What problems can decision to introduce online prescriptions lead to in Armenia?

On March 1, the decision to introduce the online prescription system came into force in Armenia, which applies to about 470 medicines. From now on, pharmacies in the country are forbidden to sell antibiotics, as well as antifungal, antiviral, hormonal, and some other drugs without an online prescription in the ARMED system.

At first glance, this decision could have a positive impact on public health by preventing the practice of self-medication, which contributes to the spread of problems such as antimicrobial and antifungal resistance caused by the misuse and unnecessary use of these drugs.

On the other hand, many healthcare experts, pharmacies, and medical practitioners argue that this innovation was introduced in Armenia too hastily and the system is simply not ready for it yet, not even all doctors are aware of it yet. And by the time the system is finally regulated and begins to function more or less normally, many may face serious problems, such as missing the use of a vital drug—because the pharmacy won't sell it to them and the doctor isn't yet aware of online prescriptions—which can lead to tragic consequences.

Third, it is still difficult to imagine what this whole system will be like when it "works normally," as there are many nuances and special cases that are simply not taken into account, or are taken into account, but in such a way as to complicate people's lives as much as possible.

For example, what should people do who can't go out and buy their prescribed prescription? What to do if the doctor or pharmacist made a mistake in the online prescription? What to do if the power in the pharmacy goes off, there is no access to ARMED, and the drug is urgently needed? These are just some of the questions that arise today for both ordinary people and professionals working in health care.

Medicines that should not be interrupted

On the evening of March 1, 39-year-old Araksia—the patient's name has been changed at her request—went to the pharmacy to buy a hormonal drug that was prescribed to her more than a week ago to maintain her pregnancy. To her surprise, the pharmacy refused to sell the drug on the grounds that there was no online prescription in her name.

The doctor had warned Araksia that the medicine should be used at very specific times, and there was only one hour left for the required time, and the medicine that she had bought earlier had already run out. In a state of panic, she called the doctor to find out what to do. The doctor admitted to hearing about the new order for the first time, and that had to clarify this matter with the management of the clinic on Monday; that is, in three days.

“Words cannot describe the stress I experienced that evening. I was rushing from pharmacy to pharmacy and trying to grasp what I should do, although I am not allowed to walk a lot," said the woman.

It is unlikely that Araksia is the only woman in Armenia who has faced such a problem in recent days. And it is not yet known what consequences this has led to, especially in the case of patients receiving hormonal drugs, the use of which cannot be stopped or delayed.

Drug abuse: Hormones and antibiotics have different "status"

It is easy to imagine how a person, when he has a cold, runs to the pharmacy to buy antibiotics, and in addition, even buys antifungal drugs, although he does not need both. It is much more difficult to imagine that a person can buy and start taking hormonal drugs based on his own whim. Armenia’s population treats these medicines with great reverence, so to speak. Most people are afraid of hormonal drugs, even if they are prescribed by a doctor.

So, if there are people who are engaged in "self-medication" using hormones, then they are very few in Armenia. That is why it is absolutely incomprehensible to many people why now hormonal drugs are also sold only by online prescription. People in Armenia bought them with a doctor's prescription anyway; it was just easier to do then than now.

Marina Harutyunyan, Head of the Department of Drug Policy and Medical Technologies of the Ministry of Health of Armenia, told NEWS.am Medicine that taking hormonal drugs can be accompanied by side effects and problems, so taking them without supervision is wrong. If it is about the long-term use of a specific drug, it is recommended to consult the doctor who prescribed it at least twice a year; if necessary, the doctor will send the patient for additional tests—for example, to make sure that there are no problems with blood clotting—adjust the dose, or simply write a new online prescription for the next six months.

According to Harutyunyan, all this stems from the interests of the patient and will help to maintain his health and protect from a number of problems. According to her, this will not increase the financial burden because in case of consultation and getting medication at the polyclinic, the patient will be served free of charge.

The system vs. the doctors

Today, there are about 2,600 pharmacies and about 14,000 doctors in Armenia who have the right to write prescriptions. As Artur Khachatryan, President of the Association of Independent Pharmacies of Armenia, stated in an interview with NEWS.am Medicine, most of the pharmacies have already joined the ARMED system—although there are certain problems here, related to, for example, the lack of identification cards of many employees—the same cannot be said about the doctors. Many of them still don't know about the new order at all, the others do, but they still can't connect to the system due to technical reasons. Moreover, there are still doctors in Armenia who find it difficult to use modern smartphones and computers.

As per Marina Harutyunyan, during the last three months, the Ministry of Health of Armenia sent circulars to medical institutions and pharmacies of the country and conducted offline and online educational programs to teach the procedure of using the ARMED system. According to her, this program is simple and does not require special knowledge, so even older doctors can handle it.

Despite all this, in the whole of Armenia—not only in the provinces, but also in the capital Yerevan—there are still many doctors who  know almost nothing about the new order, and are aware of the ARMED system only to the extent that they have heard about it. Moreover, not everyone who already works with this program is satisfied with the "experience."

Thus, urologist Davit Tonoyan told on Instagram the other day how he tried to write prescriptions online until 8:30pm. He had to be take patient information home where the internet connection is better, as there was no way to write a prescription during the day at work.

"The UI/UX design of the website is terrible, there is no intuitive idea how to work with it, everything is very complicated, everything is poorly made and works very poorly. In addition, it is necessary to write a separate prescription to prescribe each drug. If previously a doctor could prescribe five drugs by computer or by hand, writing the dose and other information on a single sheet, now he must write a separate prescription for each drug. Pharmacy employees may have a lot of questions," he said, adding that drug lists are also made in a very clumsy way.

According to him, all this can cause serious damage to the healthcare system of Armenia.

"I am in favor of prescriptions, but it should not be implemented so poorly," he said in conclusion.

"Buy it for me"

Gohar—name changed—has also faced problems in recent days. She regularly bought medicine for her relative who cannot leave the house. Since Gohar works full-time, she usually did not have time to visit her relative, and therefore she sent the purchased medicines through a delivery service. But after March 1, she will no longer be sold that medication, even if their online prescriptions are in the system.

As per Marina Harutyunyan, Head of the Department of Drug Policy and Medical Technologies of the Ministry of Health of Armenia, other people can buy medicines for those patients who cannot leave the house. But for this, the patient will be required to provide a power of attorney in the name of the person who will buy the drug, as well as the data of the patient's passport and the passport itself.

It turns out that Gohar has to go to her relative, get a power of attorney from that person, buy the drugs—which, by the way, are not sold in all pharmacies—and bring them and give them to her relative, spending much more time for all this than before.

What legal force can a power of attorney written on ordinary paper at home have? And what to do if the patient is unable to write this power of attorney for some reason? These questions also remain unanswered for now.

Other questions

According to Artur Khachatryan, many things are still not clear regarding the new order. For example, can prescriptions be given only for drugs registered in Armenia? Or also for drugs that are not registered in the country, but have a sales permit?

The problem, as per Khachatryan, is that over the last few years, the number of drugs registered in Armenia has decreased from 5,300 to 3,000, and about 50 percent of them are simply not available in the country’s pharmacies. What and how can doctors prescribe medicines in such conditions? What to do with the medicines that the patient needs, but are not on the ARMED list?

In addition, it is not clear what to do about the mistakes that both doctors and pharmacists can make.

"For example, a pharmacy employee can inadvertently ‘close’ a prescription given for six months even though the patient bought only one box of the prescribed medicine. The next time he comes to buy the second box, it will turn out that he cannot buy it because his prescription is already ‘closed.’ He has to go to the doctor again and spend a lot of time on it," said Khachatryan.

According to him, even the doctors can make mistakes while writing prescriptions. For example, accidentally writing "gel" instead of "pills," or writing the wrong dose. If the error is discovered at the pharmacy, the latter’s employee cannot give the patient the pills that were originally prescribed; he can only sell what is written on the prescription.

The good news is that the doctors do not have to be physically present in their office to write the prescriptions; they can access the ARMED system from any device, including their smartphones. So if a patient could theoretically contact his doctor without going back to the office, the doctor would be able to write a new prescription. But in practice, the doctor may, for example, be on vacation in another country or somewhere in the mountains where there are problems with the internet connection.

More problems or benefit?

After learning that many drugs would be available in Armenia only by prescription as of March 1, some people panicked and bought nearly a year's supply of antibiotics and other drugs. This information was also confirmed by the pharmacies visited by Armenian News-NEWS.am employees.

"The population is in a panic, people came and bought different medicines, not knowing whether they will use them later or not," says Vahan Grigoryan, manager of the Vaga Pharm pharmacy.

Of course, doing such a thing is completely pointless, as a person cannot know in advance what disease he will have, what medicines he may need. It may turn out that he really needs antibiotics, but not the drugs he bought in advance. Moreover, there is another risk. Some patients may start taking the drugs they bought at any sign of illness, fearing that they will have to throw these drugs away when they expire. And this can simply contribute to the deepening of the problem, against which the Armenian state is actively trying to fight. People will continue to take drugs they don't need.

According to Artur Khachatryan, the decision to introduce online prescriptions in Armenia is truly too hasty, incomplete, and thoughtless. What surprises him the most is that the adopted draft decision is practically no different from the one they wanted to adopt back in 2017, but then the members of the government quickly realized that it was too crude, unfinished, and abandoned it. Now, almost nothing has changed in the program itself, and it's not like the healthcare system of Armenia is more ready for it, but it was adopted for some reason.

"It seems to me that the [Armenian] leadership and the government were not properly presented what the problems are with this program. When you listen to the government session, everything seems so good. People who don't work in this field may think that it's great that now everything will be online. However, when you realize how many unsolved problems there are, you begin to see the other side of the coin," said Artur Khachatryan.

In her turn, Marina Harutyunyan noted that this program is not at all inviolable, and it can be adjusted if necessary.

"If global problems are noticed, we are ready to listen and propose changes. However, complaints should be justified and constructive, not just ‘we don't want to and we can't.’ This is for the health of all of us and we should realize it. It is not necessary to think about how to circumvent the law, but to contribute to the achievement of the common goal," she said.

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