With the spread of informatics within the health system in Spain, it was to be expected that health service managers would decide to change the prescription, dispensation and payment system. The current system, with the exception of mechanical aspects such as the incorporation of bar codes and self-copying paper for prescriptions, is rather antiquated and has changed little in structural terms since the implementation of official Social Security prescription forms.
For many years this has remained the only system in operation for the process of prescription, dispensation and payment, and has undergone no substantial modifications since its inception. Before the primary care system was reformed, long lines formed at social security outpatient centers to obtain prescriptions. Reforms in primary care were accompanied by greater attention to chronic conditions; this led to the medicalization of chronic processes, and this in turn, along with other cultural and health care-related factors, led once again to crowding, long waits and inefficiency at primary care centers.
In recent years there have been several attempts (varying in organizational level and scope) to decrease the patients´ need to visit the health center to obtain official prescriptions for long-term medication, and to attempt to reduce the administrative burden on health centers.1 Health centers have made a number of attempts to reduce bureaucracy, and systems have been created to favor a more rational use of consultations.2 Some of these measures have been the creation of a long-term medication card and the establishment of parallel consultancies staffed by nursing or administrative personnel--a measure that requires additional human and technical resources. Local projects have been tested with software to detect drug interactions associated with long-term treatment cards or authorized medications.3
The article by Suárez-Varela et al published in this issue of Atención Primaria describes the results 6 months after the implantation of computer-aided prescribing at a health center in Andalusia (southern Spain). Computer-aided prescribing reduced by 60% the mean number of administrative consultations to obtain prescriptions for long-term treatments. The authors evaluate one of the first pilot studies of computer-aided prescribing in Spain, and the study has since been replicated in other regions (Andalusia, Valencia, and Galicia). The process was begun when Parliament approved the introduction of computer-aided prescribing through an Accompanying Law passed in December 2003.4 The authors subtitled their article "From Utopia to Reality" as a reflection and summary of the expectations this development has generated, and the substantial change it implies. However, from the viewpoint of the prescribing physician, certain issues need to be clarified for a program of this type to be successful.
In principle, the process will need additional economic resources, but computerizing the health centers and pharmacies that are not yet fully computerized should be seen as a necessary part of modernizing the health system.
Mechanization of the prescription process, simply by eliminating handwriting, can reduce prescription errors by as much as 60%,5 but computers can help in other important ways by flagging known contraindications, which account for up to 4% of all severe adverse reactions, and by avoiding known allergies and active ingredient duplication.
Prescribing physicians in Spain have rather reluctantly agreed that there is a need to use computer-based resources to modernize two basic tools of our trade: medical records and prescriptions. However, the computerization of medical records has not been without its problems (e.g., slow communications systems, complex medical histories, software incompatibilities, and disconnect between levels of care and professional training, among other obstacles). Computer-aided prescribing adds new problems that need to be dealt with to allow the process to spread so that pilot testing can take place in other settings: Will it be necessary to obtain the patient's informed consent? Will personal information regarding diagnoses be involved? Will there be advantages in terms of patient's safety (allergies, interactions, contraindications, active ingredient duplication)? Will the digital signature system be sufficiently secure? Will the system be easy for all users? Will the system for modifying prescriptions be agile? Will it prevent current multiple dispensations at pharmacies? Will it prevent the current indiscriminate substitution at pharmacies of generics for both acute and long-term treatments? Will it prevent the stockpiling of medications at home? Will it stop other specialists from issuing long-term prescriptions without consulting the family physician?
Regarding the first 2 questions, the National Association of Health Service Users and Consumers (Asusalud) has raised objections with respect to the need to obtain the patient's informed consent for treatment and the possible transmission of information this might imply. This health users' association fears that information about patients might be used inappropriately because there is as yet no provision for data protection.
Regarding the patients' physical safety, the benefits the system is expected to offer are essential because medication errors are preventable errors. This is not an easy undertaking, and in the United Kingdom, where the use of computer-aided processes by general practitioners is more widespread than in Spain, it has been found that some programs were unable to detect prescribing errors.6
Aside from issues of safety, the processes most in need of improvement are essentially prescribing by the physician and compliance by the patient. Reducing the number of unnecessary consultations will benefit both.
A newer problem is the indiscriminate substitution of generic drugs--even those used for long-term treatments--at the pharmacy. We do not know who substitution benefits, as this practice serves only to confuse the patient. We hope that computer-aided prescribing will make current practices more rational and help to bring data on dispensing practices into the open. Another (older) problem is posed by prescriptions issued by other specialists and that must be renewed by the family physician. These induced prescriptions are not approved or accepted by the primary care physicians, and are known to be one of the routes through which new medications are introduced in practice. We hope that the new computer-aided prescribing system will make it possible to identify the physician who issues prescriptions for indications that have not been considered and approved by the family physician.
Computer-aided prescribing will probably improve administrative processes, provide billing and payment information in real time, and avoid delays (which can be as long as 2 months) in updating the information held in the present system.
To conclude, it is our understanding that a process of this scope, involving almost all actors in health care, should be designed on the basis of meticulous planning with a view to the actual benefits for all parties involved. The new prescribing system should thus aim to deal with current problems while avoiding the creation of new ones.
