E-Government / E-Health seminar:

online pharmacy

Seminar paper
University of Fribourg Department of informatics IS
Prof. Andreas Meier

January 2005: David Bchler Juchstr. 31 1712 Tafers david.baechler@unifr.ch

e-Health seminar: online pharmacy

David Bchler david.baechler@unifr.ch

Table of contents
1 Abstract!.................................................................................................................................... 3 2 Online pharmacy over the Internet!........................................................................................ 4
2.1 Different types of online pharmacy sites!....................................................................................4
2.1.1 Traditional pharmacy services online!..................................................................................................... 4 2.1.2 Online doctor or pharmacist visit!........................................................................................................... 4 2.1.3 Drug stores!..............................................................................................................................................5

2.2 Risks of online pharmacy!............................................................................................................ 5

2.2.1 Risk of online drug shops!....................................................................................................................... 5 2.2.2 Risks of prescribing based sites!..............................................................................................................6 2.2.3 Marketing tricks to confuse consumers!.................................................................................................. 6

2.3 Benefits of online pharmacy!........................................................................................................6 2.4 Existing (legal) online-pharmacy in Switzerland/Europe ........................................................ 8 !
2.4.1 Mediservice (Switzerland)!......................................................................................................................8 2.4.2 International!............................................................................................................................................8 2.4.3 Freely available drugs!............................................................................................................................. 8 2.4.4 Caution when using online services!....................................................................................................... 9

2.5 Conclusion!.................................................................................................................................... 9

3 Online pharmacy in Hospitals!.............................................................................................. 10

3.1 difference to private pharmacy!.............................................................................................10 3.2 Existing systems for clinical online-pharmacy!........................................................................ 10
3.2.1 Hospilog!................................................................................................................................................10 3.2.2 Predimed!............................................................................................................................................... 11 3.2.3 BoxPicker (Swisslog)!........................................................................................................................... 11

3.3 Reasons for an electronic medication system!.......................................................................... 12 3.4 Critical success factors!.............................................................................................................. 12 3.5 Risks!............................................................................................................................................ 13
3.6.1 New errors!............................................................................................................................................ 14 3.6.2 Examples of computer entry errors!...................................................................................................... 14 3.6.3 Problems (general)!................................................................................................................................14

3.7 Conclusion!.................................................................................................................................. 15

References!.................................................................................................................................16

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1 Abstract
In todays rapidly changing world of e-commerce, almost anything can be bought over the Internet and delivered right to your front door. Virtually everyday there is news of yet another company selling some type of product online. Included in this mass of products is prescription medication. Not only is it possible to order prescribed medications over the Internet, in some cases it is even not necessary to be examined, or to consult with a doctor. To some, this new type of cybermedicine is an affront to traditional medicine, as well as potentially dangerous to consumers.

For consumers, the idea of ordering in an online-pharmacy is interesting for several reasons: Lower cost and convenience for elderly people or those living in rural areas, as well as the ability to privately consult with a pharmacist are just a few of the benefits. But in addition to these advantages, there are still substantial risks. These include easy access to illegal or unapproved drugs, medication offered without a prescription, and drugs marketed with fake health claims.

But online pharmacy, in the sense of digital pharmacy, plays also more and more an important role in hospitals. Medication in hospitals is a pretty complex process. There are a lot of persons involved and the pharmacy itself with all the special drugs has to be always up to date. Online pharmacy here should help to reduce errors and save costs.

This paper is divided into these two main parts internet and hospital. It tries to show the different risks and benefits of online pharmacy. Further, different existing solutions, with special focus on Switzerland, will be presented.

e-Health seminar: online pharmacy

David Bchler david.baechler@unifr.ch

2 Online pharmacy over the Internet

2.1 Different types of online pharmacy sites
First of all it is important to distinguish different types of online pharmacy.

2.1.1 Traditional pharmacy services online There are websites, which offer traditional pharmacy services online only. These pharmacyonly based sites will only dispense medicine to a consumer who has first obtained a prescription from a doctor and then submitted it (electronically or not) to the online pharmacy. Pharmacy-only sites are the least controversial because they do not actually initiate the drug sale. These sites process valid prescriptions, which have already been obtained from a licensed physician. The most significant legal problem with these sites occurs when the pharmacy fails to obtain the appropriate official license for each country where it intends to do business.

2.1.2 Online doctor or pharmacist visit A second category of online pharmacies are prescribing based sites. These sites often employ both pharmacists and doctors. However, they should be distinguished from the web sites that also may employ doctors and pharmacists, but only offer medical advice or health related information. This latter type includes thousands of online medical sites and is not the subject of this paper. Usually the prescribing based sites will provide an online doctor visit either through a medical questionnaire or a simultaneous videoconference between the doctor and patient. For this consultation, a fee is charged. After the patient entered the information and the doctor reviewed it, a prescription may be issued which is then processed at an (online) pharmacy. The strongest criticism of these sites is that an online form or questionnaire, no matter how detailed, simply cannot substitute for a physical exam. Without an actual face-to-face exam, critics contend that patient warning signs that might easily be detected by touch, could go unnoticed, posing potential risk to the patient. For this reason, prescribing based web sites are highly controversial.

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e-Health seminar: online pharmacy

David Bchler david.baechler@unifr.ch

2.1.3 Drug stores Finally, a third type of online pharmacy is referred to as online drug shops. This is an appropriate description because these web sites are primarily engaged in the sale of drugs. Here, essentially everything a consumer must do in order to obtain a controlled substance or any other prescription drug, is simply go to the site and purchase the drug with a credit card. With these sites, no examination is necessary and no medical questionnaire needs to be answered. Online drug shops often operate from foreign countries and are therefore usually beyond the reach of local law and authorities. Although many consumers do not realize it, online drug shops are considered illegal by most law enforcement agencies. These sites are considered to be the most dangerous because potentially dangerous controlled substances, including narcotics, will be sold to virtually anyone. The anonymous nature of the Internet, combined with the fact that many of these pharmacies are foreign based, make them very difficult to control or stop. That is a heavily growing business and even the UN calls for action.1

2.2 Risks of online pharmacy

2.2.1 Risk of online drug shops The greatest risk lies with prescribing based sites and online drug shops. In the first, there is either no doctor interaction at all, or one that is superficial and perhaps insufficient to see all potential problems. In the latter, customers can simply go to the site, get a price list of various drugs, and place an order. There is no examination of the customer and there is no warning of potential side effects of the medicine being purchased. Many of these online drug shops are located in foreign countries. And many of the drugs that are sold from foreign-based pharmacies are not tested and controlled at the same high level of quality as drugs manufactured in western countries. Even worse, many of these drugs sold are not approved at all. Therefore, buying drugs from these web sites can lead to serious health risks. But trying to stop them from operating in is complicated, especially if the transaction is legal in the country where the shop is originating.

http://www.e-health-insider.com/news/item.cfm?ID=673
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e-Health seminar: online pharmacy

David Bchler david.baechler@unifr.ch

2.2.2 Risks of prescribing based sites The risks with prescribing based sites are also real. Many prescribing based sites only offer a brief consultation with a doctor that might consist of a patient answering a few questions before a prescription is issued. However, some prescribing based sites do offer a very thorough Internet exam through video conferencing, rejecting inappropriate patients and only prescribing certain non controlled substances. Nevertheless, critics contend that drugs have been prescribed too easily to people who turn out to be inappropriate candidates for the medicine. This of course can lead to serious consequences for the person that is unaware of a condition which otherwise would have been exposed by a physical examination. An online questionnaire is no substitute for a genuine examination.

2.2.3 Marketing tricks to confuse consumers Often, slick web sites can confuse consumers by pretending that there is nothing illegal about placing an order for prescription drugs without consultation of a physician. Potential buyers need to remember though, a drug that requires a prescription from a doctor, doesnt cease to do so simply because it can be purchased over the Internet from the comfort of home. Purchasing prescription-free drugs can even be legal in a certain country, but (not yet) in another one. Even though the chance of being prosecuted for importing a personal quantity of a prescription drug is small, it is still a violation of the law. Many patients are unaware of this fact.

2.3 Benefits of online pharmacy

Much less controversial is the pharmacy only sites. Here, there is no doubt that under proper circumstances, pharmacy only sites can provide enormous benefits. The principal advantages most often cited are: Lower prices through increased competition among pharmacies; more thorough and private consultations with a pharmacist;
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e-Health seminar: online pharmacy

David Bchler david.baechler@unifr.ch

greater access to medicine for seniors or people who live in rural areas; speed and ease of choosing and ordering products; comparative shopping among different retailers to get the best deals; access to a huge amount of health care information that is usually unavailable at a conventional pharmacy. With computer based systems it is also possible to check if you can prescribe two medicaments together or not. There is much more information.

An Australian pharmacist wrote in a forum: Should we consider the benefits? Having operated one of Australia's largest online pharmacies for over 4 years, we are now seeing many positive outcomes with online pharmacy trade. Integrated systems allow 100 percent screening of allergies, conditions and medications for all products, not just prescriptions. In addition, our rural remote and regional customers can now have a full range pharmacy model, with pharmacist contact 7 days per week. In addition, via e-commerce we can deliver far more health information. Internet pharmacy will never and should never replace traditional pharmacy models, however it does solve some of the issues where consumers do not have access to a full range pharmacy service. If you own a pharmacy and do not provide this, then that is where internet becomes a competitor.

On the downside, online drug shops and prescribing based sites may have substantial risks. However, both may also provide legitimate patients who are in need a way of obtaining necessary medication, more conveniently and at a lower cost.

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e-Health seminar: online pharmacy

David Bchler david.baechler@unifr.ch

2.4 Existing (legal) online-pharmacy in Switzerland/Europe

2.4.1 Mediservice (Switzerland) In Switzerland, there is one main service provider on the Internet medical market: Mediservice2 . Mediservice is the first direct service pharmacy. Drugs are only delivered on original prescriptions of a Swiss physician. It is even recommended by several swiss health insurance companies. The main benefit is the better price, 24/7 service and home delivery.

2.4.2 International But there are more and more online pharmacies that try to work from one location legally in different countries. The first and biggest one in Europe is DocMorris3. Its is a fast growing company. Actually they have about 1.1% of the whole drug market. But medium-term they expect to serve about 8% of the market.4 The company resides in the Netherlands. Nevertheless they have to be officially accepted in every single country they want to do business with. The biggest legal online pharmacies reside in the US. There they have a longer tradition than the stores in Europe (e. g. drugstore.com)

2.4.3 Freely available drugs The most important business is the market of freely available medicaments. There is a big trend for self-medication. The main reason for ordering online is the (potentially) lower price. But one has to be extremely cautious when doing online orders. Especially in the US, online pharmacy is well accepted and a heavily growing business. The tons of daily Spam-Mails document it.

2 3
4

http://www.mediservice.ch http://www.docmorris.com
http://www.ecin.de/news/2003/04/22/05690/ page 8

e-Health seminar: online pharmacy

David Bchler david.baechler@unifr.ch

2.4.4 Caution when using online services When using pharmacy only sites, one should use familiar, reputable pharmacies. Official certificates are important. Before making a purchase, the prices and shipping costs of different pharmacies should be compared as they can vary considerably. Finally, there should be the opportunity to consult online with a pharmacist. If there is no available contact with a pharmacist, or no cost savings, or if it takes a week to get the medication, then it might be worth to do business with the traditional pharmacy.

2.5 Conclusion
In conclusion, cyber-medicine can offer enormous benefits to consumers. But there are still substantial risks. In buying prescriptions online, consumers will be well advised to adhere to some basic advice. First, as this comment makes clear, one has to be extremely cautious when visiting online drug shops. Unless shopping for drugs, which are unapproved or unavailable in the local country, buying drugs from these sites may do more harm than good. Second, the legal status of many prescribing based sites is still uncertain and may vary from country to country. Therefore, it may not be a great idea to use these sites as a way of purchasing medicine from a new doctor that has not first performed a proper physical examination. Instead, perhaps the best use of these sites may be either to get refills of prescriptions or to get personal medical advice.

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e-Health seminar: online pharmacy

David Bchler david.baechler@unifr.ch

3 Online pharmacy in Hospitals

3.1 difference to private pharmacy
Hospital pharmacies have different roles to community pharmacies. Pharmacists in hospital pharmacies often have more complex clinical medication management issues whereas pharmacists in community pharmacies often have more complex business and customer relations issues. Unlike community pharmacies, which are usually independently owned, hospital pharmacies are usually a department of the hospital where it is located. Hospital pharmacies usually stock a larger range of medications, including more specialized medications, than would be needed in the community pharmacy. Traditionally, hospital pharmacies have also prepared various injectable preparations.

3.2 Existing systems for clinical online-pharmacy

In Switzerland there are two systems that are currently being tested: Hospilog and Predimed. There is also a swiss vendor (Swisslog) that constructs robotic systems for pharmacies.

3.2.1 Hospilog Medication error is a major source of problems during drug dispensing, particularly when this process is performed manually. Computerized medication dispensing cabinets can help reduce the rate of errors. On that background Hospilog was developed. Electronic medicine dispensers, make the handling of medicines in hospitals and other healthcare facilities safer, more transparent and economical. Hospilog is based on electronic cabinets of the American enterprise Pyxis. The prescription is made electronically. Then the cabinets hand out the demanded medicament. The whole system is connected to the existing hospital information system.5 The system was also successfully tested at the HCUG (Hpital de luniversit de Genve). It recentely won the award of the swiss eHealthcare congress.

http://www.ehealthcare.ch/eHealthCare04/Award/Portrait_AWARD.pdf
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e-Health seminar: online pharmacy

David Bchler david.baechler@unifr.ch

3.2.2 Predimed Predimed controls all the data of patients. The expenditure of medicaments is not controlled through electronic cabinets. The focus lays on the software and availability of data. Electronic drug prescription is included and even one of the main points. The users have mobile online touch-screen computers and also fix base stations. The system is currently tested at the CHUV Lausanne. In the near future it will be introduced at several departments of the hospital. The hospital in Nyon is also interested in the system.6

3.2.3 BoxPicker (Swisslog) This is a robot controlled logistic system for pharmacies. The system is not only used in hospitals. The medicaments are stored automatically by a robot. The system keeps also track of outdated drugs or the stock amount. Especially in Germany there are several systems running. A bigger system has also been introduced at a hospital in the UK. 7

http://trendcare.p51.breezecentral.com/p32048500 http://www.swisslog.com/internet/hcs/hcs/adms/26.pdf
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e-Health seminar: online pharmacy

David Bchler david.baechler@unifr.ch

3.3 Reasons for an electronic medication system

In a hospital a lot of people are involved in the process of medication. Errors occur pretty often. The prescription is sometimes not well readable or incomplete. Sometimes wrong decision are taken because there is just not enough information. The logistic is also very complex in a hospital pharmacy. A lot of different drugs have to stored and managed. The security aspect is another important point. Only approved persons should have access to certain medicaments. An electronic system could also lead to a more strict use of drugs, because the staff has to think how and where to enter the information. The prescribing of less drugs is also an important cost factor. The improved logistic can save costs too. By introducing such a system, the whole workflow has to be analyzed and improvements can be done. And last but not least the data generated by such a system can be used for further (business) analysis.

3.4 Critical success factors

According to Dr. med. Raphael Kessler, head physician of the inner medicine department at the hospital Tafers, the following points are very important for the success of a computer based medicament system in a hospital.

In order for electronic hospital systems to succeed, the user acceptance is maybe the most important key point. As a technical system is useless if it is not accepted hence used. Thats also why the technical infrastructure has to work perfectly. Support must be rapidly available. and computers must have a rapid response time. There must be local flexibility and changes should be made rapidly, otherwise people tend to lose interest in the process. It is also essential to have local support staff for computer systems, rather than remote support staff who does not understand the local situation. It is helpful if the computer support staff is also health professionals employed in the hospital, as it is easier for them to understand computing than it is for computer experts to understand medicine and health care.

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e-Health seminar: online pharmacy

David Bchler david.baechler@unifr.ch

The implementation of electronic prescribing systems must be a hospital initiative, as it would not succeed if it was seen as a departmental project. When looking for suitable systems, it is important to see them operating in another hospital, a demonstration version is not really adequate. To win acceptance from staff, the first part of an electronic system to become available should provide convenient, rapid access to useful services. Prescribing should be activated later as this part of the system is harder to learn and staff is less willing to use it. A new system must also work with existing information systems, maybe it can even be included.

3.5 Risks
Technology has the potential both to reduce and to create new types of medication errors. Thats why it should be implemented with care. The MEDMARX report analyzing medical errors reported in 2002 shows that computer entry problems accounted for 10.3% of all the causes of error analyzed from 174,109 reports. The figure was down very slightly on the 2001 report, which recorded computer entry errors in 11% of reports. Computer entry errors were slightly less likely to be cited in adverse incidents, which resulted in harm to a patient in 2002 (8.2% of reports). Fax and scanner errors were cited in 1.7% of reports.

The report observes: Unquestionably, the adoption of new technology has greatly influenced the medication use process in todays healthcare delivery. Direct prescriber order entry, automated dispensing devices (in pharmacies and patient care areas), and sophisticated infusion devices are among the many technological advances adopted ostensibly to improve efficiency and safety during an era of abundant drug approvals, soaring drug costs and healthcare worker shortages. 8

http://www.e-health-insider.com/news/item.cfm?ID=584 page 13

e-Health seminar: online pharmacy

David Bchler david.baechler@unifr.ch

3.6.1 New errors However, according to records in the MEDMARX database, technology can also induce unforeseen errors that may not have been present previously. Therefore healthcare facilities must adopt new technology in a deliberate, careful and integrated manner that minimizes the introduction of new errors throughout the medication process and that maximizes the technology available to provide alerts, safety checks, dosage calculations and decision support. The report counsels healthcare providers to develop interdisciplinary teams with expertise in content and process re-design to ensure that new technology is not introduced in ways that harm patient safety.

3.6.2 Examples of computer entry errors Four examples of errors from administering medication. Prescribing error: A medicament is ordered for the wrong patient in another room (e. g. room 205 instead of room 204). Documenting error: Orders for one patient are entered into the computer system under another patients profile. The patient profile has maybe a similar number or a similar name. Dispensing error: The dose of the medicament is not correctly entered du to an inadvertence. Administration error: A nurse accesses a computer screen not realizing that it relates to a different patient. The wrong medication is administered and given to the patient. the areas of prescribing, documenting, dispensing and

3.6.3 Problems (general) Problems that arise from the implementation of an electronic hospital and prescribing system includes the fact that the computer system generates a great deal of paper. Also, while lap-top computers were ideal, some staff prefers static terminals. The issue of security is a high priority for staff and patients alike. As an example a nurse shouldn't log in with the name of a physician and prescribe medicaments. Another problem arises with staff that is at the hospital for only a short time and has therefore no access to the system or does not know how to use it.
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e-Health seminar: online pharmacy

David Bchler david.baechler@unifr.ch

3.7 Conclusion
Developing such a system is time and cost intensive but there are quality improvements for prescriptions and more security for the patient. The return of invest is very difficult to measure, especially if it is a very new system. Despite all the problems, computerized systems could improve the quality of prescribing, make it easier to monitor prescribing and minimize omission of doses by nurses. Also risks can be minimized and eventually clinical governance data can be collected. Electronic systems are a useful tool for the pharmacy service and increase the need for pharmacists as they uncover medication-related problems that had previously gone unnoticed.

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David Bchler david.baechler@unifr.ch

References
Karl Jhn, Eckhard Nagel: "e-Health", Springer Verlag, 2004.

Weblinks (January 2005): Hospilog: http://www.ehealthcare.ch/eHealthCare04/Award/Portrait_AWARD.pdf http://www.hcuge.ch/Pharmacie/rd/posters/eahp04_pb_pyxis.pdf Predimed: http://trendcare.p51.breezecentral.com/p32048500 http://www.siemens.com/page/1,3771,1037717-2-999_0_0-175,00.html BoxPicker (Swisslog): http://www.swisslog.com/internet/hcs/hcs/adms/26.pdf

Technology can reduce/create errors: http://www.e-health-insider.com/news/item.cfm?ID=584 Different individual reasons to choose online pharmacy: http://www.heise.de/newsticker/meldung/47030 Pros and cons of online pharmacy: http://www.journalistenakademie.de/lesepr/mm116.htm UN calls for action: http://www.e-health-insider.com/news/item.cfm?ID=673 Opening of the (online) market in Germany http://www.ecin.de/news/2004/01/05/06564/

Online pharmacies mentioned in the text: http://www.mediservice.ch (CH) http://www.docmorris.com (Europe) http://www.drugstore.com (US)

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