Netherlands e-Prescription Services

All GPs in the Netherlands use an electronic medical record management system, which includes a module to create prescriptions electronically called the Elektonisch Voorshrijf Systeem (EVS). Since 2014, prescribers are mandated to use the EVS to generate prescriptions. However, while regional networks exist, there is still no national system for the electronic exchange of prescription information. GPs send the electronic prescription to the patient’s nominated pharmacy as an EDIFACT message using the secure healthcare mail system.

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 infrastructure, electronic messages, and safety).

It also coordinates the implementation of health IT projects and provides a level of national support, including training, a helpdesk, and maintenance of Web-patient portals.

On January, 2012 the Netherlands implemented a new law that requires prescriptions to be transferred electronically to the pharmacy. 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. It is very risky to prescribe drugs without the help of an automated system that instantly signals drug interactions and possible allergic reactions. This is unnecessarily dangerous and no longer justified. 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 prescriptions is repeat prescriptions that are often generated by the GPs.

Two organizations were founded, each of which played an important role in the development and adoption of ePrescribing:

1. Ozis Foundation was established to develop open standards for the electronic exchange of data between healthcare providers. The foundation developed regional clusters (OZIS rings), which facilitated electronic communication between regional GPs and pharmacies. The last OZIS cluster was phased out in December 2015.
2. The Nationaal ICT Instituut in de Zorg (Nictiz) was established initially to create a framework for the exchange of patient information and for communication between GPs and other healthcare providers (in terms of national infrastructure, electronic messages, and safety). Latterly, it coordinates the implementation of health IT projects and provided governance for eHealth projects.

As a short-term goal, Nictiz focused on exchanging medication records, which were considered of interest to health practitioners. Thereafter, Nictiz developed a national healthcare information hub, the National Switching Point (Landelijk Schakel Punt [LSP]), as part of the AORTA project. AORTA is the Dutch national healthcare infrastructure for the exchange of healthcare data. Using the LSP, GPs could see the patient’s summary record, while both GPs and pharmacists could see the patient’s medication record.

Lessons learned

The high adoption rate of the GP Information Systems, with ePrescription module, is attributed to two factors.

First, the Coordination Workgroup on Informatisation and Automation worked with vendors during the development of the GP Information System model to identify minimum requirements and ensure the standard of the final system. GPs could then obtain certification for compliance with this standard, which guaranteed the standard of the system for GPs and allowed the Workgroup to regulate GP practice management systems.

Second, the Dutch Association of General Practitioners and the Dutch College of General Practitioners worked with vendors to ensure that the EVS was compatible with the health information system while the now defunct District Associations of General Practitioners liaised with GPs to ensure EVS compatibility with their systems.

Other factors that contributed to the adoption of ePrescribing in the Netherlands include:

• the early adoption of the EDIFACT messaging standard for regional OZIS clusters, with funding available to vendors to support implementation
• the ongoing maintenance of the national drug reference catalogue by Royal Dutch Pharmacists Association (KNMP),
• the existence of the national healthcare identifier, which uniquely identified all patients in the Netherlands, since 2008.

The EVS electronic prescription system is integrated into the GP information systems, in which all GPs in the Netherlands record medical data about their patients. The system monitors unsafe situations and so has improved both the quality of prescriptions and the use of electronic medical records. It has also reduced expenditure on medications.

When debating the AORTA project in 2012, the Dutch government also highlighted the value of standardization and of providing high-quality health information. However, it appears that the decision that healthcare providers could connect to any infrastructure has resulted in the development of a number of regional infrastructures in parallel and that these infrastructures have yet to achieve full interoperability.