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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-
ignated as an important strategic policy to improve health
care in Europe. The aim of the European Union is to have a
cross-border electronic healthcare system in Europe which
will enable EU citizens to obtain e-Prescriptions anywhere
in Europe. Cross border e-Prescription presents a myriad of
challenges. This paper examines the issues concerning the
EU eHealth interoperability policy, specifically with regards
to the cross-border use of e-Prescription. The research in-
volved conducting a review of the most current literature
and government reports regarding e-Prescription implemen-
tation on a national level in several European countries. The
European Union is pushing for more cross border health
data exchange. Despite favourable attitudes towards cross
border e-Prescriptions, multiple perceived barriers impede
its incorporation in clinical practice. There are varying inter-
pretations and implementations of data protection and con-
fidentiality laws in the 27 member states. Infrastructures are
not in place to support the system and stakeholders in some
jurisdictions are reluctant to embrace e-health due to the
high cost and the lack of security of the systems. The study
concludes that member states have varying degrees of health
care policy, privacy enforcement and laws concerning data
protection, telecommunication services and digital signature
with regards to e-Prescription. Interoperability of different
systems is only a partial solution. Security and enforcement
of privacy must also be equally enforced.
Keywords E-Prescription .E-health .Health portal .Cross
border .Privacy .Data protection .Security
1 Introduction
The advent of new technologies is affecting the way health-
care is delivered. New medical technologies are assisting in
developing new health care models that will benefit the
health sector and patients alike. Rapid and reliable ICTs
have become vital components in improving the quality of
health care in Europe as they provide an important oppor-
tunity in improving coordination across the entire healthcare
delivery chain. New technologies can improve disease pre-
vention, diagnosis and treatment, facilitate patient safety and
improve health systems’coordination, use of resources and
sustainability and reduce waiting times and errors.
The use technology in health has led to different applica-
tions in various programs, such as tele-medicine, e-
Prescription and e-consultation. They have significantly
changed the way health care is provided. Tele-medicine
implies “medical care at a distance without physical contact
or without the presence of the patient
1
”[1] or medicine/ med-
ical act delivered at a geographic distance by electronic
means, and include the use of teleradiology, video conferenc-
ing, high-resolution cameras, or tele-robotics. E-consultation
is the use of electronic computing and communication tech-
nologies in medical consultation processes and is complimen-
tary to existing practices. It allows patients to have real-time
webcam and email consultations with doctors. E-Prescription
is a simple tool to generate prescriptions electronically. It is
generally understood as a prescriber’s ability to electronically
send an accurate, error-free and understandable prescription
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.
1
Definition used by Daniel Mart of the Comité Permanent des Méde-
cins Européens/Standing Committee of European Doctors (CPME)
P. Kierkegaard (*)
Department of Computer Science, University of Copenhagen,
Copenhagen, Denmark
e-mail: patrick.kierkegaard@diku.dk
Health Technol. (2013) 3:205–219
DOI 10.1007/s12553-012-0037-0
To promote the use of tele-medicine and e-Prescription,
several countries have enacted laws and implemented policies
to make them widely available. For example, in the US, there
are 6 states (Florida, Maryland, New Mexico, Ohio, Pennsyl-
vania, Vermont) mandating payment for tele-medicine provid-
ed services. Governments across the world are providing
incentives for implementing e-prescriptions, and at the same
time penalizing non-compliance. One such attempt is the US
implementation of American Recovery and Reinvestment Act
(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
an estimated US$22 billion in medical and drug costs over the
next decade [2,3]. In addition, the adoption of e-prescribing
under the ARRA is expected to increase to about 70 to 75 % of
the total prescribers over the next 5 to 6 years [3].
The United States and Europe constitute the two major
markets for e-Prescription systems globally. Of the two,
Europe represents the largest market for e-Prescription
systems.
In Europe, Denmark is the leading country in terms of
telehealth. The e-Journalen provides patients and health care
professionals digital access to information on diagnoses,
treatments and notes from Electronic Health Record (EHR)
systems in all public hospitals. In 2011, the system contained
health data on more than 85 % of the Danish population and
1.2 million entries [4]. Denmark is the only country in Europe
which has a health portal that allows patients to have access to
their medication profiles and to re-order certain repeat
medications themselves.
E-health is a major agenda in EU policy. The European
Union is committed to delivering top quality health-care by
improving cross border cooperation among member states.
The EU has enacted the Cross Border Health Directive,
which enables EU residents to receive health services within
the EU borders. The EU Directive on the application of
patients’rights in cross-border healthcare (2011/24/EU)
aims to establish rules for facilitating access to safe and
high-quality cross border healthcare in the Union, to ensure
patient mobility and to promote cooperation on healthcare
between Member States [5]. It applies to patients who
decide to seek healthcare in a Member State other than the
Member State of affiliation.
The eHealth Action Plan and the Digital Agenda for
Europe set the headline targets for making well connected
eHealth services a reality in EU Member States. To these
extents, a series of key EU policies to promote eHealth
interoperability are currently being implemented. The EU
is developing ICT infrastructures that would enable secure
access to patient health information among different Euro-
pean healthcare systems. Interoperability can be defined as
the capability for independent and heterogeneous health
information systems to exchange health-related data for
use by doctors, healthcare providers and patients. This
would include a centralised patient summary and a cross
border e-Prescription system. In order to reap these benefits,
eHealth tools and solutions need to be interoperable. Howev-
er, centralised access to a patient’s health record and e-
Prescription present a myriad of challenges. This paper exam-
ines the issues concerning the EU eHealth interoperability
policy, specifically with regards to the cross-border use of
e-Prescription.
2 EU health strategy: legal basis
Article 152 of the EC Treaty says that a “high level of
human health protection shall be ensured in the definition
and implementation of all Community policies and activities”.
The European Commission has been investing in eHealth
research for over 20 years. Since 2004, it has set targeted
policy initiatives aimed at fostering widespread adoption of
eHealth technologies across the EU. The Action Plan for a
European eHealth Area focused on the implementation and
deployment aspects of eHealth systems in Europe. The main
objective of this eHealth Action Plan is to enable easy and
equal access to quality healthcare for all citizens in any place
and at any time in the European Union. This objective consists
of developing on-line systems which requires interoperability
among healthcare services at any geographical level. It advo-
cates the development of interoperability approaches for pa-
tient identifiers, medical data messaging and electronic health
records. The ultimate goal is to enable access to the patient’s
electronichealth record and emergency data from any place in
Europe even outside a citizen’s country of origin or residence
whenever this is required.
In 2010, the flagship initiatives Digital Agenda for Europe
and Innovation Union were launched as part of the EU’s
“Europe 2020”strategy for smart, sustainable and inclusive
growth. The EU’s Digital Agenda focuses on ICTs capability
to reduce energy consumption, support ageing citizens’lives,
revolutionises health services and deliver better public serv-
ices. The Digital Agenda for Europe includes a number of
targeted eHealth actions and goals as part of a wider strategy
towards sustainable healthcare and ICT-based support for
dignified and independent living. The Innovation Union
strategy introduces the concept of a pilot European Innovation
Partnership on active and healthy ageing. Under the Innova-
tion program, the adoption of electronic medical prescriptions
is part of this wider European health policy, which also
promotes generic medication.
The European Patients Smart Open Services project
(epSOS) is a European large scale pilot launched in 2008
as part of the Innovation strategy. It involves 27 beneficia-
ries out of 12 EU-member states, including ministries of
health, national competence centres and industry. The
206 Health Technol. (2013) 3:205–219
project aims at developing, testing and validating technical
specifications to ensure interoperability of patient summa-
ries and cross-border use of electronic prescriptions. This
facilitates the usage of the data for patients seeking health-
care abroad. It aims at improving the quality of healthcare
for citizens when travelling to another European country.
The services developed in the course of the epSOS project
are tested in a pilot operation phase. For the first time
European patients will have the opportunity to use cross-
border E-Prescription services if they require prescribed
drugs in participating epSOS pilot countries.
Article 11 of the recently passed EU Directive 2011/24/EU
of the European Parliament and of the Council of 9 March
2011 on the application of patients’rights in cross-border
healthcare provides for the recognition of prescriptions issued
in another member state for dispensation in any member state
of the European Union. Table 1highlights Article 11 of EU
Directive 2011/24/EU.
The Directive thus provides for the right for a patient to
receive any medicinal product authorised for marketing in
the Member State of treatment, even if the medical product
is not authorised for marketing in the Member State of
affiliation, provided that it is an indispensable part of obtain-
ing effective treatment in another Member State. Thus,
where medical products are authorised within a Member
State and have been prescribed in that Member State by a
member of a regulated health profession for an individual
named patient, it should, in principle, be possible for such
prescriptions to be medically recognised and for the medic-
inal products to be dispensed in another Member State in
which the medicinal products are authorised. The imple-
mentation of the principle of recognition must be facilitated
by the adoption of measures necessary for safeguarding the
safety of a patient, and avoiding the misuse or confusion of
medicinal products. These measures include the adoption of
a non-exhaustive list of elements to be included in prescrip-
tions. Nothing in the Directive prevents Member States from
having further elements in their prescriptions, as long as this
does not prevent prescriptions from other Member States
that contain the common list of elements from being recog-
nised. The recognition of prescriptions should also apply for
medical devices that are legally placed on the market in the
Member State where the device will be dispensed.
The recognition of prescriptions from other member
states, however, does not affect the national law of govern-
ing, prescribing and dispensing if the national law does not
contravene the EU law (including generic and substitution)
and the rules of the reimbursement of medicinal products.
However, the pharmacists can also refuse for ethical reasons
to dispense a product that was prescribed in another member
state if the latter has also the same right to refuse to dispense
the same prescription. The recognition of prescriptions from
other Member States should not affect any professional or
ethical duty that would require pharmacists to refuse to
dispense the prescription
Finally, the reimbursement of medicinal products is not
affected by the rules on mutual recognition of prescriptions,
but covered by the general rules on reimbursement of cross-
border healthcare. Thus, nothing should oblige a Member State
of affiliation to reimburse an insured person for a medicinal
product prescribed in the Member State of treatment, where
that medicinal product is not among the benefits provided to
that insured person by the statutory social security system or
national health system in the Member State of affiliation.
In order to implement the recognition of prescriptions in
the European Union, the Directive gives the European Com-
mission the following rights:
(a) measures enabling a health professional to verify the
authenticity of the prescription and whether the prescrip-
tion was issued in another Member Stateby a member of
a regulated health profession who is legally entitled to do
so through developing a non-exhaustive list of elements
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
prescribing party and the dispensing party in order to
contribute to a complete understanding of the treatment,
in due respect of data protection;
(b) Guidelines supporting the Member States in developing
the interoperability of e-Prescriptions;
(c) Measures to facilitate the correct identification of me-
dicinal products or medical devices prescribed in one
Member State and dispensed in another, including
measures to address patient safety concerns in relation
to their substitution in cross border healthcare where
the legislation of the dispensing Member State permits
such substitution. The Commission shall consider, inter
alia, using the International Non-proprietary Name and
the dosage of medicinal products;
Table 1 Article 11, EU Directive 2011/24/EU
Article 11
Recognition of prescriptions issued in another Member State
1. If a medicinal product is authorised to be marketed on their territory,
in accordance with Directive 2001/83/EC or Regulation (EC) No
726/2004, Member States shall ensure that prescriptions issued for
such a product in another Member State for a named patient can be
dispensed on their territory in compliance with their national legis-
lation in force, and that any restrictions on recognition of individual
prescriptions are prohibited unless such restrictions are:
(a) limited to what is necessary and proportionate to safeguard human
health, and non-discriminatory; or
(b) based on legitimate and justified doubts about the authenticity,
content or comprehensibility of an individual prescription.
Health Technol. (2013) 3:205–219 207
(d) measures to facilitate the comprehensibility of the in-
formation to patients concerning the prescription and
the instructions included on the use of the product,
including an indication of active substance and dosage.
In adopting measures or guidelines, the Commission
must give regard to the proportionality of any costs of
compliance with, as well as the likely benefits of, the measures
or guidelines. Since the continuity of cross-border healthcare
depends on transfer of personal data concerning patients’
health from one Member State to another, the fundamental
rights of the individuals with regards to the processing of their
personal data must be safeguarded. The right to the protection
of personal data is a fundamental right recognised by Article
8 of the Charter of Fundamental Rights of the European
Union. Directive 95/46/EC of the European Parliament and
of the Council of 24 October 1995 on the protection of
individuals with regard to the processing of personal data
and on the free movement of such data establishes the right
for individuals to have access to their personal data
concerning their health, for example the data in their medical
records containing such information as diagnosis, examina-
tion results, assessments by treating physicians and any treat-
ment or interventions provided shall apply in the context of
cross-border healthcare covered by this Directive.
3 E-Prescription in the EU
From 2006 to 2010, European member states have reported
considerable increase in national health activities. E-
prescribing is defined in the EU e-Health Strategy report
as “the electronic capture and then transfer of prescription
by a healthcare provider to a pharmacy for retrieval of the
medicine by the patient and the recording of dispensation in
the patient’s record. The Final Strategy Report on E-Health
reported that only a few countries have implemented a fully
operational national system and these are mainly in primary
care and excludes medications dispensed in hospitals. Up till
now, patients rarely have access to their own medication
profiles or are able to reorder certain repeat medications
themselves, e.g. via the web [6]. Table 2shows the state
of e-prescribing in the European Union in 2010.
Table 2shows that there is increasing acceptance of e-
prescribing in Europe According to a report on the technology
by market research firm Frost & Sullivan, system sales should
more than triple in the next 6 years. According to the analysis,
the European market for e-Prescription systems, including
integrated and stand-alone e-Prescription systems, was worth
$95.4 million in 2008 and should reach $449.7 million by
2015 [7]. It is however expected to be higher - reaching
$508.38 million by the year 2017, according to a new report
by companiesandmarkets.com [8].
However, there is still resistance from some of the EU
prescribers to adopt the technology of e-Prescription. A study
conducted in 2011 by the Turku City Health Care compared
the use of e-Prescriptions in 2002 and 2011 [9]. The study
found that five countries were using e-Prescriptions as a part
of their daily practice, but only Denmark and Sweden reported
nationwide use. These countries were the same that used e-
Prescriptions nationally already in 2002. Pilots presented in
2002 have not yet advanced into daily practice. Nationwide
use of e-Prescriptions is not more common than in 2002.
In 2010 only a few European Union countries had imple-
mented a fully functional primary care e-Prescription ser-
vice. However, the majority (16) reported it as an element of
their national eHealth strategy plan. Countries that have
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-
eral Practitioner (GP) to transfer and dispensation, is done
electronically. Pilots on e-Prescription can currently be
found in the Czech Republic, Finland, Italy and Poland
[6]. The following section looks at the status of e-
Prescription in the European Union.
3.1 A look at the e-Prescription in EU member states
The Scandinavian countries are leading Europe in deploying
e-Prescription. Electronic prescriptions are widely used only
in three European countries: Denmark (97 %), Sweden
(81 %) and the Netherlands (71 %) [10]. Other countries
which use the prescription process routinely are Estonia,
Iceland, England and Scotland.
3.1.1 EU leaders
Denmark Electronic prescribing networks linking physi-
cians and pharmacies have been in place in Denmark since
the late 1990s. The Danish Medicines Agency is responsible
for the system which handles electronic prescriptions issued
by the doctor. All prescriptions are stored in a secure system
that can be accessed by the patient as well as prescribers and
pharmacies. The electronic prescription gives the doctor, the
patient and the pharmacy an overview of all the medicine
that has been prescribed to the patient. This means that the
Table 2 State of E-Prescribing in the European Union 2010
E-capture E-transfer E-dispensation
Currently available 15 9 7
Planned for near future 5 8 6
Unavailable 12 15 19
Source: eHealth Strategies study, 2010 [6]
208 Health Technol. (2013) 3:205–219
pharmacy can advise patients on a highly professional basis,
because the pharmacy staff can see precisely what medicine
the patient has received previously.
The doctor can indicate on the electronic prescription the
name of the pharmacy where the medicine can be collected
and the pharmacy has the possibility of having it ready when
the patient arrives. The patient can also contact the pharma-
cy in advance to ask them to prepare the medicine via his
medicine profile. If the patient does not know which phar-
macy he wants to pick up the medicine, the prescription is
simply stored electronically and the patient can choose any
pharmacy in Denmark.
Apoteket.dk is the health portal created by the Danish
Pharmacy Association. Patient can buy medicine online for
delivery or pickup at their local pharmacy. It also provides
an automatic call service via sms when patients are
reminded when their medicines are due to be taken.
From a rather slow start with less than 4,000 documents
in the first year (1994), by 2011, 85 % of the country’s total
prescriptions were sent electronically. Medcom recently re-
leased statistics for the digital exchange of health data in
Denmark [4] indicating that the exchange of health care
documents is now almost fully electronic with more than
60 million messages sent:
&Doctors sent on average 1312543 EDI-messages per.
month
&In 2011 Specialist doctors sent on average 52840 EDI-
messages per. month
&In 2011 Hospitals sent on average 95144 EDI-messages
per. month
&In 2011, After hours medical assistance (Lægevagt) sent
on average 52536 EDI-messages per. month
&Prescription renewals sent by Pharmacies to the Munici-
palities were on average 61625 EDI-messages per. Month
Sweden E-prescribing began in 1981 in Jönköping. The
development of e-Prescriptions in Sweden increased rapidly
in 2000 as a result of collaboration between the National
Corporation of Swedish Pharmacies (Apoteket AB) and
regional healthcare bodies.
A national mailbox for e-Prescriptions allows the patient
to have access to valid prescriptions at any pharmacy with
the presentation of valid identification. Patients may also
store their prescriptions in a national online repository, with
no need for paper prescriptions and with the introduction of
new services, like mail order prescription drugs. The Na-
tional Pharmacy Register was also implemented in 2005 in
which all dispensed drugs are stored for the duration of
15 months. With the patients’consent, doctors and pharma-
cists may retrieve information from the database for reasons
of optimising their patients’medical therapy. Only the pre-
scribing physicians and Apoteket AB’s pharmacy personnel
have access to the prescription. The patients can then get
their medication dispensed at any convenient time and phar-
macy throughout Sweden [11]. The patient has, with a secure
digital signature, full access to the register on the internet [12].
In a study conducted by Bengt Åstrand [12,13], he attributed
the success of e-Prescription on the following prerequisites:
&The early shared learning experiments in different
organisations;
&The high penetration of electronic healthcare records in
primary care;
&The determination by strong and enduring national/re-
gional stakeholders, expressed as shared local/regional
implementation teams;
&The confidence in a secure handling, with a virtual
private network for communication, with secure identi-
fication for personal integrity;
&The national registers allowing secure identification of
drugs, prescribers, pharmacists, and prescriptions;
Standardisation of terminology, nomenclature, and com-
munication protocols;
&The low degree of detailed regulations, giving high
responsibility to stakeholders, beneficial for the entre-
preneurial development of the new technology;
&The new legislation allowing national databases, inde-
pendent of reimbursement form, but with a high degree
of patient consent and transparency;
&The high public penetration rate for mobile phones,
personal computers, and the internet;
&The high degree of public and professional acceptance.
More than 2 million e-prescriptions are transmitted each
month in Sweden [11,14].
Netherlands The implementation of the nationwide EHCR
was initiated by the National IT Institute for Healthcare in
the Netherlands (NICTIZ), which was created in 2002.
NICTIZ initiated the legal framework for the exchange of
patient information and for communication between GPs
and other health providers (in terms of the national infra-
structure, electronic messages, and safety). It also coordi-
nates the implementation of health IT projects and provides
a level of national support, including training, a helpdesk,
and maintenance of Web-patient portals [15]. On January,
2012 the Netherlands implemented a new law that requires
prescriptions to be transferred electronically to the pharma-
cy [16]. Prof. Dr van der Wal, the Inspector General of the
Dutch Healthcare Inspectorate announced that the switch to
an electronic prescription was due to the numerous errors
being made in the dispensation of the medicines. He said:
It is very risky to prescribe drugs without the help of
an automated system that instantly signals drug
Health Technol. (2013) 3:205–219 209
interactions and possible allergic reactions. This is
unnecessarily dangerous and no longer justified [17].
The announcement received initial mixed reaction from
health care givers with specialists, giving consultation to
patients in an ambulatory setting or day care, expressing
reluctance to use electronic devices to enter patient data. The
mobility of the specialists, running from one consultation
room to another, hinders them from sitting down behind a
workstation. It is easier for specialists to write a written
prescription as they have to continuously move to various
consultation rooms. In contrast, the GP has the workstation
on a desk in the consultation room. Currently, most GPs in
the Netherlands are already registering their prescriptions
electronically and 70 to 80 % of the volume of all prescrip-
tions is repeat prescriptions that are often generated by the
GPs.
Estonia One of the newest innovations in Estonia’s cutting-
edge e-Healthcare system, e-Prescription is a centralized,
paperless system for issuing and handling medical prescrip-
tions. Since January 2010, Estonia has implemented an elec-
tronic prescription system and around 85 % of the medical
prescriptions have gone digital. Only 15 months after its
launch, around 80 % of prescriptions are now e-prescriptions
[18].
Doctors can prescribe medications for patients using their
computer software and forward an electronic prescription to
the national database. The e-prescription is then immediate-
ly accessible in every pharmacy on a patient’srequest.
When a doctor prescribes medicine using the system, he or
she does so electronically with the aid of an online form. At
the pharmacy, all a patient needs to do is present an ID Card.
The pharmacist then retrieves the patient’s information from
the system and fills the prescription. All hospitals and phar-
macies in the nation are connected to the system. Because
the e-Prescription system draws on data from the national
health insurance fund, any state medical subsidies that the
patient is entitled to also appear, and the medicine is dis-
counted accordingly. Another major advantage of the system
is that doctor visits are no longer needed for routine refills. A
patient can contact the doctor by e-mail, Skype or phone, and
the doctors can issue refills with just a couple clicks of a
mouse. This frees up time for both the patient and the doctor,
and reduces administrative strain on the hospital [19].
3.1.2 Trailing but moving
Austria ‘eMedikation’, i.e. electronic prescriptions is the
first large-area of Austria’s Electronic Health Record project,
started on 1 April 2011 in three pilot regions. Pharma-
cists, doctors and hospitals will be able to see the medication
a patient has been prescribed. Thus, possible multiple
prescriptions and medications’side-effects will be made avail-
able. In 2012 eMedication will be rolled and initial medical
findings will be saved in electronic health records, while by
2015, most of the medical findings will have been included
there. Documents and medical findings such as laboratory and
radiological results, discharge letters, and medication data
should be saved, if they are required for the treatment and
care of patients. The data must be updated and relevant, so
they will be deleted after a certain period of time (6 months or
3 years), with possibilities of extension. Furthermore, patients’
wills and powers of attorney can be stored [20].
A pilot of the ‘e-Medikation’was conducted in three
regions of Austria from April to December 2011. The results
of an independent scientific evaluation of the pilot were
presented on 10 May 2012. The results revealed that 85 %
of the participating patients felt secure with physicians or
pharmacists who participated in the e-Medikation pilot project
and that the majority of respondents found the medication list
complete and updated, as well as positive for patient safety
[21].
Belgium Electronic transmission of prescriptions is so far
limited to in-house prescriptions in hospitals, and even there
ePrescribing is only used with very limited success due for
example, to the complexity of dosing schemes in hospitals
and due to administrative and security related burdens. A
first E-Prescription pilot was implemented in the European
FP6 ePrescript project, but acceptance by physicians and
pharmacists was relatively low. So far, prescribers and
patients have not been convinced that ePrescribing might
generate any added value. Furthermore, the absolute free-
dom of choosing at any time any pharmacy for each pre-
scription hampers the implementation of ePrescribing, at
least compared to the situation in countries with one dedi-
cated pharmacy or with non-competing pharmacies. Other
issues are patients’fears of increased compliance control by
the health authorities. There are also concerns that so far
there is a lack of clear and credible official statements
regarding secondary use or misuse of the prescription data
[22].
Bulgaria In 2010 the first pilot for E-Prescription system
had taken place in two villages where 10 GPs were linked
with pharmacies; however a larger scaled pilot was not
followed up [23]. In 2011, the Bulgarian Ministry of Health
received approximately €5 million for the project to develop
an Integrated Health Information System (IHIS) which
involves the creation and implementation of an electronic
prescription and an electronic patient record over a period of
27 month [24].
Croatia e-Prescription was introduced in January 2010 but
was only available for use in primary care within 10
210 Health Technol. (2013) 3:205–219
participating counties [25]. Since 3 January 2011, paper
prescriptions for medicines have been replaced with elec-
tronic prescriptions. In practice, the switch from paper to an
electronic prescribing system requires the prescriber to
transmit electronically prescription information via comput-
er to that of the pharmacist. Patients can then get their
medicines simply by using their medical card. The system
is run from two identical servers, one located in Rijeka and
the other one in Zagreb; in case either of the two servers
fails, one will continue to work avoiding thus any loss of
data. The project of the computerization of the primary
health care system cost HRK 55 million and given the
current cost of paper for a prescription which is HRK 15
million, the investment is expected to pay off in two to two
and half years [26].
Cyprus E-Prescription has only been gradually implemented
since 2008 and the share is less than 20 % at that time. And
because the patient’s first encounter with the health system in
case of illness is with the GP (either public or private), the
envisaged E-Prescription scheme is mainly GP-based.
For coming years, it is planned to completely replace paper
prescriptions [27].
Czech Republic Electronic prescriptions have been intro-
duced in the Czech Republic. The law on medicine prescrip-
tion has been amended. Doctors may now issue E-
Prescriptions if the patient has given his consent. Previously,
Czech health insurance funds have no access to the e-
Prescription system and therefore are not able to check that
a given prescription was actually filled out by a doctor (and
consequently reimburse the prescribed medicines).
2
Now,
the electronic signatures of the doctors are necessary on
the E-Prescription. The prescription is added with a PIN
code to send it to the hospital pharmacy through internet
or local computer network. The health agencies assign the
PIN. Different letters on the e-prescription indicates about
the payment whether by the patient, or whether it is partially
or fully covered by health insurers [28].
England In 1997 the government proposed the creation of
an “NHS information superhighway that links GP surgeries
to any specialist centre in the country”[29]. The United
Kingdom is making a particularly large investment with the
National Programme for IT (NPfIT). There are currently two
programmes for electronic prescribing in the United Kingdom:
ePrescribing (acute healthcare settings) [30] and the Electronic
Prescription Service (primary care sector) [31]. In 2009, the
Electronic Prescription Service had a reported average of 33 %
for total daily prescriptions. However, there is resistance
among health professionals about the centralization of data
due to the security and confidentiality of data. Organisational,
resourcing and technological issues have been cited as the
main adoption challenges [32].
Finland According to the Act on Electronic Prescriptions
(61/2007) which entered into force in 2007, Kela, the inde-
pendent social security institution, is in charge of maintaining
the centralised system (Prescription Centre) which contains
the prescriptions written out by doctors as well as the dispens-
ing data of pharmacies [33]. On 20 May 2010, the first
electronic prescription was written and dispensed in Finland
in the city of Turku (south-west Finland) [34]. Since 2011, 12
hospital districts have issued electronic prescriptions and in
April 2012, the millionth electronic prescriptions had been
issued. In spring 2012, the use of the E-Prescription system
will start in most hospital districts [35]. According to the law
on electronic prescriptions, public healthcare institutions will
use electronic prescriptions by April 2013, whereas the private
sector will do by April 2014.
France In France, law no. 2007–127 introduced a pharma-
ceutical record for every beneficiary of social health insur-
ance. In contrast to the nation-wide electronic health record,
which is opt-out based, the pharmaceutical record is optional
and is thus opt-in based. The patient has the right to refuse the
update of the record with specific drug information, to refuse
access to it, and to close it [36].
Germany Patients are equipped with a smartcard—the
‘elektronische Gesundheitskarte’, electronic health card.
The Gesundheitskarte is issued by the health insurance
company and gives doctors and pharmacists access to pa-
tient data. Medical professionals use smartcards—separate
‘health professional cards’—when accessing patient infor-
mation and electronic prescriptions [37]. Gemalto, which is
responsible for German National Health Insurance Scheme
issued 2.5 million health cards. It is issuing an additional 15
million second generation health cards in 2012. The new
Sealys eHealth card features a portrait photo of the insured
person on the front. Together with the secure authentication
function of the operating system, this enhances the legitimacy
of the rightful cardholder and further reduces fraud. In addi-
tion, the card shall in future enable secure access to an online
patient file and store electronic prescriptions. With the
holder’s consent, additional personal information can be
stored on the card, including emergency data such as allergies
or drug intolerance [38].
Greece All social insurance funds have been integrated into
the electronic prescription system. By 2017 the system will
2
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
discussed by the country’s parliament.
Health Technol. (2013) 3:205–219 211
be extended to all branches of the national health system and
other providers of healthcare services [39]. In July 2012,
Greece launched 18 new pilot sites for the epSOS E-
Prescription service in the Athens region for citizens coming
from another country [40].
Hungary In November 2006, the legislation for electronic
drug prescribing in Hungary changed, requiring compulsory
information on drugs to be added to e-prescribing software.
At the moment, E-Prescription use is at a planning stage in
Hungary. But a launch of this eHealth application in the near
future does not seem within reach, as recent policy document
do not include E-Prescription as a feature of the eHealth
infrastructure. E-prescription solution has not been fully in-
troduced. In April 2009, the format of the traditional paper-
based prescriptions was changed and several hospitals had IT
problems due to not having the appropriate printers to print the
new version of the prescription [41].
Italy Since January 2010 the central system for the electronic
transmission of the data of medical prescriptions has been
available [42].
Latvia Introduction of centralized system is encountering
problems. Introduction of the system is not possible for
many pharmacies because of incomplete infrastructure and
the introduction of the system charges higher investments
for them. IS procurement procedures for e-Prescription is
still in progress and IS development system has not yet
started. The estimated cost is 338700 EUR [43].
Northern Ireland The Electronic Prescribing and Eligibility
System (EPES) has been operational since May 1, 2008
throughout Northern Ireland. The system is paper-based
and uses two dimensional barcode technologies. Northern
Ireland Health and Social Care now has at its disposal a
single, patient-centred, electronic history of prescribing and
dispensing, and the ability to call up electronically and view
each of the 16.8 million prescription forms returned annually
to the Central Services Agency (CSA) [44].
Norway The E-Prescription programme was introduced on
18 October 2011 and has since been gradually rolled out
throughout the country. It is expected that full adoption will
occur by 2013 [45]. 40 municipalities and 82 pharmacies are
currently involved in the E-Prescription programme and
a personalised web service named ‘Mine resepter’pro-
vides citizens with an overview of their valid E-Prescriptions
[46].
Poland E-Prescription system is only operational in selected
areas. The programme is currently in an initial phase and so far
the adequate equipment has not been fully distributed nor the
regional healthcare system been prepared. Challenging
aspects that emerged throughout the beginning of the regional
pilot in 2009 and 2010 are the need for many complementary
investments—mostly into technical and infrastructural equip-
ment. Furthermore, it is almost impossible to implement a
complementary E-Prescription system before every patient
has their own healthcare ID card however there is an idea to
use new National ID documents that will be fully electronic
with proper chip [47].
In mid-March 2011 a prototype E-Prescription system
was implemented in the pharmacies and clinics of Leszno
city and county where 19 health institutions, 15 pharmacies
and four clinics are connected to the e-Prescription system.
An additional 2,400 doctors joined in early May 2011 and it
was reported that pharmacists had processed more than
5,100 electronic prescriptions. It is expected that the number
of participating entities will increase. The prototype systems
were tested in Leszno city and county until September 2011
[48].
Portugal In Portugal, most hospitals and health centres
have had electronic applications for prescribing since
2004,
3
which allow doctors to issue a prescription using a
computer with access to a local or national drug database.
These prescriptions are electronically sent to a national
database for invoicing control purposes. Most pharmacies
also have access to specific applications to electronically
register the delivery of a drug. However, there is no eTrans-
mission of prescription from a doctor to pharmacy or no
medication record for the patient (except at a local level) and
only very basic decision support tools in place. Currently, in
the northern region, 95 % at least use the computer for
prescription and around 60 % of the hospitals are
choosing the computer over handwritten prescriptions. Cur-
rently, 64 % of prescriptions are produced by informatics
applications [49].
212 Health Technol. (2013) 3:205–219
E-Prescriptions became mandatory for medicines to be
reimbursed by the State in August 2011 as part of the
Economic and Financial Adjustment Programme provisions
that Portugal is required to implement by the end of 2011. E-
Prescriptions are only valid if it includes a user name and
number, the beneficiary account number in the subsystem
and the responsible financial institution identified. Prescrip-
tions are considered tampered with and are not subject to
reimbursement if they contain any handwriting apart from a
doctor’s signature [50].
3
Administrative Order n.° 711/2007, 11 June 2007 and RCM n.° 96,
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
support the physician daily activity (Sistema de Apoio ao Médico—
SAM), application developed by ACSS is in field in Hospitals and
Healthcare Centres since 2004.
Romania The Health Reform Law 95/2006 establishes how
the prescriptions are made. The Social Health Insurance
Houses reimburse, in part or entirely, the pharmacies the
cost of drugs prescribed by physicians, as it is established in
the framework contract or in subsequent government ordi-
nances. Till now, computerised procedures for prescriptions
(e.g. transmission of prescriptions) have been used mainly
in hospitals, between physicians and internal pharmacies,
but mainly for administrative purposes (e.g. consumption,
stock management) and not, for recording medication to
control incompatibilities. The IT applications for pharmacies
outside hospitals are made by private companies and used
mainly for the stock management or for reimbursements
from Health Insurance [54]. Legally no specific provisions
on e-Prescription are foreseen in Romanian Law. Order no.
832/302/2008 does specify the model of the medical pre-
scriptions, but this mainly entails that prescriptions need to
be signed, dated and stamped with the physicians’code
[54]. In May 2012, the Electronic Prescription IT System
(SIPE), a National Health Insurance House project financed
from non-repayable European funds, was implemented.
Doctors will manage prescriptions online, assisted by medical
rules (interactions between medicines, contraindications, cor-
relations between diagnostic, age and prescribed medicines
etc.) engine [51,52].
Slovakia Representatives of healthcare providers, profession-
al organisations in healthcare and health insurance companies
have completed the preparatory phase in the implementation
of the eHealth programme. Many aspects of the project have
undergone significant changes during this phase. The changes
have been designed to remove inefficiencies and accelerate
the availability of useful electronic services for citizens, doc-
tors, health insurance and other actors in the sector. The first
applications will be deployed throughout Slovakia by the end
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
will be able to obtain information about the medicines pre-
scribed by other doctors [53].
Spain The electronic transmission of prescriptions to phar-
macies is a regional routine in Spain There is an uneven
implementation of electronic prescription within Spain and
interoperability of the regional e-prescription systems is an
issue.. Andalusia has an advanced system than the other
Spanish regions. Regions with e-prescription systems
reported the following e-prescription take up during 2008–
2009: Malaga 56.3 %, Balearic Islands 53.46 %, Cordoba
50.34 %, Extremadura 50.3 %, Andalusia 46 %, Almeria
41 %, Mallorca 14.12 %, Menorca 3.04 %. Madrid is
undergoing a pilot and Navarra, Cantabria, Murcia, Ceuta
and Melilla are preparing pilots [54].
3.1.3 EU countries at a standstill: no e-prescription on sight
Luxembourg E-Prescription is still not a reality. Currently
no work has been undertaken on e-Prescription [55].
Malta E-Prescription is currently not used in Malta. The
main challenge for introducing E-Prescription is currently
the validity issue of electronic signatures. There is currently
no standard and fraud prevention system for electronic
signatures in Malta. The use and validity of electronic
signatures are laid out in the “Electronic Commerce Act”,
which does not make any provisions regarding health related
services [56].
Ireland There are currently no active ICT projects aiming
for E-Prescription implementation [57].
Lithuania There are no information systems in use, which
could deliver an infrastructure for any kind of eHealth
application. Furthermore, the medications register is not
entirely developed in Lithuania and a legal and organisational
framework is still missing. The project ‘eHealth services’is
one of the stages in the development of the Lithuanian elec-
tronic health system. This project includes the implementation
of base Hospital information system in three regional health-
care institutions (in Kaunas, Klaipėda and Vilnius) and inte-
gration of these systems to the National electronic health
system. It is still in the initial stages [58].
Slovenia E-Prescription is still in the planning stage. E-
Prescription stakeholders cannot agree on a common set of
data, which is included in the medication record of the
patient. The matter of decentralised or centralised data storage
has not been resolved and there is no consensus on the
legislative framework [59].
4 Benefits of e-Prescription
Aprescriber’s ability to electronically send an accurate,
error-free and understandable prescription directly to a phar-
macy from the point-of-care—is an important element in
improving the quality of patient care. E-Prescription will
assist in decreasing the number of adverse drug events
caused due to errors in hand-written prescriptions. It could
provide a means to crosscheck on double medication,
contra-indications and dosage at the moment of prescribing.
A study by the University of NSW has found that the use
of electronic prescriptions can slash medication error rates in
hospitals by up to two-thirds. Prescribing errors at two
Australian hospitals dropped between 58 and 66 % when
commercial e-prescribing systems were used instead of
handwritten scripts. Procedural errors, such as incomplete
Health Technol. (2013) 3:205–219 213
or unclear medication orders, fell by over 90 %, while the
number of serious clinical mistakes, including those that
result in death, decreased by 44 %. However, the research
also highlighted the fact that the electronic systems them-
selves created new—albeit less serious—errors that never
occurred in paper-based orders but could system design could
be fixed to remove errors [60].
In the USA, medication errors kill 7,000 patients a year
and account for nearly 1 in 20 hospital admissions [61,62].
A recent study conducted by Kaiser Permanente Colorado
on 12,061 men and women who were given new prescrip-
tions for diabetes, blood pressure or cholesterol medications
over a period of 18 months showed that the use of electronic
prescription improves the number of patients who follow
doctor’s orders on medications for chronic illnesses. Non-
adherence among patient was reduced from around 22 % to
only 7–13 % when electronic prescribing system was
employed [63]. The new study found that only 7 % of the
Kaiser patients neglected to fill their prescriptions for blood
pressure medication, while 11 % failed to pick up new
prescriptions for diabetes medications and 13 % did not pick
up cholesterol medication. In Kaiser Permanente Colorado,
the pharmacy and doctor’s offices are all part of the same
system and are linked using electronic medical records.
Medication orders are sent electronically, rather than using
traditional paper scripts. The electronic transmission of a
prescription to a pharmacy increases the likelihood that it
will be picked up by the patient. It eliminates the patient’s
responsibility of delivering the prescription to the pharmacy,
a problem cited by more than one-third of patients who
either forgot to drop it off or had difficulty doing so [64].
Prior studies have found as many as 28 % of paper prescrip-
tions never make it to the pharmacy [65].
Previous research has found that up to 22 % of patients in
healthcare systems not integrated with pharmacies fail to fill
new prescriptions. One month after discharge from hospital
many patients do not take the right medicine in the right way
decreasing treatment efficiency and resulting in repeated
costs. According to a US study, e-prescribing could prevent
nearly two million medication errors, saving countless lives.
Much of this is attributed to the decision-support aspects of
the technology, such as immediate access to patient medi-
cation histories and safety alerts. The federal government
could save up to $26 billion over the next decade just in the
Medicare program—even after providing funds for equip-
ment, training and support—as long as physicians are first
incentivized and then required to use the technology as a
condition for participating in the Medicare program. The
study concluded that this approach of combining a require-
ment with financial incentives would result in approximate-
ly 80 % of physicians adopting e-prescribing technology
[66]. The National Progress Report on E-Prescribing and
Interoperable Healthcare Year 2011 by Surescripts, report a
consistent 10 % increase in patient first fill medication
adherence among physicians who adopted e-prescribing
technology. One finding was that the improved medication
adherence from e-prescriptions can lead to 10-year estimated
savings of between $140 billion to $240 billion, measured in
health care cost savings and improved health outcomes [67].
In Slovakia, the implementation of e-Prescription is
expected to improve healthcare. A national health portal is
being established where patients can find reliable health
information verified by prominent experts in the field, while
doctors will be able to obtain information about the medi-
cines prescribed by other doctors. The Ministry of Health
explains:
“Many patients suffer from multiple chronic diseases
and also use several different drugs simultaneously.
Such patients can often not tell their doctor which
medicines have been prescribed by another doctor
and a specialist can’t assess the potential risk of inter-
actions of drugs prescribed and taken by the patient.
At the same time, and as a result of lack of information
among doctors, there can be duplicate prescriptions. In
this case, the patient may receive a double dose of an
active ingredient, without it being known by either the
doctors or patient, as drugs of different trade names
can include the same active ingredients. On the basis
of electronic information the treating doctors will have
an overview of the patient’s diagnosis and an exact
description of what medicines the patient is taking.
This eliminates the risk of possible drug and food
interactions and also of the described risk of double
prescription of drugs with the same active ingredients,
which will ultimately ensure the quality and safe pa-
tient treatment and excellent feedback and doctor
awareness.”[68]
It is difficult to read hand written prescriptions and some
important information may be missing from the hand written
prescription such as dosage and frequency. E-prescription
enables the prescribers to accurately and clearly enter com-
plete medication orders and those who administer medicines
will have clear and legible medication orders. With e-
Prescription, doctors can monitor the history of the patient’s
medicine uses. It also enables the patient to obtain the
medicine anywhere, avoiding the long waiting time. For
pharmacists, eliminating manual entry of prescriptions at
the pharmacyshould reduce liabilities that are due to incorrect
dispensing due to larger volumes of prescriptions. Prescription
data can be stored securely without the risk of paper records
being lost.
In the UK, a 2009 report commissioned by the General
Medical Council (GMC) suggested that almost 1 in 10
prescribed items in hospitals had errors associated with them
The study involved hospital pharmacists in 19 hospitals in
214 Health Technol. (2013) 3:205–219
North West England. Out of 124260 medication orders
checked by pharmacists within the study hospitals over a
predefined period, 11,077 errors were detected (6). Of these,
2 % were classified as potentially lethal (4). Worryingly,
errors were made by all grades of doctors, including con-
sultants. Nearly all these errors were reportedly intercepted
by pharmacists before the patients received the medicines
prescribed [69]. In a separate part of the study that
examined qualitative factors in prescribing, many doc-
tors stated that pharmacists provided an important safety
net to prevent patients receiving the wrong medication.
For example, if a system links up to a patient database, it
may be able to provide details about medicines that spe-
cific patients need to avoid because of interactions with
other drugs. In addition, if a doctor mistakenly pre-
scribes a medicine that could potentially interact with another
and the electronic system could immediately flag up a
warning [69].
According to industry publication Pharmacy Voice, doc-
tors are erroneously filling out tens of thousands of prescrip-
tion forms that leave patients severely injured or even dead.
Pharmacists are forced to check tens of thousands of pre-
scriptions every week which contain the wrong doses, quan-
tities and instructions for medicines. In just 1 week, 44,500
prescriptions had to be double-checked in 4,409 pharmacies
across England. Inaccuracies on the prescriptions even in-
clude the wrong drugs and incorrect strengths and quanti-
ties. The prescription ‘incidents’were recorded during a 1-
week audit at each of the pharmacies in 2011 [70]. This data
shows the value of safety checks carried out in pharmacies
and the importance of electronic information transfer be-
tween prescriber, patient and pharmacist.
E-Prescription can also help unleash the digital single
market for healthcare by opening up competition among
pharmacies and reducing costs for patients. It is expected
to eliminate the practice of false prescriptions, which is a
growing social problem. It is significantly more difficult to
forge a prescription that is sent electronically.
It also helps reduce fraud. According to the Center for
Health Information, “The adoption of e-prescribing can
significantly reduce prescription drug fraud and abuse. Elec-
tronic systems give providers, pharmacies, payers and gov-
ernment agencies the ability to see events in near real-time
that may be virtually undetectable with paper prescriptions.
Audit trails show exactly which physician or provider pre-
scribed a medication and when, and expert systems can
detect unusual prescribing patterns. Pharmacies have the
ability to prevent patients from filling a prescription at
multiple locations. Fraud and abuse detection is currently
done retrospectively and often months after a crime or
error occurred. E-Prescribing can accelerate their analy-
sis and prevent fraud and abuse from happening in first
place [71].
5 Challenges
The EU policy on interoperable health systems is an ambi-
tious attempt to improve quality and safety of care through
strengthened coordination, up to date patient status informa-
tion and e-Prescription cross and border health care using a
standard interoperable technology. However, e-prescriptions
are also fraught with risks. New and unfamiliar technologies
can generate ethical concerns, and issues of citizen’s trust
and confidence must be addressed. Legal and regulatory
issues are among the most challenging aspects of eHealth:
privacy, confidentiality, data protection, and liability chal-
lenges.Theyneedtobeaddressedinordertoenablea
sustainable implementation and use of eHealth applications.
Currently, the use of e-Prescription is currently regulated
only by the general legal framework, in particular by laws
on patient rights and data protection, and by regulations on
professional conduct. Citizens must be protected from the
misuse of data and legislation must be fully harmonized and
enforced in all member states, including those related to
patients’rights, privacy, certification of patient records re-
lated software, public information, or digital signatures.
There is a variation in the way that member states interpret
the Data Protection Directive and this affects the content of
the proposed centralised record system. There is no assur-
ance how a member state is actually treating the data. For
example, academics and the life sciences industry will have
unparalleled access to the cradle-to-grave health records of
about 52 million people in England through the Clinical
Practice Research Datalink (CPRD) connecting patient in-
formation from GPs and hospitals to other records, such as
disease and mental health registries and genetics databases.
The combined datasets can be searched to answer medical
research questions [72].
The right of data protection is a fundamental right stated
in Article 8 of the EU Charter of fundamental rights. As
electronic prescription deals with electronic health record,
the processing of medical data is governed by the EU Data
protection directive and WP 131. According to this provi-
sion, everyone has the right to the protection of their own
personal data. The general principles laid down in Article 6
of the Directive include in particular, the purpose limitation
principle, the proportionality principle, the data quality prin-
ciple and the principle which requires personal data to be
kept for no longer than is necessary for the purposes for
which the data were collected or further processed. Further-
more other general principles such as the information
requirements, the data subject’s right of access, rectification
and deletion and security related obligations have to be
observed. Such data must be processed fairly for specified
purposes and either on the basis of the consent of the person
concerned or some other legitimate basis laid down by
national law. Everyone has the right of access to data which
Health Technol. (2013) 3:205–219 215
has been collected about them and the right (if incorrect) to
have it rectified. All data contained in medical documenta-
tion, in electronic health records and in EHR systems are
considered “sensitive personal data”and are also subject to
the special data protection rules on the processing of sensi-
tive information contained in Article 8 of the Directive.
Article8(1)oftheDataProtection Directive 95/46/EC
prohibits the processing of personal data concerning health
in general. Article 6 of the Council of Europe Convention
No 108 prohibits automatic processing of such data “unless
domestic law provides appropriate safeguards”. However,
there are exemptions to the general prohibition of processing
medical data. The Directive provides for mandatory limited
derogations laid down in Article 8 (2) and (3) plus an
optionalexemptioninArticle8(4).AccordingtoArt.
8 (3) of the Data Protection Directive 95/46/EC, the prohi-
bition to process personal health data shall not apply where
the processing of the health data is required for the purposes
of preventive medicine, medical diagnosis, the provision of
care or treatment or the management of health-care services,
and where those data are processed by a health professional
subject under national law or rules established by national
competent bodies to the obligation of professional secrecy
or by another person also subject to an equivalent obligation
of secrecy. Cross border electronic prescription creates a
new risk scenario, which calls for new, additional safeguards
as counterbalance as prescription records are kept through-
out a lifetime and are available to all pharmacies. For ex-
ample, medical prescription for a person on HIV or abortion
available to chemists would be detrimental to the patient’s
reputation if data is leaked. Information on what treatments
a person is taking, and for what conditions, is amongst the
most sensitive and personal possible. It would be a complete
breach of trust if this was made available in a form which
enabled individual patients to be identified.
On the technical side, multiple access points over an open
network like the internet increases possible patient data
interception. They make the processing of sensitive personal
data more complex with direct implications for the rights of
the individuals. As a consequence, confidentiality concerning
medical data about their patients may no longer be fully
applicable in an online environment. The data processing
operations must be regulated by common security and com-
munications standards and central services and directories. No
further processing of data must be allowed under than to
manage health care.
Any cross border e-Prescription system must also guar-
antee that the possible infringements of privacy and must be
balanced by liability for damages caused e.g. by incorrect or
unauthorized use of data.
Data breaches caused by hacking or identity theft pose
dangers to patients. The hacking incident at Virginia De-
partment of Health Professions which operates the Virginia
Prescription Monitoring Program is cause for alarm and
greater need for security. The Virginia Department of Health
Professions is the state agency which operates the Virginia
Prescription Monitoring Program, which makes available
online a database of patient records and prescriptions with
the intent of preventing abuse of controlled substances. A
hacker downloaded personal health information of eight
million individuals, including 35 million prescription
records,andthenreplacedtheinformationonthestate
website with a crude “ransom”note demanding $10 million
in exchange for unlocking the encrypted file containing
what is supposedly the only copy of the patient information
seized [73].
One of the problems of electronic prescription is the
danger of datamining. In the US, Walgreens is being sued
by customers who are not happy that their prescription
information—even though it has been de-identified—is being
sold by Walgreens to data-mining companies [74].
In general, pharmacies are allowed to sell their prescrip-
tion drug records after the data has been de-identified. The
information once shared is completely anonymized. How-
ever, there is the danger that a patient can be re-identified
with data mining practices. Data mining firms could, hypo-
thetically, create profiles based on these de-identified prescrip-
tion records. Such prescription profiles would constitute
certain patient’s prescription habits, including an individual’s
medication types, pharmacies visited and dates dispensed.
Linking and mining further public information to these drug
profiles could result in patient re-identification. These poten-
tial dangers led ,for example, the state of Vermont to enact a
law that prohibiting pharmacies from selling or using prescrip-
tion records for any marketing purposes without the express
consent of the prescribing physician. In Sorrell v. IMS Health,
plantiffs data-mining firms and PhRMA, an association rep-
resenting pharmaceutical drug manufacturers, challenged this
Vermont law and argued that this restriction on their use of
information violates their free speech rights. In November,
2010, the Second Circuit agreed with plaintiffs’argument and
struck downthe law. The three judge panel held that the statute
restricted commercial speech—not merely conduct—and that
it failed to advance the state’s asserted interests in lowering
health care costs and protecting public health [75].
In a report published at the Journal of American Medical
Informatics, an analysis of 3,850 computer-generated pre-
scriptions written over a 4-week period found 452 contained
errors, including 163 that could harm the patient, As many
as 12 % of the drug prescriptions sent electronically to
pharmacies contain errors, a rate that matches handwritten
orders for medicine from physicians, researchers said. The
rate was consistent with past studies reviewing the risk of
errors when a doctor writes a prescription and hands it to the
patient, the researchers said. The most common error was
the omission of key information, such as the dose of
216 Health Technol. (2013) 3:205–219
medicine and how long or how many times a day it should
be taken, the researchers said [76]. Other issues included
improper abbreviations, conflicting information about how
or when to take the drug and clinical errors in the choice or
use of the treatment, the researchers said. The results under-
mine the expected safety benefits from computer-generated
prescriptions.
Cross-border electronic prescription requires interoperabil-
ity of the systems and use of standardized solutions. Electronic
prescription across national borders is impeded by many
obstacles, which may relate to other systems or to lack of
standardization. In order to ensure a successful deployment, it
would be important to ensure interoperability between nation-
al systems. However, this entails a substantial investment for
pharmacists and difficulties for small pharmacists.
6 Conclusion
The European Union is pushing for more patient registration
and prescription in electronic format. Despite favourable
attitudes towards cross border e-Prescriptions, multiple per-
ceived barriers impede its incorporation in clinical practice.
There has been inconsistency in the way member states are
implementing the EU policy.
Security and privacy in general remains a problem. Cross
border e-Prescription is still perceived as difficult since
some of the member states have varying interpretations
and enforcement of data protection. There is a need to find
practical workable solutions within the legal framework.
While the EU policy of promoting health care is commend-
able through cross border cooperation, the policy is fraught
with problems since member states have varying degrees of
health care policy, privacy enforcement and interpretation of
laws concerning data protection, telecommunication services
and digital signature. Interoperability of different systems is
only a partial solution. Security and enforcement of privacy
must also be equally enforced. More importantly, the status of
the health care system must not only be satisfactory and
effective. It must be outstanding.
Conflict of interest The author declares that he has no conflict of
interest.
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