 3 years), with possibilities of extension. Furthermore, patients’
prescription as they have to continuously move to various wills and powers of attorney can be stored [20].
consultation rooms. In contrast, the GP has the workstation A pilot of the ‘e-Medikation’ was conducted in three
on a desk in the consultation room. Currently, most GPs in regions of Austria from April to December 2011. The results
the Netherlands are already registering their prescriptions of an independent scientific evaluation of the pilot were
electronically and 70 to 80 % of the volume of all prescrip- presented on 10 May 2012. The results revealed that 85 %
tions is repeat prescriptions that are often generated by the of the participating patients felt secure with physicians or
GPs. pharmacists who participated in the e-Medikation pilot project
and that the majority of respondents found the medication list
Estonia One of the newest innovations in Estonia’s cutting- complete and updated, as well as positive for patient safety
edge e-Healthcare system, e-Prescription is a centralized, [21].
paperless system for issuing and handling medical prescrip-
tions. Since January 2010, Estonia has implemented an elec- Belgium Electronic transmission of prescriptions is so far
tronic prescription system and around 85 % of the medical limited to in-house prescriptions in hospitals, and even there
prescriptions have gone digital. Only 15 months after its ePrescribing is only used with very limited success due for
launch, around 80 % of prescriptions are now e-prescriptions example, to the complexity of dosing schemes in hospitals
[18]. and due to administrative and security related burdens. A
Doctors can prescribe medications for patients using their first E-Prescription pilot was implemented in the European
computer software and forward an electronic prescription to FP6 ePrescript project, but acceptance by physicians and
the national database. The e-prescription is then immediate- pharmacists was relatively low. So far, prescribers and
ly accessible in every pharmacy on a patient’s request. patients have not been convinced that ePrescribing might
When a doctor prescribes medicine using the system, he or generate any added value. Furthermore, the absolute free-
she does so electronically with the aid of an online form. At dom of choosing at any time any pharmacy for each pre-
the pharmacy, all a patient needs to do is present an ID Card. scription hampers the implementation of ePrescribing, at
The pharmacist then retrieves the patient’s information from least compared to the situation in countries with one dedi-
the system and fills the prescription. All hospitals and phar- cated pharmacy or with non-competing pharmacies. Other
macies in the nation are connected to the system. Because issues are patients’ fears of increased compliance control by
the e-Prescription system draws on data from the national the health authorities. There are also concerns that so far
health insurance fund, any state medical subsidies that the there is a lack of clear and credible official statements
patient is entitled to also appear, and the medicine is dis- regarding secondary use or misuse of the prescription data
counted accordingly. Another major advantage of the system [22].
is that doctor visits are no longer needed for routine refills. A
patient can contact the doctor by e-mail, Skype or phone, and Bulgaria In 2010 the first pilot for E-Prescription system
the doctors can issue refills with just a couple clicks of a had taken place in two villages where 10 GPs were linked
mouse. This frees up time for both the patient and the doctor, with pharmacies; however a larger scaled pilot was not
and reduces administrative strain on the hospital [19]. followed up [23]. In 2011, the Bulgarian Ministry of Health
received approximately €5 million for the project to develop
3.1.2 Trailing but moving an Integrated Health Information System (IHIS) which
involves the creation and implementation of an electronic
Austria ‘eMedikation’, i.e. electronic prescriptions is the prescription and an electronic patient record over a period of
first large-area of Austria’s Electronic Health Record project, 27 month [24].
started on 1 April 2011 in three pilot regions. Pharma-
cists, doctors and hospitals will be able to see the medication Croatia e-Prescription was introduced in January 2010 but
a patient has been prescribed. Thus, possible multiple was only available for use in primary care within 10
Health Technol. (2013) 3:205–219 211

participating counties [25]. Since 3 January 2011, paper Electronic Prescription Service had a reported average of 33 %
prescriptions for medicines have been replaced with elec- for total daily prescriptions. However, there is resistance
tronic prescriptions. In practice, the switch from paper to an among health professionals about the centralization of data
electronic prescribing system requires the prescriber to due to the security and confidentiality of data. Organisational,
transmit electronically prescription information via comput- resourcing and technological issues have been cited as the
er to that of the pharmacist. Patients can then get their main adoption challenges [32].
medicines simply by using their medical card. The system
is run from two identical servers, one located in Rijeka and Finland According to the Act on Electronic Prescriptions
the other one in Zagreb; in case either of the two servers (61/2007) which entered into force in 2007, Kela, the inde-
fails, one will continue to work avoiding thus any loss of pendent social security institution, is in charge of maintaining
data. The project of the computerization of the primary the centralised system (Prescription Centre) which contains
health care system cost HRK 55 million and given the the prescriptions written out by doctors as well as the dispens-
current cost of paper for a prescription which is HRK 15 ing data of pharmacies [33]. On 20 May 2010, the first
million, the investment is expected to pay off in two to two electronic prescription was written and dispensed in Finland
and half years [26]. in the city of Turku (south-west Finland) [34]. Since 2011, 12
hospital districts have issued electronic prescriptions and in
Cyprus E-Prescription has only been gradually implemented April 2012, the millionth electronic prescriptions had been
since 2008 and the share is less than 20 % at that time. And issued. In spring 2012, the use of the E-Prescription system
because the patient’s first encounter with the health system in will start in most hospital districts [35]. According to the law
case of illness is with the GP (either public or private), the on electronic prescriptions, public healthcare institutions will
envisaged E-Prescription scheme is mainly GP-based. use electronic prescriptions by April 2013, whereas the private
For coming years, it is planned to completely replace paper sector will do by April 2014.
prescriptions [27].
France In France, law no. 2007–127 introduced a pharma-
Czech Republic Electronic prescriptions have been intro- ceutical record for every beneficiary of social health insur-
duced in the Czech Republic. The law on medicine prescrip- ance. In contrast to the nation-wide electronic health record,
tion has been amended. Doctors may now issue E- which is opt-out based, the pharmaceutical record is optional
Prescriptions if the patient has given his consent. Previously, and is thus opt-in based. The patient has the right to refuse the
Czech health insurance funds have no access to the e- update of the record with specific drug information, to refuse
Prescription system and therefore are not able to check that access to it, and to close it [36].
a given prescription was actually filled out by a doctor (and
consequently reimburse the prescribed medicines).2 Now, Germany Patients are equipped with a smartcard—the
the electronic signatures of the doctors are necessary on ‘elektronische Gesundheitskarte’, electronic health card.
the E-Prescription. The prescription is added with a PIN The Gesundheitskarte is issued by the health insurance
code to send it to the hospital pharmacy through internet company and gives doctors and pharmacists access to pa-
or local computer network. The health agencies assign the tient data. Medical professionals use smartcards—separate
PIN. Different letters on the e-prescription indicates about ‘health professional cards’—when accessing patient infor-
the payment whether by the patient, or whether it is partially mation and electronic prescriptions [37]. Gemalto, which is
or fully covered by health insurers [28]. responsible for German National Health Insurance Scheme
issued 2.5 million health cards. It is issuing an additional 15
England In 1997 the government proposed the creation of million second generation health cards in 2012. The new
an “NHS information superhighway that links GP surgeries Sealys eHealth card features a portrait photo of the insured
to any specialist centre in the country” [29]. The United person on the front. Together with the secure authentication
Kingdom is making a particularly large investment with the function of the operating system, this enhances the legitimacy
National Programme for IT (NPfIT). There are currently two of the rightful cardholder and further reduces fraud. In addi-
programmes for electronic prescribing in the United Kingdom: tion, the card shall in future enable secure access to an online
ePrescribing (acute healthcare settings) [30] and the Electronic patient file and store electronic prescriptions. With the
Prescription Service (primary care sector) [31]. In 2009, the holder’s consent, additional personal information can be
stored on the card, including emergency data such as allergies
2
or drug intolerance [38].
However, health insurance companies shall gain access to an elec-
tronic repository, where the electronic information on prescriptions is
stored, under the amended Czech health insurance law currently being Greece All social insurance funds have been integrated into
discussed by the country’s parliament. the electronic prescription system. By 2017 the system will
212 Health Technol. (2013) 3:205–219

be extended to all branches of the national health system and regional healthcare system been prepared. Challenging
other providers of healthcare services [39]. In July 2012, aspects that emerged throughout the beginning of the regional
Greece launched 18 new pilot sites for the epSOS E- pilot in 2009 and 2010 are the need for many complementary
Prescription service in the Athens region for citizens coming investments—mostly into technical and infrastructural equip-
from another country [40]. ment. Furthermore, it is almost impossible to implement a
complementary E-Prescription system before every patient
Hungary In November 2006, the legislation for electronic has their own healthcare ID card however there is an idea to
drug prescribing in Hungary changed, requiring compulsory use new National ID documents that will be fully electronic
information on drugs to be added to e-prescribing software. with proper chip [47].
At the moment, E-Prescription use is at a planning stage in In mid-March 2011 a prototype E-Prescription system
Hungary. But a launch of this eHealth application in the near was implemented in the pharmacies and clinics of Leszno
future does not seem within reach, as recent policy document city and county where 19 health institutions, 15 pharmacies
do not include E-Prescription as a feature of the eHealth and four clinics are connected to the e-Prescription system.
infrastructure. E-prescription solution has not been fully in- An additional 2,400 doctors joined in early May 2011 and it
troduced. In April 2009, the format of the traditional paper- was reported that pharmacists had processed more than
based prescriptions was changed and several hospitals had IT 5,100 electronic prescriptions. It is expected that the number
problems due to not having the appropriate printers to print the of participating entities will increase. The prototype systems
new version of the prescription [41]. were tested in Leszno city and county until September 2011
[48].
Italy Since January 2010 the central system for the electronic
transmission of the data of medical prescriptions has been Portugal In Portugal, most hospitals and health centres
available [42]. have had electronic applications for prescribing since
2004,3 which allow doctors to issue a prescription using a
Latvia Introduction of centralized system is encountering computer with access to a local or national drug database.
problems. Introduction of the system is not possible for These prescriptions are electronically sent to a national
many pharmacies because of incomplete infrastructure and database for invoicing control purposes. Most pharmacies
the introduction of the system charges higher investments also have access to specific applications to electronically
for them. IS procurement procedures for e-Prescription is register the delivery of a drug. However, there is no eTrans-
still in progress and IS development system has not yet mission of prescription from a doctor to pharmacy or no
started. The estimated cost is 338700 EUR [43]. medication record for the patient (except at a local level) and
only very basic decision support tools in place. Currently, in
Northern Ireland The Electronic Prescribing and Eligibility the northern region, 95 % at least use the computer for
System (EPES) has been operational since May 1, 2008 prescription and around 60 % of the hospitals are
throughout Northern Ireland. The system is paper-based choosing the computer over handwritten prescriptions. Cur-
and uses two dimensional barcode technologies. Northern rently, 64 % of prescriptions are produced by informatics
Ireland Health and Social Care now has at its disposal a applications [49].
single, patient-centred, electronic history of prescribing and E-Prescriptions became mandatory for medicines to be
dispensing, and the ability to call up electronically and view reimbursed by the State in August 2011 as part of the
each of the 16.8 million prescription forms returned annually Economic and Financial Adjustment Programme provisions
to the Central Services Agency (CSA) [44]. that Portugal is required to implement by the end of 2011. E-
Prescriptions are only valid if it includes a user name and
Norway The E-Prescription programme was introduced on number, the beneficiary account number in the subsystem
18 October 2011 and has since been gradually rolled out and the responsible financial institution identified. Prescrip-
throughout the country. It is expected that full adoption will tions are considered tampered with and are not subject to
occur by 2013 [45]. 40 municipalities and 82 pharmacies are reimbursement if they contain any handwriting apart from a
currently involved in the E-Prescription programme and doctor’s signature [50].
a personalised web service named ‘Mine resepter’ pro-
vides citizens with an overview of their valid E-Prescriptions 3
Administrative Order n.° 711/2007, 11 June 2007 and RCM n.° 96,
[46]. 27 July 2007 authorise all the national health services to launch public
tenders in order to buy informatics systems for electronic prescriptions,
invoicing and administrative management. Although, the system to
Poland E-Prescription system is only operational in selected
support the physician daily activity (Sistema de Apoio ao Médico—
areas. The programme is currently in an initial phase and so far SAM), application developed by ACSS is in field in Hospitals and
the adequate equipment has not been fully distributed nor the Healthcare Centres since 2004.
Health Technol. (2013) 3:205–219 213

Romania The Health Reform Law 95/2006 establishes how 3.1.3 EU countries at a standstill: no e-prescription on sight
the prescriptions are made. The Social Health Insurance
Houses reimburse, in part or entirely, the pharmacies the Luxembourg E-Prescription is still not a reality. Currently
cost of drugs prescribed by physicians, as it is established in no work has been undertaken on e-Prescription [55].
the framework contract or in subsequent government ordi-
nances. Till now, computerised procedures for prescriptions Malta E-Prescription is currently not used in Malta. The
(e.g. transmission of prescriptions) have been used mainly main challenge for introducing E-Prescription is currently
in hospitals, between physicians and internal pharmacies, the validity issue of electronic signatures. There is currently
but mainly for administrative purposes (e.g. consumption, no standard and fraud prevention system for electronic
stock management) and not, for recording medication to signatures in Malta. The use and validity of electronic
control incompatibilities. The IT applications for pharmacies signatures are laid out in the “Electronic Commerce Act”,
outside hospitals are made by private companies and used which does not make any provisions regarding health related
mainly for the stock management or for reimbursements services [56].
from Health Insurance [54]. Legally no specific provisions
on e-Prescription are foreseen in Romanian Law. Order no. Ireland There are currently no active ICT projects aiming
832/302/2008 does specify the model of the medical pre- for E-Prescription implementation [57].
scriptions, but this mainly entails that prescriptions need to
be signed, dated and stamped with the physicians’ code Lithuania There are no information systems in use, which
[54]. In May 2012, the Electronic Prescription IT System could deliver an infrastructure for any kind of eHealth
(SIPE), a National Health Insurance House project financed application. Furthermore, the medications register is not
from non-repayable European funds, was implemented. entirely developed in Lithuania and a legal and organisational
Doctors will manage prescriptions online, assisted by medical framework is still missing. The project ‘eHealth services’ is
rules (interactions between medicines, contraindications, cor- one of the stages in the development of the Lithuanian elec-
relations between diagnostic, age and prescribed medicines tronic health system. This project includes the implementation
etc.) engine [51, 52]. of base Hospital information system in three regional health-
care institutions (in Kaunas, Klaipėda and Vilnius) and inte-
Slovakia Representatives of healthcare providers, profession- gration of these systems to the National electronic health
al organisations in healthcare and health insurance companies system. It is still in the initial stages [58].
have completed the preparatory phase in the implementation
of the eHealth programme. Many aspects of the project have Slovenia E-Prescription is still in the planning stage. E-
undergone significant changes during this phase. The changes Prescription stakeholders cannot agree on a common set of
have been designed to remove inefficiencies and accelerate data, which is included in the medication record of the
the availability of useful electronic services for citizens, doc- patient. The matter of decentralised or centralised data storage
tors, health insurance and other actors in the sector. The first has not been resolved and there is no consensus on the
applications will be deployed throughout Slovakia by the end legislative framework [59].
of 2012. The first project applications will involve a national
health portal where patients can find reliable health informa-
tion verified by prominent experts in the field while doctors 4 Benefits of e-Prescription
will be able to obtain information about the medicines pre-
scribed by other doctors [53]. A prescriber’s ability to electronically send an accurate,
error-free and understandable prescription directly to a phar-
Spain The electronic transmission of prescriptions to phar- macy from the point-of-care—is an important element in
macies is a regional routine in Spain There is an uneven improving the quality of patient care. E-Prescription will
implementation of electronic prescription within Spain and assist in decreasing the number of adverse drug events
interoperability of the regional e-prescription systems is an caused due to errors in hand-written prescriptions. It could
issue.. Andalusia has an advanced system than the other provide a means to crosscheck on double medication,
Spanish regions. Regions with e-prescription systems contra-indications and dosage at the moment of prescribing.
reported the following e-prescription take up during 2008– A study by the University of NSW has found that the use
2009: Malaga 56.3 %, Balearic Islands 53.46 %, Cordoba of electronic prescriptions can slash medication error rates in
50.34 %, Extremadura 50.3 %, Andalusia 46 %, Almeria hospitals by up to two-thirds. Prescribing errors at two
41 %, Mallorca 14.12 %, Menorca 3.04 %. Madrid is Australian hospitals dropped between 58 and 66 % when
undergoing a pilot and Navarra, Cantabria, Murcia, Ceuta commercial e-prescribing systems were used instead of
and Melilla are preparing pilots [54]. handwritten scripts. Procedural errors, such as incomplete
214 Health Technol. (2013) 3:205–219

or unclear medication orders, fell by over 90 %, while the consistent 10 % increase in patient first fill medication
number of serious clinical mistakes, including those that adherence among physicians who adopted e-prescribing
result in death, decreased by 44 %. However, the research technology. One finding was that the improved medication
also highlighted the fact that the electronic systems them- adherence from e-prescriptions can lead to 10-year estimated
selves created new—albeit less serious—errors that never savings of between $140 billion to $240 billion, measured in
occurred in paper-based orders but could system design could health care cost savings and improved health outcomes [67].
be fixed to remove errors [60]. In Slovakia, the implementation of e-Prescription is
In the USA, medication errors kill 7,000 patients a year expected to improve healthcare. A national health portal is
and account for nearly 1 in 20 hospital admissions [61, 62]. being established where patients can find reliable health
A recent study conducted by Kaiser Permanente Colorado information verified by prominent experts in the field, while
on 12,061 men and women who were given new prescrip- doctors will be able to obtain information about the medi-
tions for diabetes, blood pressure or cholesterol medications cines prescribed by other doctors. The Ministry of Health
over a period of 18 months showed that the use of electronic explains:
prescription improves the number of patients who follow
“Many patients suffer from multiple chronic diseases
doctor’s orders on medications for chronic illnesses. Non-
and also use several different drugs simultaneously.
adherence among patient was reduced from around 22 % to
Such patients can often not tell their doctor which
only 7–13 % when electronic prescribing system was
medicines have been prescribed by another doctor
employed [63]. The new study found that only 7 % of the
and a specialist can’t assess the potential risk of inter-
Kaiser patients neglected to fill their prescriptions for blood
actions of drugs prescribed and taken by the patient.
pressure medication, while 11 % failed to pick up new
At the same time, and as a result of lack of information
prescriptions for diabetes medications and 13 % did not pick
among doctors, there can be duplicate prescriptions. In
up cholesterol medication. In Kaiser Permanente Colorado,
this case, the patient may receive a double dose of an
the pharmacy and doctor’s offices are all part of the same
active ingredient, without it being known by either the
system and are linked using electronic medical records.
doctors or patient, as drugs of different trade names
Medication orders are sent electronically, rather than using
can include the same active ingredients. On the basis
traditional paper scripts. The electronic transmission of a
of electronic information the treating doctors will have
prescription to a pharmacy increases the likelihood that it
an overview of the patient’s diagnosis and an exact
will be picked up by the patient. It eliminates the patient’s
description of what medicines the patient is taking.
responsibility of delivering the prescription to the pharmacy,
This eliminates the risk of possible drug and food
a problem cited by more than one-third of patients who
interactions and also of the described risk of double
either forgot to drop it off or had difficulty doing so [64].
prescription of drugs with the same active ingredients,
Prior studies have found as many as 28 % of paper prescrip-
which will ultimately ensure the quality and safe pa-
tions never make it to the pharmacy [65].
tient treatment and excellent feedback and doctor
Previous research has found that up to 22 % of patients in
awareness.” [68]
healthcare systems not integrated with pharmacies fail to fill
new prescriptions. One month after discharge from hospital It is difficult to read hand written prescriptions and some
many patients do not take the right medicine in the right way important information may be missing from the hand written
decreasing treatment efficiency and resulting in repeated prescription such as dosage and frequency. E-prescription
costs. According to a US study, e-prescribing could prevent enables the prescribers to accurately and clearly enter com-
nearly two million medication errors, saving countless lives. plete medication orders and those who administer medicines
Much of this is attributed to the decision-support aspects of will have clear and legible medication orders. With e-
the technology, such as immediate access to patient medi- Prescription, doctors can monitor the history of the patient’s
cation histories and safety alerts. The federal government medicine uses. It also enables the patient to obtain the
could save up to $26 billion over the next decade just in the medicine anywhere, avoiding the long waiting time. For
Medicare program—even after providing funds for equip- pharmacists, eliminating manual entry of prescriptions at
ment, training and support—as long as physicians are first the pharmacy should reduce liabilities that are due to incorrect
incentivized and then required to use the technology as a dispensing due to larger volumes of prescriptions. Prescription
condition for participating in the Medicare program. The data can be stored securely without the risk of paper records
study concluded that this approach of combining a require- being lost.
ment with financial incentives would result in approximate- In the UK, a 2009 report commissioned by the General
ly 80 % of physicians adopting e-prescribing technology Medical Council (GMC) suggested that almost 1 in 10
[66]. The National Progress Report on E-Prescribing and prescribed items in hospitals had errors associated with them
Interoperable Healthcare Year 2011 by Surescripts, report a The study involved hospital pharmacists in 19 hospitals in
Health Technol. (2013) 3:205–219 215

North West England. Out of 124260 medication orders 5 Challenges

checked by pharmacists within the study hospitals over a
predefined period, 11,077 errors were detected (6). Of these, The EU policy on interoperable health systems is an ambi-
2 % were classified as potentially lethal (4). Worryingly, tious attempt to improve quality and safety of care through
errors were made by all grades of doctors, including con- strengthened coordination, up to date patient status informa-
sultants. Nearly all these errors were reportedly intercepted tion and e-Prescription cross and border health care using a
by pharmacists before the patients received the medicines standard interoperable technology. However, e-prescriptions
prescribed [69]. In a separate part of the study that are also fraught with risks. New and unfamiliar technologies
examined qualitative factors in prescribing, many doc- can generate ethical concerns, and issues of citizen’s trust
tors stated that pharmacists provided an important safety and confidence must be addressed. Legal and regulatory
net to prevent patients receiving the wrong medication. issues are among the most challenging aspects of eHealth:
For example, if a system links up to a patient database, it privacy, confidentiality, data protection, and liability chal-
may be able to provide details about medicines that spe- lenges. They need to be addressed in order to enable a
cific patients need to avoid because of interactions with sustainable implementation and use of eHealth applications.
other drugs. In addition, if a doctor mistakenly pre- Currently, the use of e-Prescription is currently regulated
scribes a medicine that could potentially interact with another only by the general legal framework, in particular by laws
and the electronic system could immediately flag up a on patient rights and data protection, and by regulations on
warning [69]. professional conduct. Citizens must be protected from the
According to industry publication Pharmacy Voice, doc- misuse of data and legislation must be fully harmonized and
tors are erroneously filling out tens of thousands of prescrip- enforced in all member states, including those related to
tion forms that leave patients severely injured or even dead. patients’ rights, privacy, certification of patient records re-
Pharmacists are forced to check tens of thousands of pre- lated software, public information, or digital signatures.
scriptions every week which contain the wrong doses, quan- There is a variation in the way that member states interpret
tities and instructions for medicines. In just 1 week, 44,500 the Data Protection Directive and this affects the content of
prescriptions had to be double-checked in 4,409 pharmacies the proposed centralised record system. There is no assur-
across England. Inaccuracies on the prescriptions even in- ance how a member state is actually treating the data. For
clude the wrong drugs and incorrect strengths and quanti- example, academics and the life sciences industry will have
ties. The prescription ‘incidents’ were recorded during a 1- unparalleled access to the cradle-to-grave health records of
week audit at each of the pharmacies in 2011 [70]. This data about 52 million people in England through the Clinical
shows the value of safety checks carried out in pharmacies Practice Research Datalink (CPRD) connecting patient in-
and the importance of electronic information transfer be- formation from GPs and hospitals to other records, such as
tween prescriber, patient and pharmacist. disease and mental health registries and genetics databases.
E-Prescription can also help unleash the digital single The combined datasets can be searched to answer medical
market for healthcare by opening up competition among research questions [72].
pharmacies and reducing costs for patients. It is expected The right of data protection is a fundamental right stated
to eliminate the practice of false prescriptions, which is a in Article 8 of the EU Charter of fundamental rights. As
growing social problem. It is significantly more difficult to electronic prescription deals with electronic health record,
forge a prescription that is sent electronically. the processing of medical data is governed by the EU Data
It also helps reduce fraud. According to the Center for protection directive and WP 131. According to this provi-
Health Information, “The adoption of e-prescribing can sion, everyone has the right to the protection of their own
significantly reduce prescription drug fraud and abuse. Elec- personal data. The general principles laid down in Article 6
tronic systems give providers, pharmacies, payers and gov- of the Directive include in particular, the purpose limitation
ernment agencies the ability to see events in near real-time principle, the proportionality principle, the data quality prin-
that may be virtually undetectable with paper prescriptions. ciple and the principle which requires personal data to be
Audit trails show exactly which physician or provider pre- kept for no longer than is necessary for the purposes for
scribed a medication and when, and expert systems can which the data were collected or further processed. Further-
detect unusual prescribing patterns. Pharmacies have the more other general principles such as the information
ability to prevent patients from filling a prescription at requirements, the data subject’s right of access, rectification
multiple locations. Fraud and abuse detection is currently and deletion and security related obligations have to be
done retrospectively and often months after a crime or observed. Such data must be processed fairly for specified
error occurred. E-Prescribing can accelerate their analy- purposes and either on the basis of the consent of the person
sis and prevent fraud and abuse from happening in first concerned or some other legitimate basis laid down by
place [71]. national law. Everyone has the right of access to data which
216 Health Technol. (2013) 3:205–219

has been collected about them and the right (if incorrect) to Prescription Monitoring Program is cause for alarm and
have it rectified. All data contained in medical documenta- greater need for security. The Virginia Department of Health
tion, in electronic health records and in EHR systems are Professions is the state agency which operates the Virginia
considered “sensitive personal data” and are also subject to Prescription Monitoring Program, which makes available
the special data protection rules on the processing of sensi- online a database of patient records and prescriptions with
tive information contained in Article 8 of the Directive. the intent of preventing abuse of controlled substances. A
Article 8 (1) of the Data Protection Directive 95/46/EC hacker downloaded personal health information of eight
prohibits the processing of personal data concerning health million individuals, including 35 million prescription
in general. Article 6 of the Council of Europe Convention records, and then replaced the information on the state
No 108 prohibits automatic processing of such data “unless website with a crude “ransom” note demanding $10 million
domestic law provides appropriate safeguards”. However, in exchange for unlocking the encrypted file containing
there are exemptions to the general prohibition of processing what is supposedly the only copy of the patient information
medical data. The Directive provides for mandatory limited seized [73].
derogations laid down in Article 8 (2) and (3) plus an One of the problems of electronic prescription is the
optional exemption in Article 8 (4). According to Art. danger of datamining. In the US, Walgreens is being sued
8 (3) of the Data Protection Directive 95/46/EC, the prohi- by customers who are not happy that their prescription
bition to process personal health data shall not apply where information—even though it has been de-identified—is being
the processing of the health data is required for the purposes sold by Walgreens to data-mining companies [74].
of preventive medicine, medical diagnosis, the provision of In general, pharmacies are allowed to sell their prescrip-
care or treatment or the management of health-care services, tion drug records after the data has been de-identified. The
and where those data are processed by a health professional information once shared is completely anonymized. How-
subject under national law or rules established by national ever, there is the danger that a patient can be re-identified
competent bodies to the obligation of professional secrecy with data mining practices. Data mining firms could, hypo-
or by another person also subject to an equivalent obligation thetically, create profiles based on these de-identified prescrip-
of secrecy. Cross border electronic prescription creates a tion records. Such prescription profiles would constitute
new risk scenario, which calls for new, additional safeguards certain patient’s prescription habits, including an individual’s
as counterbalance as prescription records are kept through- medication types, pharmacies visited and dates dispensed.
out a lifetime and are available to all pharmacies. For ex- Linking and mining further public information to these drug
ample, medical prescription for a person on HIV or abortion profiles could result in patient re-identification. These poten-
available to chemists would be detrimental to the patient’s tial dangers led ,for example, the state of Vermont to enact a
reputation if data is leaked. Information on what treatments law that prohibiting pharmacies from selling or using prescrip-
a person is taking, and for what conditions, is amongst the tion records for any marketing purposes without the express
most sensitive and personal possible. It would be a complete consent of the prescribing physician. In Sorrell v. IMS Health,
breach of trust if this was made available in a form which plantiffs data-mining firms and PhRMA, an association rep-
enabled individual patients to be identified. resenting pharmaceutical drug manufacturers, challenged this
On the technical side, multiple access points over an open Vermont law and argued that this restriction on their use of
network like the internet increases possible patient data information violates their free speech rights. In November,
interception. They make the processing of sensitive personal 2010, the Second Circuit agreed with plaintiffs’ argument and
data more complex with direct implications for the rights of struck down the law. The three judge panel held that the statute
the individuals. As a consequence, confidentiality concerning restricted commercial speech—not merely conduct—and that
medical data about their patients may no longer be fully it failed to advance the state’s asserted interests in lowering
applicable in an online environment. The data processing health care costs and protecting public health [75].
operations must be regulated by common security and com- In a report published at the Journal of American Medical
munications standards and central services and directories. No Informatics, an analysis of 3,850 computer-generated pre-
further processing of data must be allowed under than to scriptions written over a 4-week period found 452 contained
manage health care. errors, including 163 that could harm the patient, As many
Any cross border e-Prescription system must also guar- as 12 % of the drug prescriptions sent electronically to
antee that the possible infringements of privacy and must be pharmacies contain errors, a rate that matches handwritten
balanced by liability for damages caused e.g. by incorrect or orders for medicine from physicians, researchers said. The
unauthorized use of data. rate was consistent with past studies reviewing the risk of
Data breaches caused by hacking or identity theft pose errors when a doctor writes a prescription and hands it to the
dangers to patients. The hacking incident at Virginia De- patient, the researchers said. The most common error was
partment of Health Professions which operates the Virginia the omission of key information, such as the dose of
Health Technol. (2013) 3:205–219 217

medicine and how long or how many times a day it should 3. The United States e-Prescription Systems Market to Reach US $205
be taken, the researchers said [76]. Other issues included Million by 2017. Global Industry Analysts, Inc. 2012. http://
www.strategyr.com/pressMCP-6583.asp. Accessed April 23 2012.
improper abbreviations, conflicting information about how 4. Medcom. eHealth in Denmark—eHealth as a part of a coherent
or when to take the drug and clinical errors in the choice or Danish health care system. Copenhagen: Danish Ministry of
use of the treatment, the researchers said. The results under- Health; 2012.
mine the expected safety benefits from computer-generated 5. Directive 2011/24/eu of the European Parliament and of the coun-
cil of 9 March 2011 On the application of patients’ rights in cross-
prescriptions. border healthcare. Off J Eur Union. 2011;L88/45.
Cross-border electronic prescription requires interoperabil- 6. Stroetmann KA, Artmann J, Stroetmann VN, Protti D, Dumortier
ity of the systems and use of standardized solutions. Electronic J, et al. European countries on their journey towards national
prescription across national borders is impeded by many eHealth infrastructures. Final European progress report: European
Commission—Directorate General Information Society and Media,
obstacles, which may relate to other systems or to lack of ICT for Health Unit; 2011.
standardization. In order to ensure a successful deployment, it 7. Wireless and handheld devices are transforming e-Prescription
would be important to ensure interoperability between nation- systems across Europe. Frost Sullivan Med Devices. 2009;2(4):88.
al systems. However, this entails a substantial investment for 8. King M. European E-Prescriptions Market will reach $500mn by
2017. Companiesandmarkets.com. 2011. http://www.companie
pharmacists and difficulties for small pharmacists. sandmarkets.com/News/Healthcare-and-Medical/European-E-
Prescriptions-Market-will-reach-500mn-by-2017/NI2232. Accessed
June 9 2012.
6 Conclusion 9. Mäkinen M, Rautava P, Forsström J, Äärimaa M. Electronic pre-
scriptions are slowly spreading in the European Union. Telemed e-
Health. 2011;17(3):217–22. doi:10.1089/tmj.2010.0111.
The European Union is pushing for more patient registration 10. Dobrev A, Haesner M, Hüsing T, Korte WB, Meyer I. Benchmarking
and prescription in electronic format. Despite favourable ICT use among general practitioners in Europe. Final Report. Bonn:
attitudes towards cross border e-Prescriptions, multiple per- European Commission Information Society and Media Directorate
General; 2008.
ceived barriers impede its incorporation in clinical practice. 11. E-prescriptions in Sweden. Stockholms läns landsting 2011. http://
There has been inconsistency in the way member states are www.webbhotell.sll.se/etjansterlakemedel/E-recept/In-English/.
implementing the EU policy. Accessed Jan 12 2012.
Security and privacy in general remains a problem. Cross 12. Prescriptions minus the paper. Public service review: Europe-
an Union. 2008. http://www.publicservice.co.uk/article.asp?
border e-Prescription is still perceived as difficult since publication0European%20Union&id0353&content_name0Medical
some of the member states have varying interpretations %20Information%20and%20E-Health&article010403. Accessed
and enforcement of data protection. There is a need to find Jan 12 2012.
practical workable solutions within the legal framework. 13. Åstrand B. ePrescribing: studies in pharmacoinformatics. Kalmar:
University of Kalmar; 2007.
While the EU policy of promoting health care is commend- 14. epSOS. Country profile: Sweden. epSOS.eu. 2012. http://www.
able through cross border cooperation, the policy is fraught epsos.eu/home/project-members-beneficiaries/participating-
with problems since member states have varying degrees of countries/sweden.html. Accessed July 9 2012.
health care policy, privacy enforcement and interpretation of 15. Dijk LVV, Vries HD, Bell DS. Electronic prescribing in the United
Kingdom and in the Netherlands. Rockville, MD: Agency for
laws concerning data protection, telecommunication services Healthcare Research and Quality. Prepared by RAND Europe2011
and digital signature. Interoperability of different systems is Contract No.: AHRQ Publication No. 11-0044-EF.
only a partial solution. Security and enforcement of privacy 16. iSOFT e-Prescribing system prepares hospitals for medication
must also be equally enforced. More importantly, the status of transfer directive. iSOFT A CSC Company. 2011. http://www.isof
thealth.com/~/media/Files/Global. Accessed 23 April. 2012.
the health care system must not only be satisfactory and 17. The Netherlands—Compulsory ePrescribing by 2012. (E)Hospital.
effective. It must be outstanding. 2012;12(5).
18. EPrescribing in Estonia. EPSA—the Europen Public Sector Award.
http://www.epsa-projects.eu/index.php?title0EPrescribing_in_
Conflict of interest The author declares that he has no conflict of Estonia. Accessed April 10 2012.
interest. 19. Digital Society Components: e-Prescription. Estonia ICT Demo
Center. 2012. http://e-estonia.com/components/e-prescription.
Accessed April 10 2012.
20. eMedikation to be launched in April 2011 in three pilot regions; 2011.
References ELGA GmbH. 2011. http://www.epractice.eu/en/news/5290353.
Accessed Jan 16 2012.
21. ELGA: Evaluierungsbericht e-Medikation empfiehlt österreich-
1. Whitehouse D, Virtuoso S. Telemedicine and innovative technol- weite Umsetzung. HEALTH-CARE-COM GmbH. 2012. http://
ogies for chronic disease management. Colloqium report. Brussels, www.e-health-com.eu/details-news/elga-evaluierungsbericht-e-
Belgium: Commission of the European Communities; 2008. medikation-empfiehlt-oesterreichweite-umsetzung/. Accessed
2. Steinbrook R. Health care and the American recovery and rein- May 11 2012.
vestment act. N Engl J Med. 2009;360(11):1057–60. doi:10.1056/ 22. Devlies J, Walossek U, Artmann J, Giest S, Dumortier J.
NEJMp0900665. Country Brief: Belgium: European Commission—Directorate
218 Health Technol. (2013) 3:205–219

General Information Society and Media, ICT for Health Unit; 41. Jaksa R, Giest S, Dumortier J. Country Brief: Hungary. European
2010. Commission—Directorate General Information Society and Media,
23. Dobrev B, Dimitrova D, Artmann J, Heywood J, Dumortier J. ICT for Health Unit; 2010.
Country Brief: Bulgaria: European Commission—Directorate 42. Lo “stato dell’arte” della sanità elettronica in Itali. Telemeditalia.
General Information Society and Media; 2010. 2010. http://www.telemeditalia.it/it/ej-tecsanitar/content/detail/0/
24. Ministry of Health to begin development of national health infor- 179/1909/lo-stato-dellarte-della-sanita-elettronica-in-ital.html.
mation system. eHealth Foundation Bulgaria. 2011. http://www. Anno VIII - Edizione 6 - giugno
ehealth-bg.org/bg/view_news.php?news_id065. Accessed Jan 16 43. Springe R. IS E-health framework implementation: architecture
2012. concepts and solutions in context of Estonian experience and
25. E-Health comes to Croatia in January. In: Croatian Times 2010. Latvia’s challenge: Centre of Health Economics, Latvia.
http://www.croatiantimes.com/news/General_News/2010-09-19/ 44. Whitehouse D, Wallosek U, Artmann J, Giest S. Country Report:
13841/E-Health_comes_to_Croatia_in_January. Accessed Jan 16 Northern Ireland: European Commission—Directorate General In-
2012. formation Society and Media, ICT for Health Unit; 2010.
26. ePrescribing system to be implemented across country by end of 45. E-resept er en suksess. Ministry of Health and Care Services. 2011.
January 2011. Ministarstvo uprave Republike Hrvatske. 2011. http://www.regjeringen.no/en/dep/hod/Whats-new/News/2011/e-
http://www.epractice.eu/en/news/5268896. Accessed Jan 16 2012. resept-er-en-suksess.html?id0661814. Accessed May 11 2012
27. Angelidis P, Giest S, Dumortier J, Artmann J. Country Brief: 46. Tryggere legemiddelbruk i Telemark med e-resept. Ministry of
Cyprus: European Commission—Directorate General Information Health and Care Services. 2012. http://www.helsedirektoratet.no/
Society and Media, ICT for Health Unit; 2010. Om/nyheter/Sider/tryggere-legemiddelbruk-i-telemark.aspx.
28. European countries introduce E-prescription. medgear.org. 2012. Accessed July 10 2012
http://www.medgear.org/entry/european-countries-introduce-e- 47. Turowiec S, Giest S, Dumortier J, Artmann J. Country Brief:
prescription/. Accessed July 23 2012. Poland: European Commission—Directorate General Information
29. The new NHS: modern, dependable. UK Department of Health. Society and Media, ICT for Health Unit; 2010.
1997. http://www.archive.official-documents.co.uk/document/doh/ 48. Over 5 000 ePrescriptions registered in pilot ePrescription. ePractice.
newnhs/contents.htm. Accessed 23 July 2012. 2011. http://www.epractice.eu/en/news/5306416. Accessed Jan 16
30. ePrescribing. NHS Connecting for Health. 2012. http://www. 2012.
connectingforhealth.nhs.uk/systemsandservices/eprescribing. 49. Pereira AdC, Giest S, Dumortier J, Artmann J. Country Brief:
Accessed Jan16 2012. Portugal. European Commission—Directorate General Information
31. Electronic Prescription Service (EPS). NHS Connecting for Society and Media, ICT for Health Unit; 2010.
Health. 2012. http://www.connectingforhealth.nhs.uk/systemsand 50. Prescrição electrónica de medicamentos. A Saúde em Portugal
services/eps. Accessed Jan16 2012. 2011. http://www.portaldasaude.pt/portal/conteudos/a+saude+
32. Whitehouse D, Giest S, Dumortier J, Artmann J, Heywood J. Coun- em+portugal/noticias/arquivo/2011/8/pem.htm. Accessed July 10
try Report: England: European Commission—Directorate General 2012.
Information Society and Media, ICT for Health Unit; 2010. 51. Farcas D, Artmann J, Heywood J, Dumortier J. Country Brief:
33. Hämäläinen P, Reponen J, Winblad I. eHealth of Finland: check Romania: European Commission—Directorate General Informa-
point 2008. Helsinki: National Institute for Health and Welfare; tion Society and Media, ICT for Health Unit; 2010.
2009. Contract No.: Report 1/2009. 52. The electronic prescription will ensure quick and transparent access
34. Electronic prescription debuts European ePractice Newsletter N.333 to medicines for all patients. SIVECO Romania. 2012. http://www.
http://www.epractice.eu/files/newsletter/ePractice_Newsletter_ siveco.ro/en/the-electronic-prescription-will-ensure-quick-and-
N.%20333%20-%2006%20July%202010.pdf. Accessed April 10 transparent-access-to-medicines-for-all-patients.html. Accessed 29
2012 May 2012.
35. Miljoonas sähköinen resepti kirjoitettiin vapunaattona. Ministry 53. Kovac P, Giest S, Dumortier J, Artmann J. Country Brief: Slovakia:
Of Social Affairs And Health 2012. http://www.stm.fi/tiedotteet/ Commission—Directorate General Information Society and Media,
tiedote/-/view/1798805#fi. Accessed July 15 2012. ICT for Health Unit; 2010.
36. Legifrance. oi n° 2007–127 du 30 janvier 2007 ratifiant l’ordonnance 54. Corbellini MA, Giest S, Heywood J, Artmann J, Dumortier J.
n° 2005–1040 du 26 août 2005 relative à l’organisation de certaines Country Brief: Spain: Commission—Directorate General Information
professions de santé et à la répression de l’usurpation de titres et de Society and Media, ICT for Health Unit; 2010.
l’exercice illégal de ces professions et modifiant le code de la santé 55. Krippes R, Schwebag M, Benzschawel S, Artmann J. Country
publique (1) (Titre résultant de la décision du Conseil constitutionnel Brief: Luxembourg: Commission—Directorate General Information
n° 2007–546 DC du 25 janvier 2007). Legifrance.gouv.fr. 2007. Society and Media, ICT for Health Unit; 2010.
http://www.legifrance.gouv.fr/affichTexte.do;jsessionid09983 56. Restall B, Giest S, Dumortier J, Artmann J. Country Brief: Malta:
FCE443351C317252FFBCF4CD1CD4.tpdjo14v_2?cidTexte0 European Commission—Directorate General Information Society
JORFTEXT000000822417&categorieLien0id. and Media, ICT for Health Unit; 2010.
37. Germany’s national e-health programme: contested but driven 57. Kenny T, Giest S, Dumortier J, Artmann J. Country Report: Ireland:
forward. ehi eHealth Insider. European Commission—Directorate General Information Society
38. Gemalto to issue an additional 15 million eHealth cards in 2012 for and Media, ICT for Health Unit; 2010.
AOK insurees. Gemalto NV, Amsterdam. 2012. http://www. 58. Lithuania is ready to accelerate the development of electronic
gemalto.com/php/pr_view.php?id01221. Accessed Mar 23 2012. healthcare services. Ministry of Health of the Republic of Lithua-
39. Electronic prescription system to become operational in all social nia. 2012. http://sena.sam.lt/en/main/news?id0152690. Accessed
insurance funds by May 2011. ePractice Editorial Team 2012. July 10 2012.
http://www.epractice.eu/en/news/5279415. Accessed Jan 16 2012. 59. Drnovsek S, Giest S, Dumortier J, Artmann J. Country Brief:
40. #epSOS #ePrescription service starts in #Greece | @epsosproject Slovenia: Commission—Directorate General Information Society
@EU_eGOV @EU_ICT4Society. European Commission—Euro- and Media, ICT for Health Unit; 2010.
pa. 2012. http://ec.europa.eu/information_society/newsroom/cf/ 60. Westbrook JI, Reckmann M, Li L, Runciman WB, Burke R, Lo C,
item-detail-dae.cfm?item_id08264&language0default. Accessed et al. Effects of two commercial electronic prescribing systems on
July 05 2012 prescribing error rates in hospital in-patients: a before and after
Health Technol. (2013) 3:205–219 219

study. PLoS Med. 2012;9(1):e1001164. doi:10.1371/journal. 69. Dornan T, Ashcroft D, Heathfield H, Lewis P, Miles J, Taylor D, et
pmed.1001164. al. An in depth investigation into causes of prescribing errors by
61. Williams D. Medication errors. J R Coll Physicians Edinb. foundation trainees in relation to their medical education: General
2007;37:343–6. Medical Council (GMC). 2009.
62. Kohn LT, Corrigan JM, Donaldson MS. To err is human: building 70. Winter K. Patients' lives put in danger by doctors who make
a safer health system. Washington, DC: Institute of Medicine 'thousands of prescription errors every week. Daily Mail Online.
National Academy Press; 1999. 2012. 14 September, 2012.
63. Raebel M, Ellis J, Carroll N, Bayliss E, McGinnis B, 71. Electronic prescribing: building, deploying and using e-prescribing to
Schroeder E, et al. Characteristics of patients with primary save lives and save money. Center for Health Transformation; 2008.
non-adherence to medications for hypertension, diabetes, and 72. Sample I. NHS patient records to revolutionise medical research in
lipid disorders. J Gen Intern Med. 2012;27(1):57–64. doi:10.1007/ Britain. The Guardian. 2012. Tuesday 28 August 2012.
s11606-011-1829-z. 73. Messmer E. Virginia Dept. of Health: prescriptions database
64. The hidden epidemic: finding a cure for unfilled prescrip- breached but not deleted. Network World. 2009. http://www.
tions and missed doses. Boston Consulting Group; 2003 networkworld.com/news/2009/050709-va-data-breach.html.
December. Accessed July 26 2012.
65. Fischer M, Stedman M, Lii J, Vogeli C, Shrank W, Brookhart M, et 74. Harlow D. Pharmacies selling prescription information to data
al. Primary medication non-adherence: analysis of 195,930 elec- mining companies. KevinMD.com. 2012. http://www.kevinmd.
tronic prescriptions. Journal of General Internal Medicine. 2010;25 com/blog/2011/06/pharmacies-selling-prescription-information-
(4):284–90. doi:10.1007/s11606-010-1253-9. data-mining-companies.html. Accessed 1 Dec 2012.
66. Options to increase e-Prescribing in medicare: reducing medication 75. SCOTUSblog. Sorrell v. IMS Health Inc. Supreme Court of the
errors and generating up to $29 billion in savings for the federal United States blog. 2012. http://www.scotusblog.com/case-files/
government. Gorman Health Group. cases/sorrell-v-ims-health-inc?wpmp_switcher0desktop. Accessed
67. The national progress report on e-Prescribing year 2011. Sure- 1 Dec. 2012.
scripts; 2011. 76. Nanji KC, Rothchild JM, Salzberg C, Keohane CA, Zigmont K,
68. Future of national eHealth programme established as preparatory Devita J, et al. Errors associated with outpatient computerized
phase ends. Telemeditalia. 2011. http://www.epractice.eu/en/news/ prescribing systems. J Am Med Inform Assoc. 2011;18(6):730–1.
5313056. Accessed Jan 16 2012. doi:10.1136/amiajnl-2011-000205.

View publication stats