Barriers and facilitators to implementing electronic prescription: a systematic review of user groups' perceptions

Factors that influence the implementation of e-health: a systematic review of systematic reviews (an update)

Background

There is a significant potential for e-health to deliver cost-effective, quality health care, and spending on e-health systems by governments and healthcare systems is increasing worldwide. However, there remains a tension between the use of e-health in this way and implementation. Furthermore, the large body of reviews in the e-health implementation field, often based on one particular technology, setting or health condition make it difficult to access a comprehensive and comprehensible summary of available evidence to help plan and undertake implementation. This review provides an update and re-analysis of a systematic review of the e-health implementation literature culminating in a set of accessible and usable recommendations for anyone involved or interested in the implementation of e-health.

Methods

MEDLINE, EMBASE, CINAHL, PsycINFO and The Cochrane Library were searched for studies published between 2009 and 2014. Studies were included if they were systematic reviews of the implementation of e-health. Data from included studies were synthesised using the principles of meta-ethnography, and categorisation of the data was informed by the Consolidated Framework for Implementation Research (CFIR).

Results

Forty-four reviews mainly from North America and Europe were included. A range of e-health technologies including electronic medical records and clinical decision support systems were represented. Healthcare settings included primary care, secondary care and home care. Factors important for implementation were identified at the levels of the following: the individual e-health technology, the outer setting, the inner setting and the individual health professionals as well as the process of implementation.

Conclusion

This systematic review of reviews provides a synthesis of the literature that both acknowledges the multi-level complexity of e-health implementation and provides an accessible and useful guide for those planning implementation. New interpretations of a large amount of data across e-health systems and healthcare settings have been generated and synthesised into a set of useable recommendations for practice. This review provides a further empirical test of the CFIR and identifies areas where additional research is necessary.

Trial registration

PROSPERO, CRD42015017661

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-016-0510-7) contains supplementary material, which is available to authorized users.

[Perceptions on electronic prescribing by primary care physicians in madrid healthcare service]

OBJECTIVE

To investigate the opinion of Primary Care physicians regarding electronic prescribing.

METHODS

Descriptive study by means of a questionnaire sent to 527 primary care physicians.

PERIOD

June 2014. The questionnaire included closed questions about interest shown, satisfaction, benefits, weaknesses, and barriers, and one open question about difficulties, all of them referred to electronic prescribing. Satisfaction was measured using 1-10 scale, and benefits, weaknesses, and barriers were evaluated by a 5-ítems Likert scale. Interest was measured using both methods. The questionnaire was sent by e-mail for on line response through Google Drive® tool. A descriptive statistical analysis was performed.

RESULTS

The response rate was 47% (248/527). Interest shown was 8.7 (95% CI; 8.5-8.9) and satisfaction was 7.9 (95% CI; 7.8-8). The great majority 87.9% (95% CI; 83.8-92%) of respondents used electronic prescribing where possible. Most reported benefits were: 73.4% (95% CI; 67.8-78.9%) of respondents considered that electronic prescribing facilitated medication review, and 59.3% (95% CI; 53.1-65.4) of them felt that it reduced bureaucratic burden. Among the observed weaknesses, they highlighted the following: 87.9% (95% CI; 83.8-92%) of respondents believed specialist care physicians should also be able to use electronic prescribing. Concerning to barriers: 30.2% (95% CI; 24.5-36%) of respondents think that entering a patient into the electronic prescribing system takes too much time, and 4% (95% CI; 1.6-6.5%) of them perceived the application as difficult to use.

CONCLUSIONS

Physicians showed a notable interest in using electronic prescribing and high satisfaction with the application performance.

General practitioners' attitudes towards electronic prescribing and the use of the national prescription centre

RATIONALE, AIMS AND OBJECTIVES

The purpose of this study was to assess general practitioners' (GP) experience of an electronic prescription (e-prescription) system and the use of a national prescription centre.

METHODS

A web-based survey with 29 structured questions and 8 open-ended questions was used. The technology acceptance model was used to explain first users' use of e-prescribing technology. GPs (n = 269) in two different primary health care organizations, which implemented the e-prescribing module as the first of its kind in Finland.

RESULTS

Of the 269 GPs, 69 (26%) completed the survey. E-prescribing had influenced GP work and their management of patients' medication positively. Electronic health records and e-prescribing increased GPs' flexibility at work. There was a notable improvement in the management of prescription of narcotics with the introduction of e-prescribing. Issues with the e-prescribing system software delayed data processing and produced negative experience as users were forced to browse through too many pages to write a prescription.

CONCLUSIONS

E-prescribing has improved GP's patient medication management, meeting Finland's national objectives. E-prescriptions not only reinforce the process of writing, transmitting and checking the authenticity of prescriptions but also make it mandatory for all key prescription information to be present for transmission. The perceived usefulness of e-prescribing by GPs could lead to more widespread adoption of the technology. Making e-prescribing more user friendly requires reforming work processes, which in turn would enhance the effectiveness of GP work.

Perceptions and experiences of the implementation, management, use and optimisation of electronic prescribing systems in hospital settings: protocol for a systematic review of qualitative studies

INTRODUCTION

There is increasing evidence that electronic prescribing (ePrescribing) or computerised provider/physician order entry (CPOE) systems can improve the quality and safety of healthcare services. However, it has also become clear that their implementation is not straightforward and may create unintended or undesired consequences once in use. In this context, qualitative approaches have been particularly useful and their interpretative synthesis could make an important and timely contribution to the field. This review will aim to identify, appraise and synthesise qualitative studies on ePrescribing/CPOE in hospital settings, with or without clinical decision support.

METHODS AND ANALYSIS

Data sources will include the following bibliographic databases: MEDLINE, MEDLINE In Process, EMBASE, PsycINFO, Social Policy and Practice via Ovid, CINAHL via EBSCO, The Cochrane Library (CDSR, DARE and CENTRAL databases), Nursing and Allied Health Sources, Applied Social Sciences Index and Abstracts via ProQuest and SCOPUS. In addition, other sources will be searched for ongoing studies (ClinicalTrials.gov) and grey literature: Healthcare Management Information Consortium, Conference Proceedings Citation Index (Web of Science) and Sociological abstracts. Studies will be independently screened for eligibility by 2 reviewers. Qualitative studies, either standalone or in the context of mixed-methods designs, reporting the perspectives of any actors involved in the implementation, management and use of ePrescribing/CPOE systems in hospital-based care settings will be included. Data extraction will be conducted by 2 reviewers using a piloted form. Quality appraisal will be based on criteria from the Critical Appraisal Skills Programme checklist and Standards for Reporting Qualitative Research. Studies will not be excluded based on quality assessment. A postsynthesis sensitivity analysis will be undertaken. Data analysis will follow the thematic synthesis method.

ETHICS AND DISSEMINATION

The study does not require ethical approval as primary data will not be collected. The results of the study will be published in a peer-reviewed journal and presented at relevant conferences.

TRIAL REGISTRATION NUMBER

CRD42016035552.

Pharmacists' Perceptions of the Barriers and Facilitators to the Implementation of Clinical Pharmacy Key Performance Indicators

Background

In hospitals around the world, there has been no consensus regarding which clinical activities a pharmacist should focus on until recently. In 2011, a Canadian clinical pharmacy key performance indicator (cpKPI) collaborative was formed. The goal of the collaborative was to advance pharmacy practice in order to improve patient outcomes and enhance the quality of care provided to patients by hospital pharmacists. Following a literature review, which indicated that pharmacists can improve patient outcomes by carrying out specific activities, and an evidence-informed consensus process, a final set of eight cpKPIs were established. Canadian hospitals leading the cpKPI initiative are currently in the early stages of implementing these indicators.

Objective

To explore pharmacists' perceptions of the barriers and facilitators to the implementation of cpKPIs.

Methods

Clinical pharmacists employed by the Nova Scotia Health Authority were invited to participate in focus groups. Focus group discussions were audio-recorded and transcribed, and data was analyzed using thematic analysis.

Findings

Three focus groups, including 26 pharmacists, were conducted in February 2015. Three major themes were identified. Resisting the change was comprised of documentation challenges, increased workload, practice environment constraints, and competing priorities. Embracing cpKPIs was composed of seeing the benefit, demonstrating value, and existing supports. Navigating the unknown was made up of quality versus quantity battle, and insights into the future.

Conclusions

Although pharmacists were challenged by documentation and other changes associated with the implementation of cpKPIs, they demonstrated significant support for cpKPIs and were able to see benefits of the implementation. Pharmacists came up with suggestions for overcoming resistance associated with the implementation of cpKPIs and provided insights into the future of pharmacy practice. The identification of barriers and facilitators to cpKPI implementation will be used to inform the implementation process on a local and national level.

Achieving change in primary care--causes of the evidence to practice gap: systematic reviews of reviews

Background

This study is to identify, summarise and synthesise literature on the causes of the evidence to practice gap for complex interventions in primary care.

Design

This study is a systematic review of reviews.

Methods

MEDLINE, EMBASE, CINAHL, Cochrane Library and PsychINFO were searched, from inception to December 2013. Eligible reviews addressed causes of the evidence to practice gap in primary care in developed countries. Data from included reviews were extracted and synthesised using guidelines for meta-synthesis.

Results

Seventy reviews fulfilled the inclusion criteria and encompassed a wide range of topics, e.g. guideline implementation, integration of new roles, technology implementation, public health and preventative medicine. None of the included papers used the term “cause” or stated an intention to investigate causes at all. A descriptive approach was often used, and the included papers expressed “causes” in terms of “barriers and facilitators” to implementation. We developed a four-level framework covering external context, organisation, professionals and intervention. External contextual factors included policies, incentivisation structures, dominant paradigms, stakeholders’ buy-in, infrastructure and advances in technology. Organisation-related factors included culture, available resources, integration with existing processes, relationships, skill mix and staff involvement. At the level of individual professionals, professional role, underlying philosophy of care and competencies were important. Characteristics of the intervention that impacted on implementation included evidence of benefit, ease of use and adaptability to local circumstances. We postulate that the “fit” between the intervention and the context is critical in determining the success of implementation.

Conclusions

This comprehensive review of reviews summarises current knowledge on the barriers and facilitators to implementation of diverse complex interventions in primary care. To maximise the uptake of complex interventions in primary care, health care professionals and commissioning organisations should consider the range of contextual factors, remaining aware of the dynamic nature of context. Future studies should place an emphasis on describing context and articulating the relationships between the factors identified here.

Systematic review registration

PROSPERO CRD42014009410

Electronic supplementary material

The online version of this article (doi:10.1186/s13012-016-0396-4) contains supplementary material, which is available to authorized users.

Barriers and facilitators to exchanging health information: a systematic review

OBJECTIVES

We conducted a systematic review of studies assessing facilitators and barriers to use of health information exchange (HIE).

METHODS

We searched MEDLINE, PsycINFO, CINAHL, and the Cochrane Library databases between January 1990 and February 2015 using terms related to HIE. English-language studies that identified barriers and facilitators of actual HIE were included. Data on study design, risk of bias, setting, geographic location, characteristics of the HIE, perceived barriers and facilitators to use were extracted and confirmed.

RESULTS

Ten cross-sectional, seven multiple-site case studies, and two before-after studies that included data from several sources (surveys, interviews, focus groups, and observations of users) evaluated perceived barriers and facilitators to HIE use. The most commonly cited barriers to HIE use were incomplete information, inefficient workflow, and reports that the exchanged information that did not meet the needs of users. The review identified several facilitators to use.

DISCUSSION

Incomplete patient information was consistently mentioned in the studies conducted in the US but not mentioned in the few studies conducted outside of the US that take a collective approach toward healthcare. Individual patients and practices in the US may exercise the right to participate (or not) in HIE which effects the completeness of patient information available to be exchanged. Workflow structure and user roles are key but understudied.

CONCLUSIONS

We identified several facilitators in the studies that showed promise in promoting electronic health data exchange: obtaining more complete patient information; thoughtful workflow that folds in HIE; and inclusion of users early in implementation.

m-Health adoption by healthcare professionals: a systematic review

OBJECTIVE

The aim of this systematic review was to synthesize current knowledge of the factors influencing healthcare professional adoption of mobile health (m-health) applications.

METHODS

Covering a period from 2000 to 2014, we conducted a systematic literature search on four electronic databases (PubMed, EMBASE, CINAHL, PsychInfo). We also consulted references from included studies. We included studies if they reported the perceptions of healthcare professionals regarding barriers and facilitators to m-health utilization, if they were published in English, Spanish, or French and if they presented an empirical study design (qualitative, quantitative, or mixed methods). Two authors independently assessed study quality and performed content analysis using a validated extraction grid with pre-established categorization of barriers and facilitators.

RESULTS

The search strategy led to a total of 4223 potentially relevant papers, of which 33 met the inclusion criteria. Main perceived adoption factors to m-health at the individual, organizational, and contextual levels were the following: perceived usefulness and ease of use, design and technical concerns, cost, time, privacy and security issues, familiarity with the technology, risk-benefit assessment, and interaction with others (colleagues, patients, and management).

CONCLUSION

This systematic review provides a set of key elements making it possible to understand the challenges and opportunities for m-health utilization by healthcare providers.

Meeting user needs in national healthcare systems: lessons from early adopter community pharmacists using the electronic prescriptions service

Background

The Electronic Prescription Service release Two (EPS2) is a new national healthcare information and communication technology in England that aims to deliver effective prescription writing, dispensing and reimbursement service to benefit patients. The aim of the study was to explore initial user experiences of Community Pharmacists (CPs) using EPS2.

Methods

We conducted nonparticipant observations and interviews in eight EPS2 early adopter community pharmacies classified as ‘first-of-type’ in midlands and northern regions in England. We interviewed eight pharmacists and two dispensers in addition to 56 hours recorded nonparticipant observations as field notes. Line-by-line coding and thematic analysis was conducted on the interview transcripts and field notes.

Results

CPs faced two types of challenge. The first was to do with missing electronic prescriptions. This was sometimes very disrupting to work practice, but pharmacists considered it a temporary issue resolvable with minor modifications to the system and user familiarity. The second was to do with long term design-specific issues. Pharmacists could only overcome these by using the system in ways not intended by the developers. Some felt that these issues would not exist had ‘real’ users been involved in the initial development. The issues were: 1) printing out electronic prescriptions (tokens) to dispense from for safe dispensing practices and to free up monitors for other uses, 2) logging all dispensing activities with one user’s Smartcard for convenience and use all human resources in the pharmacy, and, 3) problematic interface causing issues with endorsing prescriptions and claiming reimbursements.

Conclusions

We question if these unintended uses and barriers would have occurred had a more rigorous user-centric principles been applied at the earlier stages of design and implementation of EPS. We conclude that, since modification can occur at the evaluation stage, there is still scope for some of these barriers to be corrected to address the needs, and enhance the experiences, of CPs using the service, and make recommendations on how current challenges could be resolved.