Real Time Prescription Monitoring (RTPM) is a national digital health system which was established by the Commonwealth Government. Each state and territory will implement their own local version of the RTPM system by their respective state and territory health instrumentalities. There will be core features and functionality to enable national consistency.
The need for such a system has come about due to the abuse of controlled medication such as oxycodone, morphine and fentanyl, and other high risk medication such as diazepam.
The RTPM can provide doctors and pharmacists with a comprehensive history of these medicines which have been prescribed and dispensed. It will aid to identify patients at risk of harm due to dependence or misuse, identify possibly diversion, limit prescription shopping and provide regulators with data to detect non-complying prescribers.
The purpose of the monitoring is to enable doctors and pharmacists to make safer clinical decisions and to help them identify circumstances where a patient may be receiving potentially harmful medicines beyond medical needs.
The RTPM system consists of two components:
- A National Data Exchange (NDE), which captures information from state and territory regulatory systems, prescribing and dispensing software, and a range of external data sources.
- Regulatory systems within each state or territory, which manage the authorities or permits for controlled medicines in each state and territory.
The NDE was developed and released in December 2018. Work with states and territories is continuing to integrate the NDE into their regulatory systems.
Monitored Medicines List, NSW
In NSW, it was considered that careful thought should be provided to determine which medicines can potentially pose a threat to the public and therefore should be monitored in the RTPM system.
An expert panel of academics, pharmacologists and experts in addiction medicine and pain management were involved in this decision-making.
NSW Health consulted with relevant key stakeholders, including the Royal Australian College of General Practitioners (NSW and ACT Branch), Australian Medical Association (NSW), Pharmacy Guild of Australia (NSW Branch), Pharmaceutical Society of Australia (NSW Branch), Australian College of Rural and Remote Medicine, the Royal Australasian College of Physicians – Chapter of Addiction Medicine, as well as consumer representative organisations.
The panel considered approaches in other states and territories and also used a certain criteria to guide decision-making when considering the inclusion of Schedule 4 medicines in the RTPM system as follows:
- Evidence of Harm – For a medicine to be included there should be evidence of a pattern of harm in NSW, including misuse, abuse, addiction and fatal and non-fatal overdoses.
- Trends in Prescribing – For a medicine to be included, there should be evidence of an increase in trend in prescribing rates, as well as misuse and abuse in an Australian or global context.
- Substitution Effect – A medicine or a group of medicines should be included if there is a risk that regulation of another medicine may result in the displacement of misuse to other medicines or illicit substances.
- Chilling Effect – Inclusion of medicines for monitoring in RTPM may discourage prescribing of monitored medicines when they are otherwise clinically appropriate, resulting in negative patient outcomes.
- Regulatory Burden – Care must be taken to ensure that the information collected in RTPM should be sufficiently inclusive to adequately perform its purpose in mitigating harm without adding to the significant regulatory burden that prescribers and pharmacists already face or diluting the impact of the RTPM on the actions of prescribers and pharmacists.
- Utility of Information for Clinical Care – Medicines should be considered for inclusion when the added visibility will provide clinicians greater confidence in assessing and managing the patient, leading to approved patient care. Vulnerable and complex patients are at a higher risk of harm from these high risk medicines due to poly-pharmacy and the multiplying effects of being on numerous medicines. This criterium provides for the monitoring of medicines that aren’t inherently high-risk in their own right but may be meaningful to the health practitioner and assist them to form a more accurate overall picture of the medicine’s use.
- Consistency with other jurisdictions – Consideration is given to the approaches of other states and territories in determining their lists of monitored medicines, to ensure co-ordinated approaches and to minimise cross-border issues.
The expert panel provided a formal report to NSW Health in December 2020 regarding what medicine should be included in the NSW Monitored Medicines List (MML). In March 2021, the medicines to be monitored in the RTPM system were published in an amendment to the Poisons and Therapeutic Goods Regulations 2008.
Current Status
As you are aware, the NSW MML includes:
- All medicines that are included in Schedule 8.
- All medicines that contain a Benzodiazepine when included in Schedule 4.
- All medicines that contain codeine when included in Schedule 4.
- Tramadol, Quetiapine, Pregabalin, Zopiclone and Zolpidem.
It is interesting to note that while the panel considered the inclusion of anti-depressants in the MML, these were not included because it was noted they were a marker for increasing clinical complexity and risk rather than an independent cause of harm; they would be a substantial regulatory burden to a high volume of use; inclusion may lead to further stigmatisation of patients being appropriately tested for depression and they are not monitored by any other jurisdiction.
The system will not record any medicine administered on the Opioid Treatment Program or the supply of monitored medicines from public hospitals.
The MML is a dynamic vehicle and other medicines may be added over time.
NSW Health will be commencing a phased roll out to eligible practitioners in August 2021.
Doctors working in a public hospital will be able to access the RTPM system via their securely hosted online portal and view the same information as a private practice general practitioner. The portal is available 24 hours per day.
How does the RTPM NSW work?
When a prescriber issues a prescription or a pharmacist dispenses a medicine, specific information is recorded. Most prescription information from GPs is transmitted digitally through the Prescription Exchange Services to a community pharmacy. The NSW RTPM database will collect this information when it relates to a monitored medicine. The data is made available for health practitioners to view “real time” (meaning within one minute). The information will include:
- Patient name.
- Patient address.
- Details of monitored medicines supplied (name, strength, quantity).
- Prescriber and pharmacy details.
Health practitioners who are directly involved in patient care may view information about the patient’s prescription and dispensing history for monitored medicines in RTPM through an online portal. Only eligible health practitioners who have registered with, and been validated by NSW Health, are granted access to this portal.
It should be noted that authorised officers of the NSW Ministry of Health (an example, PRU) may also access RTPM as part of their regulatory role in administering the Poisons and Therapeutic Goods legislation.
Prescribers and pharmacists using computerised prescribing or dispensing systems that are integrated with the RTPM system will also receive a notification warning them when a high risk scenario occurs, such as the use of very high doses of opioids or combinations of medicines with high risk of harm, which will pop-up on their screen when prescribing or dispensing a monitored medicine.
The Future?
A benefit and evaluation plan has been developed to monitor the impact of the implementation of the RTPM system. Short-term metrics include practitioner uptakes and access statistics which are monitored. Longer term metrics will be to determine the impact that the RTPM implementation has on harm and mortality associated with misuse of monitored medicines.
NSW Health will also monitor closely for potential unintended consequences relating to its implementation, including increased referral rates and waiting lists for specialist pain and addiction medicine services.
Comprehensive training will be made available to doctors and pharmacists on how to use the system to ensure safer prescribing and dispensing, as well as how to support the needs of patients. There will be a telephone advisory service for additional support. In addition, medical practices and community pharmacies will be provided an information packet at the start of the roll out of the RTPM. E-learning modules and other training and education materials will also be made available. These will be delivered in partnership with RACGP, PSA (NSW) and Primary Health Networks.
Other helpful resources are as follows:
- RACGP webinar titled “Alcohol and drug use for those with anxiety, depression or sleep disturbance – management tips”, delivered in January 2020 (available online through the RACGP website).
- Electronic mail-outs via RACGP in November 2018 and October 2019 which highlighted safety issues related to the use of the multiple medicines and the importance of good interprofessional communication practices.
- NSW Ministry of Health education package titled “Prescription Medicine Safety: Managing risk, driving and constructive conversations”, delivered to pharmacists in partnership with the PSA (NSW) from August 2019 (this also includes face-to-face workshops). The education package is available through the PSA website.
- The OTP Resource Manual, instigated by the NSW Ministry of Health and Pharmacy Guild of Australia (NSW).
- Guidelines for Depot Buprenorphine injections (a new long-acting formulation of an existing opioid substitution therapy Buprenorphine) became available in late 2019. The Ministry of Health’s Clinical Guidelines 2019, assist clinicians to assess patients to determine if they are suitable for the medication, initiating the patient onto the medication from illicit opioids or oral Methadone, titrating the dose, administering the injections, and ceasing treatment.
Health practitioners are reminded about access to a patient’s My Health Record (if they have not opted out).
This article was written by Principal Nevena Brown. If you have any questions or require further information about the rollout of Real Time Prescription Monitoring in NSW, please contact Nevena.