E-prescription: A pharmacist on the frustrating everyday life

The e-prescription has been mandatory since the beginning of 2024. But what sounds like efficiency and modernization in theory often turns out to be a source of frustration in everyday pharmacy life and further fuels the pharmacy crisis.

We spoke with Andreas Patrick Schenkel about his daily experiences as a pharmacist with the telematics infrastructure, the "health data highway," recalcitrant software, and uncertain patients.

Almost two years have passed since the e-prescription became mandatory for prescription-only medications. What are the biggest annoyances from your daily practice in the pharmacy?

The most common problem is still that some doctor's offices sign e-prescriptions hours after the patient contact. The patients then often come to us in the pharmacy after half an hour, and we can't retrieve anything for them. This is because doctors have to pay extra for immediate "comfort signing," and many instead use the cheaper batch signing, where prescriptions are collected and released later in the day. This problem has persisted since the test phase. In addition, there are disruptions to the telematics infrastructure.

This surely leads to difficult situations with patients?

It's very tricky. Patients are often just told in the practice: "It's on your card." If we can't retrieve anything, some think the pharmacy is incompetent and go to a competitor or leave frustrated for mail-order pharmacies. We then have to advise people to take a walk around town or sit in a café and try again in half an hour. This is a daily annoyance. We are practically already developing defense strategies so that patients don't think we're not up to it.

Are there other options? Cardlink, for example, is also supposed to enable e-prescriptions to be redeemed independently of time and location.

Only to a limited extent. Cardlink was originally introduced to make it easier for mail-order pharmacies to access e-prescriptions. Nowadays, it is also available for local pharmacies, often through pharmacy-specific apps. However, the problem is: our main target group, older patients, often do not have a modern smartphone with the necessary NFC technology. And even if they do, it's regularly a fiddly process to hold the health card correctly to the NFC interface. In addition, there are many different apps. If a patient changes pharmacies, they may have to install a new app. The official e-prescription app from Gematik, on the other hand, is a slow seller; almost no one uses it.

You mention outages and cumbersome systems. How stable is the telematics infrastructure (TI) overall, and what role do software providers like CGM play in this?

We have recurring outages that cannot be explained. Sometimes it only takes a few minutes, but sometimes the TI system also acts up for two hours. Then the service providers shift responsibility to each other. What worries us are announcements like that from our provider CGM, that after replacing the connectors (Editor's note: these are particularly secure hardware routers), problems may occur where we have to sign every change to a prescription individually with PIN entry. This slows down our work considerably. Such issues, announced as "temporary," threaten to become a permanent state.

There seems to be a strong dependence on a few large providers. How do you see the market situation for pharmacy management systems?

The market is extremely concentrated. Besides CGM, there is also Awinta, which belongs to the Noventi group, as a major player. In recent years, Noventi has bought up numerous smaller, often very good systems, only to neglect their development and switch customers to their own main products. CGM bought up a previously widely used product that was also already integrated into the billing process chain because it belonged to a professional association's own data center. Here too, the daily usability has significantly deteriorated since it came under the ownership of a large corporation. It's like Meta. For us users, there is hardly any real choice left, and the quality suffers from the lack of competition.

Besides stability, data quality is also an issue. You mentioned free-text prescriptions from dentists and other faulty orders. How much rework has the e-prescription created for you?

Quite a lot. Dentists almost exclusively issue free-text prescriptions, probably due to the simple software they use. But other practice management systems also don't always produce clean data. We receive hair-raising prescriptions that we have to correct manually and add explanatory texts to to avoid retaxations – subsequent invoice reductions through offsetting by the billing verification offices of the statutory health insurance funds.

One example is a cannabis prescription where the doctor's system automatically inserts an incorrect addition. We then have to add a legally formulated sentence to explain why the prescription looks the way it does. The e-prescription has not made the work easier; only the type of rework has shifted from handwritten to digital.

The e-prescription was also supposed to prevent fraud; does it work? BILD newspaper recently reported on organized fraud with fake paper prescriptions for expensive medications like Ozempic. The accusation in the article is that many pharmacies do not check the authenticity carefully enough. Is that true?

Smuggling a fake e-prescription into the telematics infrastructure is too difficult or impossible for almost all counterfeiters due to the VPN structure with all the certificates to ensure practice and healthcare professional identity. In this respect, the e-prescription is indeed an excellent information technology approach against prescription fraud.

However, checking the authenticity of a paper prescription – and some articles can only be prescribed on paper so far – is very difficult for pharmacies with a well-made fake. Even though most prescription-only medicines are e-prescriptions, some medications cannot yet be prescribed digitally. In such cases, the doctor can only issue the prescription on paper so that the medications can be dispensed legally correctly and safely. Health insurance companies, after the counterfeiters have "improved" other, also very inconspicuous features, now refer to the fact that the first two digits of the institution identification number (IK) of the practice do not match the federal state or billing district of the practice address.

However, no pharmacy has such detailed data readily available for immediate checking of IK number conformity in everyday practice. The accusation that we check prescriptions too leniently for authenticity is far from reality! Health insurance companies always initially refuse payment in case of counterfeiting. The burden of proof that a careful check nevertheless took place actually lies with the affected pharmacy, in a process that can go back up to 11 months.

The doctor's practice that is printed by the counterfeiters exists, and their data has also been "correctly" misused. Often, the expensive medication is pre-ordered by the crook by phone and then picked up at a time when the supposedly prescribing doctor's practice is no longer reachable by phone. This makes the inquiry with the doctor, to which we are referred by the health insurance companies as a security measure, impossible.

E-prescription

E-prescriptions are currently possible for prescription-only medicines, with reimbursement depending on the circumstances by the patient or the statutory health insurance. Most prescription-only medicines are prescribed via e-prescription. Occasionally, we also supply over-the-counter self-payer prescriptions, which the patient pays for themselves. Prescription costs for children with non-prescription medicines are covered by the health insurance, and very few are also covered for adults.

The following prescriptions are not available as electronic prescriptions:

• Narcotics prescriptions (BtM form),
• special cancer medications with the old thalidomide active ingredient and its close relatives ("T-prescription", special form!)
• Medical devices (blood pressure monitors, etc.)
• Dressings
• Test strips and all other peripheral assortments.

More and more pharmacies are resorting to only accepting pre-orders from unknown individuals by handing over the prescription in the pharmacy. And the medication will then be ready for pickup at the earliest 24 hours later. This allows contact with the doctor's practice for authenticity verification. And it deters fraudsters, as the forgery might have been discovered and the police are waiting instead of a fraudulently obtained medicine.

(mack)