SafeScript - the story behind Victoria's Real Time Prescription Monitoring System
Dr Steve Hodgkinson
Digital Transformer | Australian CIO50 Hall of Fame | IPAA Victoria Fellow | GAICD | DPhil (Oxon)
SafeScript, according to the chair of the Royal Australian College of General Practitioners, Dr Cameron Loy, "is the best public health initiative I have seen in my career" (quoted from an interview in The Age).
SafeScript won the Infrastructure & Platform category of the Australian Information Industry Association (AIIA) 2019 National iAwards and also received an IPAA 2018 Leadership Award for Evidence Based Policy.?Well done to the SafeScript team.
Award nominations are a good catalyst to bring innovation stories to the surface and put them into words, so here is the SafeScript story. This article was co-authored with Justin Lam, who wrote the IPAA awards nomination. Enjoy!
Summary
SafeScript, Victoria’s new real-time prescription monitoring system, reduces the growing harms, including deaths, caused by high-risk medicines. More Victorians die from prescription medicine overdoses than from illicit drugs or the road toll.?
SafeScript?gives doctors and pharmacists real-time information about high-risk medicines taken by their patients. This will save lives.?
More information about Victoria's SafeScript program can be found on the DHHS website here.
This video introduces SafeScript.
Also, there is a series of informative podcasts about SafeScript on NPS MedicineWise.
What problem does SafeScript solve and how does it work?
SafeScript brings together records of high-risk medicines from medical clinics and pharmacies in Victoria into a centralised repository which can be viewed by doctors and pharmacists during a patient consultation. It provides comprehensive, real-time information to help doctors and pharmacists make safer clinical decisions when prescribing or dispensing addictive medicines such as morphine, oxycodone and diazepam.
Prior to SafeScript, doctors and pharmacists did not have a full picture of what high-risk medicines their patients had received from other medical clinics and pharmacies. This sometimes led to patients obtaining dangerous quantities of high-risk medicines from multiple sources without anyone being aware.
The increasing harms, including deaths, from these medicines are a growing public health concern. In 2017, 414 Victorians died – more than deaths from illicit drugs (271) and road accidents (258).
The challenge for the project was to successfully integrate with the many disparate systems in primary care and to provide information back to clinicians quickly and concisely. SafeScript has successfully achieved this through a smart combination of leading edge technology and the reuse of existing national eHealth assets for a new purpose.
Records are automatically transmitted from medical clinics and pharmacies to SafeScript through prescription exchange services, eRx and MediSecure. These systems provide for the electronic transfer of prescriptions from a doctor to a pharmacist. Utilising the prescription exchange services negated the need to develop separate integration with over 20 clinical systems. This approach significantly reduced the development time for the project, and ensured a reliable and robust system which was already supported by the majority of practices in Australia.
A key design feature of SafeScript is the real-time alerts doctors and pharmacists receive from their clinical systems within seconds after a prescription has been generated, to quickly inform whether there is clinical risk or information that requires review.
SafeScript is built on the Microsoft Azure public cloud service platform. This ensures that the system is ubiquitously and securely available via the internet to all health professionals in Victoria, and ultimately throughout Australia.
How is this system new or unique???
SafeScript?has set a new benchmark in the cost effective design and implementation of an eHealth initiative.?
The scale of what has been implemented is unprecedented in Australia.?SafeScript?will be available to over 1,900 medical clinics, 1,300 pharmacies and 200 hospitals in Victoria. All 27,000 medical practitioners and 7,000 pharmacists in Victoria will have access to?SafeScript. Over 10 million prescription records will be transmitted to?SafeScript?each year, with a new record uploaded on average every three seconds.?
The project has demonstrated that the smart use of leading edge technology platforms and agile delivery methods, combined with the application of sound, evidence-based public policy, can result in the delivery of a system that will both have long lasting benefit to Victoria and create the platform for a national real time prescription monitoring system.?
How was SafeScript delivered?
Foundations
SafeScript is the cornerstone of a four year program of legislation, policy, process and systems reform to implement real-time prescription monitoring in Victoria. The strategic objective was to improve patient safety outcomes and reduce the harms created for people, families and communities by the unsafe use of prescription medications.
Over 30 coronial findings have called for real-time prescription monitoring to reduce the harms and deaths from prescription medicines. All medical and pharmacy groups have also strongly advocated for such a system.
In 2015, the department developed a business case and funding submission for implementation of a real-time prescription monitoring system in Victoria. This submission was successful in securing $29.5M in the 2016/17 State Budget.
The business case was based on saving lives by creating legislation, processes and systems that would require doctors and pharmacists to check a central database before prescribing and dispensing and provide them with more comprehensive and timely information about a patient’s medication history.
SafeScript?has adopted the lessons learned from prescription monitoring systems operating in the United States. The implementation of?SafeScript?is based on best practice principles, which include:
Project Team
The project was managed as a partnership between a dedicated Real Time Prescription Monitoring Implementation team, in the department's Regulation, Health Protection and Emergency Management division, and the Business Technology and Information Management (BTIM) branch in the Corporate Services division.
The project team of 11 staff comprised skill sets in project management, change management, information technology, medical advisory, policy development, medicines regulation and communications. While the system build was conducted by Fred IT Group, the in-house BTIM team conducted extensive strategy, procurement, service design, technical architecture, security/user authentication and service management design work.
Close consultation with doctors and pharmacists occurred throughout the project, including co-design and user?testing during system development to ensure?SafeScript?is easy-to-use and integrated with clinical workflow.?SafeScript?has been embraced by medical and pharmacy?organisations?who all agree it will transform clinical practice and ultimately save lives.?
The project’s governance included an expert advisory group which has provided valuable input and guidance on key policy and implementation decisions. The advisory group is comprised of representatives from all key medical and pharmacy?organisations, including:
The project is an exemplary illustration of effective, outcomes-oriented, collaboration and partnership between ‘line-of-business’ and ‘IT’ teams, between ‘in-house’ and ‘external’ resources, between government, professional associations and industry and between the department and the health sector.
External Delivery Partners
Key technology partners included:
What key challenges did the project need to overcome?
The project had to win over a wide range of stakeholders to a new and innovative technology direction, with three challenges being noteworthy:
1. Technical approach
The first challenge was for Victoria to disengage from a stalled national Electronic Recording and Reporting of Controlled Drugs (ERRCD) project that had been in progress since 2012. The ERRCD project struggled to gain support because of its out-dated technology and the difficulties of securing agreement across all states and territories to an implementation strategy. In 2016 Victoria commenced work on an alternative approach to achieve a more seamlessly integrated solution using more modern, scalable, technology. This ultimately led to Victoria disengaging from a cross-jurisdictional agreement to pursue a national system. This was a difficult decision that required significant stakeholder engagement effort at the most senior Ministerial and executive levels.
2. Seamless alerting
The second challenge was to convince health sector, professional association and departmental executives that the project had a practical approach to seamless integration. Consultation with health professionals had highlighted the fact that, to be effective, the system would need to generate alerts into the existing prescribing and dispensing systems - rather than requiring health professionals to 'look up' patients in a separate online system. This involved demonstration of a proof-of-concept using Prescription Exchanges and automated alerting to prescribing and dispensing systems. Extensive engagement was required to convince stakeholders that the technology approach was viable. The CMCRC was a key strategic partner at this stage. David Jonas and his team designed the technology proof of concept and facilitated discussions with key stakeholders to test the feasibility of, and build support for, the new model.
3. User adoption
The third challenge was to ensure that front-line users would embrace the system. Considerable attention was given to user interface design and workflow to ensure a seamless, convenient, experience. As the introduction of?SafeScript?represents a significant change in clinical practice, the project included a range of initiatives to help prepare and support health professionals and patients. The project has delivered a comprehensive training package?focused?on enhancing the clinical and counselling skills for doctors and pharmacists in the safer prescribing of high-risk medicines, and more peer-to-peer support for health professionals in managing patients with complex pain, addiction or mental health needs.?
This video is an example of the training and promotional materials used to engage with practitioners during the roll out of the solution.
The project has also delivered additional counselling and support services for patients, including a 24-hour dedicated pharmaceutical help line and a public awareness campaign to raise awareness of the harms from high-risk medicines and reduce stigma about prescription medicine dependency.?
A 24-hour technical support line is also available for system users. All calls are logged and reviewed for quality purposes. Extensive online training modules and quick reference guides are also readily available for users on the project's website.?
Extensive media campaigns promoted the introduction of the new system.
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What are the main benefits of SafeScript?
The implementation of?SafeScript?is expected to reduce the growing harms from high-risk medicines. This includes a reduction in prescription medicine-related deaths, ambulance call outs, emergency department presentations, hospital admissions, multiple provider episodes and patients receiving high doses of high-risk medicines or high-risk drug combinations.?
SafeScript?will also significantly improve the operational efficiency of regulatory compliance activities undertaken by?authorised?departmental officers. Prior to?SafeScript, compliance officers would rely on collating paper-based records or conducting physical site inspections to view medical clinic and pharmacy records.?SafeScript?provides for the rapid collection and analysis of prescription records to support health practitioner audits and investigations. What previously took compliance officers several weeks to compile and?analyse, can now be completed in a matter of minutes.?SafeScript?has enabled the department to quickly identify unsafe or unlawful practices which may be placing patients at risk of harm and allow intervention or educational activities to take place much sooner.?
The implementation of SafeScript has been well received so far by doctors and pharmacists, and there is growing anecdotal evidence of patient safety benefits already being realised, as reported in Pharmacy News.
In its first few months of operation in Western Victoria,?SafeScript?has helped doctors and pharmacists identify over 3,300 patients who are at risk of harm and overdose from visiting multiple medical clinics and pharmacies.?SafeScript?enables doctors and pharmacists to intervene earlier and help patients who are showing signs of prescription medicine dependency to receive the right treatment and support much sooner.?
Listen to Matthew McCrone, Director, Real Time Prescription Monitoring Implementation, discussing the impact of SafeScript on ABC Radio here.
The aggregate data collected by?SafeScript?will also provide further understanding and insight into the volume and trends of prescription medicine use in Victoria. This data will inform Victorian Government service planning and policy decisions to improve healthcare for the Victorian community.?
The implementation approach was designed to enable an evaluation of impact and outcomes at different stages of the project. Roll out commenced with a study area in Western Victoria in late 2018 followed by state-wide in early 2019. A full evaluation of the program will be conducted once the use of SafeScript becomes mandatory in April 2020.
Along with measuring the success of the implementation of SafeScript, such as uptake and use rates, the evaluation will explore progress in achieving the intended outcome of reducing harms from high-risk medicines. This will be informed by available data on prescription medicine-related deaths, ambulance call outs, emergency department presentations, hospital admissions, multiple provider episodes and patients receiving high doses of high-risk medicines. Much of this data is only available because of the implementation of SafeScript. The evidence-based approach taken by the SafeScript team was recognised by the project being awarded an IPAA 2018 Leadership Award for Evidence Based Policy.
What were some of the key technology considerations?
Platform+Agile approach
SafeScript?is a good illustration of the efficacy of the department’s Platform+Agile digital transformation approach. The approach is characterised?by the use of public cloud service platforms, reuse of existing solution elements and agile iterative development to find the 'sweet spot' - a practical minimum viable product.?
The essence of the Platform+Agile approach is that even highly complex problems can be tackled one piece at a time - by getting started and progressing in a step-wise manner. Indeed, complex problems (such as deployment of a national real time prescription monitoring system) usually defy a more linear, mechanistic, approach. Attempting to solve 'for the whole', by focusing on a national solution, can create paralysis if the problem is too complex. The better approach is simply to focus on getting started with a solid platform, demonstrating progress and then improving incrementally. Hence, a national real time prescription monitoring solution is perhaps better tackled one state at a time.
The mindset behind this approach was fundamental to enabling the project to break the Gordian Knot of complexity that had mired the national ERRCD project for many years. The implementation of a national system is a very difficult undertaking because of the need to agree functional requirements, technology solutions, interoperability mechanisms and funding arrangements across such a large number of government and health sector stakeholders. Finding a path forward required some fresh thinking.
The Platform+Agile approach recognises the value of leveraging pre-existing proven and scalable platforms whenever possible - to enable a project to get started quickly and to deliver tangible results. This enables a more agile, iterative, approach where the goal is to demonstrate the system, seek user feedback and then iterate the solution rapidly to align user expectations and requirements with the technology 'art of the possible'.
This mindset stimulated a fundamental rethink of the architecture of the real time prescription monitoring system based on existing technology elements. These included the prescription exchanges (eRx and MediSecure), the market leading prescribing and dispensing systems, the use of APIs for seamless integration, advanced business process rule automation and data analytics techniques, public cloud service platforms (such as Microsoft Azure) and contemporary multi-factor authentication approaches using smartphones.
The explicit goal was that the project would pursue a leading-edge technology architecture that would meet Victoria's requirements as quickly as possible while also creating a scalable and sustainable foundation for a national system - that it would both leverage existing technology platform elements as well as create a national real time prescription monitoring Platform.
The way to pursue this goal was to partner with the CMCRC to leverage their experience with designing and building national-scale technology solutions and their cross-jurisdictional, cross-sector and cross-industry relationships. This approach became the catalyst required to break free of the technical and operational complexities of the EERCD project and to agree a different, ultimately successful, path.
STOP PRESS! SafeScript has since been adopted by the Commonwealth as the basis for a National Data Exchange and Real Time Prescription Monitoring solution - led for the Commonwealth's Department of Health by Fred IT Group.
STOP PRESS! NSW Health has issued a tender for real time prescription monitoring to interoperate with the National Data Exchange. The building blocks of a national system are coming together ...
STOP PRESS! SafeScript NSW Rollout underway SafeScript NSW
Conceptual architecture
The diagram below describes the real time prescription monitoring conceptual architecture and communication flows upon which the SafeScript solution was designed.
Security?
Given the system contains sensitive health information about individuals,?SafeScript?has been built to the Victorian Protective Data Security Standards and is consistent with the security measures contained in the Australian Signals Directorate’s Information Security Manual for data classified as "PROTECTED".?SafeScript?has been independently security audited as well as security tested to these standards.?
Additional security measures to keep patient data secure include data encryption in transit and at rest, multi-factor authentication to safeguard against?unauthorised?access, and routine penetration testing to ensure data stored in?SafeScript?remains protected.?
Through the use of Microsoft Azure AD for Identity and Access Management, the project has included one of the largest deployments of multi-factor authentication in the Australian health sector to date.?SafeScript?is also integrated with the Australian Health Practitioner Registration Agency's registration database, to ensure only clinicians with current registration can have?authorised?access to?SafeScript.?
Scale?
The importance of scalability was an important consideration for the project because of large number of users, fast response time requirements and the explicit intent for the solution to have the potential to scale beyond Victoria.
DHHS had implemented a wide range of applications in public cloud services platforms over several years, and so was comfortable with the operational and information security considerations involved in basing the solution around a global cloud service platform. The key advantage, compared to more traditional on-premise infrastructure and managed service hosting arrangements, was greater confidence in the scalability, availability, security and continuous improvement of the platform. The BTIM team's experience was that the cloud innovation edge is a reality.?
SafeScript?is built on Microsoft Azure PaaS to?maximise?value in supporting availability, performance and scalability requirements, as well as providing a seamless, secure, user experience. Web apps provide access to?SafeScript?to authorised?users, ensuring a better performance regardless of bandwidth – which is important for rural or regional practitioner access.??
Openness /?Integration?
SafeScript?is built using Microsoft Azure Event Hub, Stream Analytics,?WebJobs?and Enterprise Service Bus. It ingests real-time prescription and dispensing data captured via the prescription exchanges, processing the data to be stored in Azure SQL. Data insights are pushed into?PowerBI?for further analysis and reporting.?
SafeScript?supports two architectures to?maximise?integration capability with all medical and pharmacy software. An API is available that clinical software can call that allows for prescription information to be sent to?SafeScript?prior to the prescription being printed or dispensed. The API returns a notification that contains a link to the patient’s profile in?SafeScript?and also indicates if any ‘alerts’ have been raised.?
Alternatively, for clinical software not using the API, notifications can be sent to computer desktops through installation of the?SafeScript?system tray app. Clinicians receive these notifications on their desktop within seconds after the prescription has been issued.?
Creativity?
In order to handle the high volume of data and the critical need to provide data quickly to time-poor clinicians, the project adopted a smart approach to build a seamless system that causes minimal disruption to the day-to-day workflow of busy health professionals.?
SafeScript’s?innovative design combines new technology with the efficient use of existing national eHealth assets. This negated the need for separate integration with over 20 clinical systems.?
SafeScript?uses a real-time data analytics architecture which brings together current transactions with historical data and performs complex parallel calculations ‘in-flight’ before returning a meaningful assessment within seconds. This can be easily adapted in the future to leverage Machine Learning and AI where the system continues to learn and proactively identify trends from the data it receives.?
Credits - the Project Team
Key members of the project team included:
About the Department of Health and Human Services???
The Department of Health and Human Services is one of the largest departments of the Victorian state government.
The department aspires for all Victorians to be healthy, safe and able to lead a life they value. It delivers policies, programs and services that support and enhance health and wellbeing including:?
Need help?
If you or someone you care about has a problem with prescription medicines, the SafeScript Pharmaceutical Helpline may assist with counselling, information and referral to treatment and support services.
The SafeScript Pharmaceutical Helpline is a free and confidential 24-hour telephone counselling service: 1800 737 233
Delivery Lead | Scrum Master
4 年That integration piece using the prescription exchange is a slick piece of work. Kudos.
Director Digital Strategy, Investment & Assurance
5 年Congrats Steve, this outcome would not have been possible without your leadership and intervention at the outset. It took courage and determination to change the trajectory of this project, to one which should rightly be seen as award winning. A huge effort across the board to deliver a solution that saves lives. Victorians should all be proud of the Safescripts application and the people involved in delivering it. Well done team!
?? Innovative Tech Leader | Cybersecurity Expert | Cloud Evangelist??
5 年Must have had a pretty awesome Azure Architect on that project.
Enterprise Architect | Innovating Digital Healthcare | Streamlining Care & Compliance with Nomadic Care
5 年Great work! I am honoured to have helped shape the solution in its early days. I am confident SafeScript will address this major social problem...
Technology Leader | Author | Globe Trotter | Fitness Enthusiast
5 年Wow, well done DHHS team! Amazing outcome to secure a better, safer tomorrow for all of us! ????