Transmitting and processing electronic prescriptions: experiences of physician practices and pharmacies

Electronic health records and e-prescribing in Australia: An exploration of technological utilisation in Australian community pharmacies

OBJECTIVE

This study aimed to assess the utilisation, benefits, and challenges associated with Electronic Health Records (EHR) and e-prescribing systems in Australian Community Pharmacies, focusing on their integration into daily practice and the impacts on operational efficiency, while also gathering qualitative insights from community pharmacists.

METHODS

A mixed-methods online survey was carried out among community pharmacists throughout Australia to assess the utilisation of EHR and e-prescribing systems, including the benefits and challenges associated with their use. Data was analysed based on pharmacists' age, gender, and practice location (metropolitan vs. regional). The chi-square test was applied to examine the relationship between these demographic factors and the utilisation and operational challenges of EHR and e-prescribing systems.

RESULTS

The survey engaged 120 Australian community pharmacists. Of the participants, 67 % reported usability and efficiency issues with EHR systems. Regarding e-prescribing, 58 % of pharmacists faced delays due to slow software performance, while 42 % encountered errors in data transmission. Despite these challenges, the benefits of e-prescribing were evident, with 79 % of respondents noting the elimination of illegible prescriptions and 40 % observing a reduction in their workload. Issues with prescription quantity discrepancies and the reprinting process were highlighted, indicating areas for improvement in workflow and system usability. The analysis revealed no significant statistical relationship between the utilisation and challenges of EHR and e-prescribing systems with the demographic variables of age, gender and location (p > 0.05), emphasising the necessity for healthcare solutions that address the needs of all pharmacists regardless of specific demographic segments.

CONCLUSION

In Australian community pharmacies, EHR and e-prescribing may enhance patient care but come with challenges such as data completeness, technical issues, and usability concerns. Implementing successful integration relies on user-centric design, standardised practices, and robust infrastructure. While demanding for pharmacists, the digital transition improves efficiency and quality of care. Ensuring user-friendly tools is crucial for the smooth utilisation of digital health.

Physicians' Perspectives with the E-prescribing System in Five Teaching Hospitals

OBJECTIVES

 Despite the evidence suggesting the potential of electronic prescribing (e-prescribing), this system also faces challenges that can lead to inefficiency and even failure. This study aimed to evaluate physicians' perspectives on the efficiency, effectiveness, opportunities, and challenges associated with the e-prescribing system.

METHODS

 In 2023, a descriptive analytics cross-sectional study was carried out. Due to the finite population size, all the physicians from five studied hospitals who agreed to participate in the study were included through the census method (n = 195). Data collection was conducted using a validated questionnaire. Data were analyzed using descriptive (mean, standard deviation, and frequency) and analytical (Pearson's correlation coefficient, two-sample t-test, one-way analysis of variance (ANOVA), and linear multiple regression model) statistics.

RESULTS

 The mean scores of efficiency and effectiveness were 47.47 ± 14.46 and 36.09 ± 10.67 out of 95 and 65, respectively. Removing the illegibility of the prescriptions (n = 22) was the most frequent opportunity and internet connectivity problem (n = 37) was the most frequent challenge associated with the e-prescribing system. There was a strong positive significant correlation between efficiency and effectiveness (r = 0.850, p < 0.01). Moreover, age was found to have a significant negative correlation with efficiency (B =  -7.261, p = 0.004) and effectiveness (B = - 5.784, p = 0.002).

CONCLUSION

 Physicians believe that e-prescribing enhances the efficiency and effectiveness of their work. There are many opportunity and challenges to the use of e-prescription. Assessing the needs of physicians, actively participating and training them in the stages of design and implementation, and conducting regular evaluations of the e-prescribing system are crucial to overcome the challenges. Our finding offers insightful information about how doctors see the e-prescribing system at teaching hospitals and provide a basis for managers and policy makers at the local and national levels to support the implementation of this system and plan for improvement of its shortcomings.

Benefits and barriers associated with e-prescribing in community pharmacy - A systematic review

Background

The utilization of electronic prescribing is growing, prompted by lockdown measures during the COVID-19 pandemic. However, despite this increasing adoption, there is a notable dearth of consolidated evidence regarding the challenges and opportunities associated with the integration of electronic prescribing systems within the daily clinical practices of community pharmacists.

Objective

This paper aims to systematically review the community pharmacists' perspectives on barriers and facilitators to electronic prescribing, addressing the significant need for understanding how electronic prescribing impacts the workflow and decision-making processes of pharmacists, ultimately influencing the quality of patient care.

Methods

PubMed, Embase, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases were searched from January 1, 2000, to October 25, 2022, using search terms related to electronic prescribing, computerised physician order entry, community/retail pharmacies, and pharmacists.

Results

A total of 28 studies were included in the systematic review. In these studies, community pharmacists perceived that design, interoperability, attitude towards e-prescribing technology, information quality, workflow, productivity, and accessible resources facilitated e-prescribing. In addition, the included studies emphasized the importance of technological support for the successful implementation of electronic prescribing systems. The system's design characteristics significantly improve e-prescribing technology's favourable effects. According to our review, it has been proposed that a poorly designed e-prescribing system can have a negative impact on the quality of care, implementation, and user satisfaction. In contrast, a well-designed system can significantly contribute to improvements.

Conclusions

The review highlighted that e-prescribing has both barriers and facilitators, with the quality of the system and its implementation influencing these factors. Technical issues and user acceptance (patient/prescribers/pharmacists) can act as barriers or enablers, highlighting the need for comprehensive consideration and monitoring of e-prescribing to identify and address potential issues.

Perceptions of Community Pharmacists toward the National E-Prescribing Service (Wasfaty) and Exploring the Benefits and Challenges of the Service: A Descriptive Study from Qassim Region, Saudi Arabia

BACKGROUND

Electronic prescribing systems (e-prescription) for medications have many benefits, including patient safety, increase in patient satisfaction, efficiency of pharmacy work, and quality of patient care. However, few studies have been conducted to evaluate the national e-prescription system "Wasfaty" service in Saudi Arabia, which was recently adopted.

OBJECTIVE

The aims of this study were to explore the benefits observed through the use of the system and most frequent challenges experienced by community pharmacists in the Qassim region of Saudi Arabia.

METHODS

This study was conducted using a descriptive survey on a web-based platform. The target population of the study included community pharmacists in the Qassim region of Saudi Arabia who worked in pharmacy chains utilizing the e-prescription service between September 2022 and November 2022. Descriptive statistics along with multiple ordinal regression were used for data analysis.

RESULTS

The study population consisted of 124 pharmacists, of which 62.9% (78/124) were males and 37.1% (46/124) were females. Most of the participants had a positive perception of the e-prescription system with regard to medication safety, with 68.6% (85/124) indicating that e-prescriptions reduce the risk of dispensing errors. However, 81.5% (101/124) did not agree that the e-prescription system resulted in a reduction in workload, and 70.2% (87/124) disagreed that the service increased patient satisfaction.

CONCLUSIONS

The results of this study indicated that the national e-prescription system has many benefits to healthcare employees and improves their work, particularly for patient safety, reducing medication errors, and improving the management of patient medications. The participants believe that there is a need to improve communication with prescribers, showing concern about the unavailability of some medications; thus, it is important for policymakers to encourage other pharmacy chains and suppliers to join the service to increase patient access to medications.

Going digital in Germany: An exploration of physicians’ attitudes towards the introduction of electronic prescriptions – a mixed methods approach

PURPOSE

Digitalization of medical prescriptions is a core element for the digitalization of healthcare. While some countries have introduced electronic prescriptions over 20 years ago and nearly reached 100 % penetration, physicians in Germany have only been able to use electronic prescriptions since mid-2021 and currently only 0.1 % of prescriptions are transmitted electronically. This study investigates German physicians' viewpoint towards electronic prescriptions as a potential reason for the low penetration and investigates levers to drive adoption.

BASIC PROCEDURES

We conducted a two-stage sequential mixed methods study consisting of semi-structured interviews followed by an online survey among 1136 physicians testing the main dimensions of the Unified Theory of Acceptance and Use of Technology model.

MAIN FINDINGS

Our initial interviews suggested that there was a high technology acceptance by physicians, but due to technical barriers, they were not able to use the system, explaining the low penetration. However, with the larger sample size of the survey, we identified, that while physicians see barriers for introducing electronic prescriptions, such as unclear cost reimbursement or lack of time to deal with the implementation, the majority believes these can be overcome within twelve months. Furthermore, we found that only one third of physicians is in favor of replacing paper-based prescriptions with electronic prescriptions and most physicians considers it unlikely that they will issue more than half of their prescriptions electronically within the next twelve month. Additionally, respondents perceived limited usefulness and expect high effort for using electronic prescriptions.

PRINCIPAL CONCLUSION

Low electronic prescription penetration in Germany seems to be driven by low technology acceptance, not technical barriers. This can be linked to low perceived usefulness, high effort expectancy and low perceived patient demand. Improving technical stability, system functionality and increasing physicians' level of information were seen as main levers to drive electronic prescription adoption.

Systemic Barriers in Receiving Electronically Prescribed Glaucoma Medications

PRCIS

Over a third of electronically prescribed glaucoma medications were not picked up within 1 month of patient request. Feedback-driven protocols may help minimize treatment interruptions attributed to electronic prescribing.

PURPOSE

Glaucoma treatment relies on long-term medication compliance and many socioeconomic factors impact the ability of patients to receive their medications. This study aims to quantify treatment interruptions attributable to electronically prescribed medications and propose interventions to minimize this barrier.

METHODS

This is a cross-sectional study of the electronic prescribing patterns at a tertiary care hospital serving a socioeconomically diverse patient population. Glaucoma medication refill requests received over a 6-week interval were reviewed and patient pharmacies were contacted 1 month after the request date to determine whether the medication was received by the patient. Patients who did not pick up the prescriptions were contacted and consented to participate in a survey to identify the barriers to acquiring the medications.

RESULTS

Refill requests of 198 glaucoma medications met the inclusion criteria and the most common classes were prostaglandin analogs (44%) and alpha-2-agonists (21%). Medications were not obtained within 1 month in 71 (35.9%) cases. Prior authorization requirement was significantly associated with patients not obtaining their medication (odds ratio, 0.07; 95% confidence interval, 0.03-0.45). Patient reported challenges to successful receipt electronically prescribed medications included insurance coverage (32.2%) and pharmacy availability (22.6%).

CONCLUSIONS

Approximately a third of electronically prescribed glaucoma medications were not received by patients within a month of refill request due to the need for prior authorization, insurance coverage, and pharmacy availability. A mechanism to alert providers and to address these barriers to medication access may minimize treatment interruption and disease progression.

Implementation outcomes of the Structured and Codified SIG format in electronic prescription directions

OBJECTIVE

To determine the extent of implementation, completeness, and accuracy of Structured and Codified SIG (S&C SIG) directions on electronic prescriptions (e-prescriptions).

MATERIALS AND METHODS

A retrospective analysis of a random sample of 3.8 million e-prescriptions sent from electronic prescribing (e-prescribing) software to outpatient pharmacies in the United States between 2019 and 2021. Natural language processing was used to identify direction components, including action verb, dose, frequency, route, duration, and indication from free-text directions and were compared to the S&C SIG format. Inductive qualitative analysis of S&C direction identified error types and frequencies for each component.

RESULTS

Implementation of the S&C SIG format in e-prescribing software resulted in 32.4% of e-prescriptions transmitted with these standardized directions. Directions using the S&C SIG format contained a greater percentage of each direction component compared to free-text directions, except for the indication component. Structured and codified directions contained quality issues in 10.3% of cases.

DISCUSSION

Expanding adoption of more diverse direction terminology for the S&C SIG formats can improve the coverage of directions using the S&C SIG format. Building out e-prescribing software interfaces to include more direction components can improve patient medication use and safety. Quality improvement efforts, such as improving the design of e-prescribing software and auditing for discrepancies, are needed to identify and eliminate implementation-related issues with direction information from the S&C SIG format so that e-prescription directions are always accurately represented.

CONCLUSION

Although directions using the S&C SIG format may result in more complete directions, greater adoption of the format and best practices for preventing its incorrect use are necessary.

Comparing the variability of ingredient, strength, and dose form information from electronic prescriptions with RxNorm drug product descriptions

OBJECTIVE

To determine the variability of ingredient, strength, and dose form information from drug product descriptions in real-world electronic prescription (e-prescription) data.

MATERIALS AND METHODS

A sample of 10 399 324 e-prescriptions from 2019 to 2021 were obtained. Drug product descriptions were analyzed with a named entity extraction model and National Drug Codes (NDCs) were used to get RxNorm Concept Unique Identifiers (RxCUI) via RxNorm. The number of drug product description variants for each RxCUI was determined. Variants identified were compared to RxNorm to determine the extent of matching terminology used.

RESULTS

A total of 353 002 unique pairs of drug product descriptions and NDCs were analyzed. The median (1st-3rd quartile) number of variants extracted for each standardized expression in RxNorm, was 3 (2-7) for ingredients, 4 (2-8) for strength, and 41 (11-122) for dosage forms. Of the pairs, 42.35% of ingredients (n = 328 032), 51.23% of strengths (n = 321 706), and 10.60% of dose forms (n = 326 653) used matching terminology, while 16.31%, 24.85%, and 13.05% contained nonmatching terminology, respectively.

DISCUSSION

A wide variety of drug product descriptions makes it difficult to determine whether 2 drug product descriptions describe the same drug product (eg, using abbreviations to describe an active ingredient or using different units to represent a concentration). This results in patient safety risks that lead to incorrect drug products being ordered, dispensed, and used by patients. Implementation and use of standardized terminology may reduce these risks.

CONCLUSION

Drug product descriptions on real-world e-prescriptions exhibit large variation resulting in unnecessary ambiguity and potential patient safety risks.

Impact of CancelRx on discontinuation of controlled substance prescriptions: an interrupted time series analysis

Background

Prescription opioid misuse is a serious national crisis; in 2018 the top drugs involved in prescription overdose deaths included pain medications (opioids), benzodiazepines, and stimulants. Health information technology (health IT) provides a means to address this crisis through technologies that streamline the prescribing and discontinuation process. CancelRx is a health IT function that communicates when medications, such as controlled substances, are discontinued at the clinic and therefore should not be filled at the pharmacy. Prior to CancelRx, the communication of discontinued medications was a manual process, requiring the patient or a clinic staff member to personally contact the pharmacy to inform them of the change. The objective of this study was to assess how controlled substance medication discontinuations were communicated over time, before and after the implementation of CancelRx.

Methods

Secondary data from a midwestern academic health system electronic health record and pharmacy platform were collected 12-months prior to CancelRx implementation and for 12-months post implementation. The study utilized an interrupted time series analysis (ITSA) to capture the percentage of controlled substance medications that were discontinued in the clinic’s electronic health record and discontinued in the pharmacy’s dispensing software. The ITSA plotted the percentage of successful discontinuation messages over time, particularly after the health system’s implementation of CancelRx, a novel technology.

Results

After CancelRx implementation there was an immediate (change = 77.7 percentage point) and significant (p < 0.001) increase in the number of controlled substance medications that were successfully discontinued at the pharmacy after being discontinued in the clinic. This change was sustained in the year following CancelRx (slope = 0.03 pp, 95% CI − 0.050 to 0.110) and did not revert to pre-CancelRx levels. The health IT functionality was able to effectively complete discontinuation tasks and potentially reduce workload for clinic staff.

Conclusions

Overall, this study demonstrates the role that technology can play in promoting communication between clinics and pharmacies, especially when medications such as controlled substances are discontinued.

Supplementary Information

The online version contains supplementary material available at 10.1186/s12911-022-01779-9.

Implementation of E-prescription for Multidose Dispensed Drugs: Qualitative Study of General Practitioners' Experiences

Background

Increased use of pharmaceuticals challenges both capacity and safety related to medication management for patients and changes in how general practitioners (GPs) and other health personnel interact with and follow up with patients. E-prescribing of multidose drug dispensing (eMDD) is 1 of the national measures being tested in Norway.

Objective

The objective of this study is to explore GPs’ experiences with the challenges and benefits of implementing eMDD in Norway.

Methods

Qualitative in-depth and group interviews were conducted with a total of 25 GPs between 2018 and 2020. Transcribed files were saved in NVivo to conduct a step-by-step content analysis. NVivo is a software tool for organizing, managing, and analyzing qualitative data.

Results

The study revealed that eMDD offers many benefits. At the same time, there are several challenges related to information, training, and initiation, as well as to the responsibility for the medication, interactions, and the risk of incorrect medication. An important activity in the start-up phase was an information meeting with pharmacies and technology suppliers, as well as exchanging information and instructions with pharmacies on how to get started. Four analytic themes emerged through the extraction of data: (1) start-up with eMDD (“Be patient”); (2) the need for training; (3) interaction, safety, and efficiency; and (4) the working day with eMDD.

Conclusions

There is a variation in different GPs’ needs regarding training and information, and considerable variation in competence and motivation related to the use of digital tools. There are also different degrees of understanding the everyday work of the other actors in the medication chain. In particular, the harmonization of medication lists related to the use of time, expenditures, and challenges with technological solutions in the introduction phase was emphasized as a challenge. Overall, GPs who have started using the system report great benefits; these are largely related to an increased overview of patients’ total medication lists, less time spent on prescribing prescriptions, and increased collaboration with pharmacies and nurses, both in service from providers in homes and in nursing homes.

Capacity Building for Primary Stroke Prevention Teams in Children Living With Sickle Cell Anemia in Africa

BACKGROUND

Nigeria has the highest proportion of children with sickle cell anemia (SCA) globally; an estimated 150,000 infants with SCA are born annually. Primary stroke prevention in children with SCA must include Nigeria. We describe capacity-building strategies in conjunction with two National Institutes of Health-funded primary stroke prevention trials (a feasibility trial and phase III randomized controlled trial) with initial hydroxyurea treatment for children with SCA and abnormal transcranial Doppler (TCD) velocities in Nigeria. We anticipated challenges to conducting clinical trials in a low-resource setting with a local team that had not previously been involved in clinical research and sought a sustainable strategy for primary stroke prevention.

METHODS

This is a descriptive, prospective study of challenges, solutions, and research teams in two trials that enrolled a total of 679 children with SCA.

RESULTS

As part of the capacity-building component of the trials, over eight years, 23 research personnel (physicians, nurses, research coordinators, a statistician, and a pharmacist) completed a one-month research governance and ethics training program at Vanderbilt University Medical Center, USA. A lead research coordinator for each site completed the Society of Clinical Research Professionals certification. TCD machines were donated; radiologists and nonradiologists were trained and certified to perform TCD. A scalable E-prescription was implemented to track hydroxyurea treatment. We worked with regional government officials to support ongoing TCD-based screening and funding for hydroxyurea for children with SCA at a high risk of stroke.

CONCLUSIONS

Our trials and capacity building demonstrate a sustainable strategy to initiate and maintain pediatric SCA primary stroke prevention programs in Africa.

Quality of Handoffs in Community Pharmacies

OBJECTIVES

The aims of the study were to characterize handoffs in community pharmacies and to examine factors that contribute to perceived handoff quality.

METHODS

A cross-sectional study of community pharmacists in a Midwest State of the United States. Self-administered questionnaires were used to collect information on participant and practice setting characteristics. Data were analyzed using descriptive statistics and multivariate logistic regression.

RESULTS

A total of 445 completed surveys were returned (response rate, 82%). In almost half of the time, handoffs that occur in a community pharmacy setting were inaccurate or incomplete. Nearly half of the time handoffs occur in environments full of interruptions and distractions. More than 90% of the respondents indicated that they have undergone no formal training on proper ways of handing off information. Nearly 40% of respondents reported that their pharmacy dispensing technology does not have adequate functionality to support handing off information and that at least 50% of the time, poor handoffs result in additional work to the pharmacist because of the need for complete information before providing patient care. Multivariate analysis showed that being very familiar with patients, lower daily prescription volume, not having a 24-hour operation, and larger percentage of handoffs occurring in a synchronous fashion are all associated with better handoff quality.

CONCLUSIONS

Handoffs occur frequently and are problematic in community pharmacies. Current pharmacy environments offer limited support to conduct good handoffs, and as a result, pharmacists report loss of information. This could present as a significant patient safety hazard. Future interventions should target facilitating better communication during shift changes.

CancelRx: a health IT tool to reduce medication discrepancies in the outpatient setting

OBJECTIVE

Medication list discrepancies between outpatient clinics and pharmacies can lead to medication errors. Within the last decade, a new health information technology (IT), CancelRx, emerged to send a medication cancellation message from the clinic's electronic health record (EHR) to the outpatient pharmacy's software. The objective of this study was to measure the impact of CancelRx on reducing medication discrepancies between the EHR and pharmacy dispensing software.

MATERIALS AND METHODS

CancelRx was implemented in October 2017 at an academic health system. For 12 months prior, and 12 months after CancelRx implementation, data were collected on discontinued medications in the health system's EHR and whether those prescriptions were successfully discontinued in the pharmacy's dispensing software. An interrupted time series analysis was conducted to model the occurrence of prescriptions successfully discontinued over time.

RESULTS

There was an immediate (lag = 0), significant (P < 0.001), and sustained (post-implementation slope 0.02) increase in the proportion of successful medication discontinuations after CancelRx implementation (from 34% to 93%). CancelRx had variable impact based on whether the clinic was primary care (71.4% change prepost) or specialty care (53.9% change prepost). CancelRx reduced the time between when a medication was discontinued in the clinic EHR and pharmacy dispensing software.

CONCLUSION

CancelRx automated a manual process and illustrated the role for health IT in communicating medication discontinuations between clinics and pharmacies. Overall, CancelRx had a marked benefit on medication list discrepancies and illustrated how health IT can be used across different settings to improve patient care.

From Paper to E-Prescribing of Multidose Drug Dispensing: A Qualitative Study of Workflow in a Community Care Setting

E-prescribing is now widespread and, in some countries, has completely replaced paper prescriptions. In Norway, almost all prescribing is electronic, except for multidose drug dispensing (MDD), which is still sent to the pharmacy by fax or ordinary mail. MDD is an adherence aid used by one-third of all patients receiving home care services. In this paper, we present results from a qualitative study evaluating the introduction of e-prescribing for MDD in a community health care setting. The focus is on the work and workflow for the pharmacists and nurses involved in the medication-handling process. We used the pragmatic process evaluation framework and the systematic text condensation method to analyse the data. We conducted 12 interviews with 34 nurses and pharmacists. This study shows that the e-prescribing of MDD led to greater integration between systems, both within the existing MDD system and across care levels, potentially improving patient safety. However, the structured prescriptions increased the need for clarifications, resulting in an increased overall workload. A greater understanding of the roles and responsibilities of the different professionals in the medication management chain and their needs would improve the workflow of the nurses and pharmacists involved.

Assessing automated product selection success rates in transmissions between electronic prescribing and community pharmacy platforms

OBJECTIVE

Wrong drug product errors occurring in community pharmacies often originate at the transcription stage. Electronic prescribing and automated product selection are strategies to reduce product selection errors. However, it is unclear how often automated product selection succeeds in outpatient pharmacy platforms.

MATERIALS AND METHODS

The intake of over 800 e-prescriptions was observed at baseline and after intervention to assess the rate of automated product selection success. A dispensing accuracy audit was performed at baseline and postintervention to determine whether enhanced automated product selection would result in greater accuracy; data for both analyses were compared by 2x2 Chi square tests. In addition, an anonymous survey was sent to a convenience sample of 60 area community pharmacy managers.

RESULTS

At baseline, 79.8% of 888 e-prescriptions achieved automated product selection. After the intervention period, 84.5% of 903 e-prescriptions achieved automated product selection (P = .008). Analysis of dispensing accuracy audits detected a slight but not statistically significant improvement in accuracy rate (99.3% versus 98.9%, P = .359). Fourteen surveys were returned, revealing that other community pharmacies experience similar automated product selection failure rates.

DISCUSSION

Our results suggest that manual product selection by pharmacy personnel is required for a higher than anticipated proportion of e-prescriptions received and filled by community pharmacies, which may pose risks to both medication safety and efficiency.

CONCLUSION

The question of how to increase automated product selection rates and enhance interoperability between prescriber and community pharmacy platforms warrants further investigation.

Doctors' Perceptions of E-Prescribing upon Its Mandatory Adoption in Poland, Using the Unified Theory of Acceptance and Use of Technology Method

Background: E-prescribing is the most important achievement in the automation of the healthcare sector in Poland. Obligatory electronic prescribing came into force on 8 January 2020. This innovation significantly changes the work of doctors. Therefore, it is useful to identify the factors that have an impact on doctors’ acceptance levels for the new technology. Methods: This study employs a survey based on the Unified Theory of Acceptance and Use of Technology (UTAUT) method. Our questionnaire was completed by 144 family doctors in Poland during the technology implementation phase and the initial period of obligatory e-prescribing, between 1 December 2019 and 1 March 2020. Results: The results of the survey indicate that doctors do not believe that e-prescribing improves the effectiveness of their work. In addition, this attitude does not depend on the age of the respondent. We also found, regarding the influence of societal attitudes, that doctors only rarely consider the opinions of others in relation to their job. Conclusions: The implementation of new technologies in the healthcare system must be accompanied by consideration of how user-friendly the technologies are, and whether the users will have appropriate technical and financial support.

Main Elements of National Model of Electronic Prescription System from Physicians' Point of View: A Case Study in a Developing Country

Identifying the factors and components of an electronic prescription system is of utmost importance in effective designing and implementation of this system. In this regard, the current study was conducted to determine the main factors affecting the national model of electronic prescription from the physicians' point of view. This is a cross-sectional, descriptive-analytical research carried out in 2015. Based on the census sampling method, 104 members of the board of directors of the Iranian general practitioners' associations, general practitioners' alumni association of Iran, and physicians owner of a website or weblog were selected as samples for this study. Data were collected using a valid and reliable questionnaire. After analyzing the data with SPSS software (v.16), a model was proposed using a regression algorithm. The findings indicated that accessing the current medication data and medication history of patients during prescription, and also creating the electronic patient medication record (ePMR) are the most important selective components for physicians with frequency percent of 92.1%. Moreover, from the physicians' viewpoint, the method of "transmission of prescriptions to the central national database and retrieving prescriptions information from the selected pharmacy of the patient" had the highest priority (weight coefficient) in the model of the national electronic prescription system. Therefore, the Iranian prescription system is required to be developed based on the centralized architecture and national electronic prescription database.

Implementation fidelity of patient-centered prescription label to promote opioid safe use

PURPOSE

Patient-centered labels may improve safe medication use, but implementation challenges limit use. We assessed implementation of a patient-centered "PRN" (as needed) label entitled "Take-Wait-Stop" (TWS) with three deconstructed steps replacing traditional wording.

METHODS

As part of a larger investigation, patients received TWS prescriptions (eg, Take: 1 pill if you have pain; Wait: at least 4 h before taking again; Stop: do not take more than 6 pills in 24 h). Prescriptions labels recorded at follow-up were classified into three categories: (1) one-step wording (Take 1 pill every 4 h [without daily limits]), (2) two-step wording (Take 1 pill every 4 h; do not exceed 6 pills/day), and (3) three-step wording. There were three subtypes of three-step wording: (3a) three-step, not TWS (three deconstructed steps, not necessarily TWS wording), (3b) TWS format, employing three steps with leading verbs, but "with additions or replacements" (eg, replaced "do not take" with "do not exceed"), and (3c) verbatim TWS.

RESULTS

Two hundred eleven participants completed follow-up. Mean age was 44.3 years (SD 14.3); 44% were male. One-step bottles represented 12% (n = 25) of the sample, whereas 26% (n = 55) had two-step wording. The majority (44%, n = 93) had three-deconstructed steps, not TWS (3a); 16% (n = 34) retained TWS structure, but not verbatim (3b). Only 2% (n = 4) displayed verbatim TWS wording (3c). All category three labels (utilizing deconstructed instructions) were considered adequate implementation (62%).

CONCLUSIONS

Exact intervention adherence was not achieved in the majority of cases, limiting impact. Nonetheless, community pharmacies were responsive to new instructions, but higher implementation reliability requires additional supports.

Physicians' Perceptions of Electronic Prescribing with Electronic Medical Records in Kuwaiti Primary Healthcare Centres

Objectives

This study aimed to evaluate physicians' perceptions of electronic prescribing in Kuwaiti primary healthcare centres.

Methods

This cross-sectional study was conducted between June and August 2017 among 368 physicians from 25 primary healthcare centres in Kuwait. Data were collected from the participants using a self-reported questionnaire, including sociodemographic characteristics, previous experience with computers and awareness, knowledge and use of e-prescribing systems and their functional features. In addition, perceptions of the benefits and levels of satisfaction associated with e-prescribing were explored.

Results

A total of 306 physicians completed the survey (response rate: 83%). The majority had positive perceptions regarding the use of e-prescribing, particularly in terms of time-savings (86%), healthcare quality (84%), productivity (80%) and clinical workflow and efficiency (83%). However, many respondents indicated that e-prescribing systems required additional improvements in terms of functionality.

Conclusion

Most physicians in primary healthcare centres in Kuwait recognised the importance of e-prescribing to improve the quality of patient care, streamline workflow, increase productivity and reduce medical errors. However, there is a need to improve the design and infrastructure of e-prescribing systems, which may aid in the adoption of such systems in Kuwait.

An Examination of the Prescription Renewal Process and Implications for Primary Care Physicians and Community Pharmacists

In physician practices and pharmacies, staff members work to process prescription renewals so that patients receive a steady supply of medications. These functions are essential to ensure patients have continuous access to medications and remain adherent to prescribed therapies. Despite the incorporation of e-prescribing software programs to ease management of these processes, barriers to effective management of the prescription renewal process exist. Mismanagement of pharmacy adherence programs can ultimately lead to patients receiving inappropriate medications and excessive use of staff resources. The objective of this article is to examine the prescription renewal process in both the primary care setting and the pharmacy and report challenges associated with the process. A literature review was conducted to find studies that describe pharmacists' and physicians' handlings of prescription renewals, use of e-prescribing software, and benefits and barriers to using these technologies. Although studies report e-prescribing software improves efficiency in the prescription renewal process, there is a need to reduce technological problems that create challenges in use. It is recommended that staff within physician practices and pharmacies standardize prescription renewal processes and educate patients about the prescription renewal process.

Medication safety and the usability of electronic prescribing as perceived by physicians-A semistructured interview among primary health care physicians in Finland

RATIONALE, AIMS AND OBJECTIVES

In Finland, a fully operational and nationwide electronic prescription (ePrescription) system was implemented by law in 2012 to 2015. From 2017, all prescriptions have to be electronic. ePrescriptions are intended to facilitate prescribing and to improve medication safety in Finnish health care. In this study, the aim was to explore physicians' experiences with the impacts of ePrescriptions on prescribing and medication safety in Finland.

METHOD

Data were collected by conducting 42 interviews among primary health care physicians in spring 2015. The data obtained were analyzed by means of qualitative content analysis.

RESULTS

Most of the physicians considered ePrescriptions to be convenient to issue because of the paperless procedure. Additionally, physicians stated that information concerning patients' prescriptions was better available through the Prescription Centre since physicians were able to check patients' prescriptions, including those issued elsewhere. In particular, ePrescriptions have improved the control of narcotics and medicines classified as primarily affecting the central nervous system. However, establishing a patient's overall medication through the Prescription Centre was regarded as difficult because prescription information was sometimes incoherent and had not been updated. The ePrescribing system was also described as inflexible, especially the correcting, cancelling, or renewing of ePrescriptions. For example, the system required too many "mouse clicks" and PIN entries to justify the actions taken in prescriptions. The system's slowness and the poor connection between physicians' electronic patient records and the Prescription Centre were also underlined.

CONCLUSIONS

According to the Finnish physicians interviewed, ePrescriptions have facilitated prescribing in some respects. However, the ePrescribing system still has problems and the Prescription Centre cannot be fully used for the management of a patient's overall medication.

A Quality Improvement Initiative: Improving the Frequency of Inpatient Electronic Prescribing

OBJECTIVE

To improve the frequency of electronic prescribing (e-prescribing) of discharge prescriptions at a children's hospital via a bundle of quality improvement interventions.

METHODS

Surveys and focus groups were conducted with patient families and pediatric residents to identify barriers and propose solutions to e-prescribing. These data were used to generate a series of interventions, including the following: (1) provider education; (2) changes in patient registration workflow; and (3) electronic health record changes to improve the frequency of e-prescribing on the pediatric hospital medicine (PHM) service. The primary outcome measure was the e-prescribing frequency, with a balance measure of e-prescribing errors.

RESULTS

From July 2014 through June 2015, e-prescribing frequency on the PHM service improved from a median of 7.4% to 48.9% (P < .001) and was sustained for an additional 6 months (July 2015-December 2015), surpassing meaningful use targets with associated US News and World Report hospital ranking points. The frequency of PHM prescription errors remained unchanged, and in comparison, the resident outpatient clinic revealed no statistically significant change in e-prescribing frequency during this time period.

CONCLUSIONS

Engaging front-line providers in hospital-wide initiatives and quality improvement interventions can directly affect hospital metrics in programs such as meaningful use and US News and World Report, as shown through successful improvement in PHM e-prescribing frequency. Future studies are necessary to determine whether increased e-prescribing frequency affects patient outcomes and compliance.

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.

Optimized Computerized Order Entry can Reduce Errors in Electronic Prescriptions and Associated Pharmacy Calls to Clarify (CTC)

BACKGROUND

After implementation of a system-wide EMR within our university system, e-prescribing is now commonplace.

OBJECTIVE

The authors conducted a study to assess whether optimization of computerized provider order entry (CPOE) can reduce errors in these electronically transmitted prescriptions and would require less frequent interventions from pharmacists, in particular the need for them to "call to clarify" (CTC) details of particular prescriptions. Secondary analysis based on cost assumptions was preformed to presume cost differences before and after optimization changes.

MATERIALS AND METHODS

In order to generate complete, error-free prescriptions, optimization changes were implemented in the form of in line validation messages. These messages were generated if (1) an order did not specify a provider or pharmacy; (2) the DEA requirements were not met; (3) character limits were exceeded in patient sig or demographics or (4) administration instructions had breaks or had both discrete and free text elements. Retrospectively, prescriptions were randomly selected from a nine month period before and after implementing changes. These prescriptions were analyzed by a pharmacist and a nurse to identify types of errors that would require a CTC to a prescribing provider. Errors were compared statistically to determine effectiveness of changes pre and post optimization.

RESULTS

A total of 602 prescriptions were analyzed; 301 before changes and 301 after changes. Of these prescriptions, 20.27% had errors before changes and 12.96% had errors after changes. The decline in the error rate was considered statistically significant for p<0.05. The cost savings were estimated at $76 per 100 prescriptions for pharmacist and physician time-cost estimates combined.

CONCLUSIONS

Implementing optimization changes to the CPOE resulted in a reduction in error rate requiring pharmacist CTC. This study identifies effective optimization changes for electronic prescribing that can reduce prescribing errors and may result in cost saving.

Evaluating the implementation of RxNorm in ambulatory electronic prescriptions

OBJECTIVE

RxNorm is a standardized drug nomenclature maintained by the National Library of Medicine that has been recommended as an alternative to the National Drug Code (NDC) terminology for use in electronic prescribing. The objective of this study was to evaluate the implementation of RxNorm in ambulatory care electronic prescriptions (e-prescriptions).

METHODS

We analyzed a random sample of 49 997 e-prescriptions that were received by 7391 locations of a national retail pharmacy chain during a single day in April 2014. The e-prescriptions in the sample were generated by 37 801 ambulatory care prescribers using 519 different e-prescribing software applications.

RESULTS

We found that 97.9% of e-prescriptions in the study sample could be accurately represented by an RxNorm identifier. However, RxNorm identifiers were actually used as drug identifiers in only 16 433 (33.0%) e-prescriptions. Another 431 (2.5%) e-prescriptions that used RxNorm identifiers had a discrepancy in the corresponding Drug Database Code qualifier field or did not have a qualifier (Term Type) at all. In 10 e-prescriptions (0.06%), the free-text drug description and the RxNorm concept unique identifier pointed to completely different drug concepts, and in 7 e-prescriptions (0.04%), the NDC and RxNorm drug identifiers pointed to completely different drug concepts.

DISCUSSION

The National Library of Medicine continues to enhance the RxNorm terminology and expand its scope. This study illustrates the need for technology vendors to improve their implementation of RxNorm; doing so will accelerate the adoption of RxNorm as the preferred alternative to using the NDC terminology in e-prescribing.

Analysis of National Drug Code Identifiers in Ambulatory E-Prescribing

BACKGROUND

Communication of an accurate and interpretable drug identifier between prescriber and pharmacist is critically important for realizing the potential benefits of electronic prescribing (e-prescribing) while minimizing its risk. The National Drug Code (NDC) is the most commonly used codified drug identifier in ambulatory care e-prescribing, but concerns have been raised regarding its use for this purpose. 

OBJECTIVES

To (a) assess the frequency of NDC identifier transmission in ambulatory e-prescribing; (b) characterize the type of NDC identifier transmitted (representative, repackaged, obsolete, private label, and unit dose); and (c) assess the level of agreement between drug descriptions corresponding to NDC identifiers in electronic prescriptions (e-prescriptions) and the free-text drug descriptions that were entered by prescribers. 

METHODS

We analyzed a sample of 49,997 e-prescriptions that were transmitted by ambulatory care prescribers to outlets of a national retail drugstore chain during a single day in April 2014. The First Databank MedKnowledge drug database was used as the primary reference data base to assess the frequency and types of NDC numbers in the e-prescription messages. The FDA's Comprehensive NDC Standard Product Labeling Data Elements File and the National Library of Medicine's RxNorm data file were used as secondary and tertiary references, respectively, to identify NDC numbers that could not be located in the primary reference file. Three experienced reviewers compared the free-text drug description that had been entered by the prescriber with the drug description corresponding to the NDC number from 1 of the 3 reference database files to identify discrepancies. Two licensed pharmacists with residency training and ambulatory care experience served as final adjudicators.

RESULTS

A total of 42,602 e-prescriptions contained a value in the NDC field, of which 42,335 (84.71%) were found in 1 of the 3 study reference databases and were thus considered to be valid NDC numbers. A total of 28,172 (67.70%) e-prescriptions in the sample were found to contain a representative NDC number, according to the definition used by the National Council for Prescription Drug Programs (NCPDP). The remaining e-prescriptions consisted of 4 subtypes of unrepresentative NDC numbers. In 41,298 (97.55%) e-prescriptions that contained an NDC number, the drug description associated with the number from 1 of the 3 data source files pointed to the identical semantic drug concept as the free-text drug description that had been entered by the prescriber. However, in 87 (0.21%) e-prescriptions, the free-text drug descriptions and the drug description associated with the NDC number pointed to completely different semantic drug concepts.

CONCLUSIONS

We found the use of NDC identifiers in our sample of e-prescriptions to be relatively high. However, approximately one-third consisted of unrepresentative NDC numbers (obsolete, repackaged, unit dose, or private label) that have the potential to create workflow disruptions at the dispensing pharmacy. Most disturbing was our finding that more than 2 out of every 1,000 e-prescriptions in our sample contained a free-text drug description that pointed to a completely different drug concept than that associated with its NDC value. Our study suggests the need for e-prescribing technology vendors to maintain accurate and up-to-date drug database files within their systems and to conduct regular validation checks to ensure that the drug descriptions associated with the NDC identifier and the free-text drug description that is sent in the e-prescription message point to the same drug concept. The FDA may need to consider a more active role in ensuring the accuracy of NDC assignment by drug manufacturers.

Pharmaceutical Role Expansion and Developments in Pharmacist-Physician Communication

Expanded clinical pharmacist professional roles in the team-based patient-centered medical home (PCMH) primary care environment require cooperative and collaborative relationships among pharmacists and primary care physicians (PCPs), but many PCPs have not previously worked in such a direct fashion with pharmacists. Additional roles, including formulary control, add further elements of complexity to the clinical pharmacist-PCP relationship that are not well described. Our objective was to characterize the nature of clinical pharmacist-PCP interprofessional collaboration across seven federally funded hospitals and associated primary care clinics, following pharmacist placement in primary care clinics and incorporation of expanded pharmacist roles. In-depth and semistructured interviews were conducted with 25 practicing clinical pharmacists and 17 PCPs. Qualitative thematic analysis revealed three major themes: (1) the complexities of electronic communication (particularly electronic nonformulary requests) as contributing to interprofessional tensions or misunderstandings for both groups, (2) the navigation of new roles and traditional hierarchy, with pharmacists using indirect communication to prevent PCP defensiveness to recommendations, and (3) a preference for onsite colocation for enhanced communication and professional relationships. Clinical pharmacists' indirect communication practices may hold important implications for patient safety in the context of medication use, and it is important to foster effective communication skills and an environment where all team members across hierarchies can feel comfortable speaking up to reduce error when problems are suspected. Also, the lack of institutional communication about managing drug formulary issues and related electronic nonformulary request processes was apparent in this study and merits further attention for both researchers and practitioners.

Patient perceptions of e-prescribing and its impact on their relationships with providers: a qualitative analysis

OBJECTIVE

To describe patients' perceptions of electronic (e)-prescribing and its impact on patients' quality of care, interactions with prescribers and pharmacists, and engagement in health care overall, particularly in regard to medication use.

METHODS

Semistructured, one-on-one interviews with 12 patients.

RESULTS

Patients were generally unfamiliar with the functions of integrated e-prescribing systems and did not perceive that use of such technology affected their relationships with providers. Those respondents having positive perceptions of, and experiences with e-prescribing mostly cited convenience and improvements in safety and quality, while patients with negative e-prescribing perceptions and experiences primarily expressed concern about loss of control in the medication-use process, misdirected prescriptions, and reduced communication with prescribers and pharmacists.

CONCLUSION

Patients generally felt unaffected by the use of e-prescribing technology; however, there may be opportunities to better engage and educate patients, particularly at the point of prescribing.

Challenges to the implementation of a nationwide electronic prescribing network in primary care: a qualitative study of users' perceptions

BACKGROUND AND OBJECTIVE

The objective of this study was to identify physicians' and pharmacists' perceptions of the challenges and benefits to implementing a nationwide electronic prescribing network linking medical clinics and community pharmacies in Quebec, Canada.

METHODS

Forty-nine people (12 general practitioners, 2 managers, 33 community pharmacists, and 2 pharmacy staff members) from 40 points of care (10 primary care clinics (42% of all the connected sites) and 30 community pharmacies (44%)) were interviewed in 2013. Verbatim transcripts were analyzed using thematic analysis.

RESULTS

A low level of network use was observed. Most pharmacists processed e-prescriptions by manual entry instead of importing electronically. They reported concerns about potential errors generated by importing e-prescriptions, mainly due to the instruction field. Paper prescriptions were still perceived as the best means for safe and effective processing of prescriptions in pharmacies. Speed issues when validating e-prescription messages were seen as an irritant by physicians, and resulted in several of them abandoning transmission. Displaying the medications based on the dispensing data was identified as the main obstacle to meaningful use of medication histories.

CONCLUSIONS

Numerous challenges impeded realization of the benefits of this network. Standards for e-prescription messages, as well as rules for message validation, need to be improved to increase the potential benefits of e-prescriptions. Standard drug terminology including the concept of clinical medication should be developed, and the implementation of rules in local applications to allow for the classification and reconciliation of medication lists from dispensing data should be made a priority.

Implementation of information systems at pharmacies - a case study from the re-regulated pharmacy market in Sweden

BACKGROUND

When the Swedish pharmacy market was re-regulated in 2009, Sweden moved from one state-owned pharmacy chain to several private pharmacy companies, and four new dispensing systems emerged to replace the one system that had previously been used at all Swedish pharmacies for more than 20 years.

OBJECTIVES

The aim of this case study was to explore the implementation of the new information systems for dispensing at pharmacies.

METHODS

The vendors of the four dispensing systems in Sweden were interviewed, and a questionnaire was sent to the managers of the pharmacy companies. In addition, a questionnaire was sent to 350 pharmacists who used the systems for dispensing prescriptions.

RESULTS

The implementation of four new dispensing systems followed a strict time frame set by political decisions, involved actors completely new to the market, lacked clear regulation and standards for functionality and quality assurance, was complex and resulted in variations in quality. More than half of the pharmacists (58%) perceived their current dispensing system as supporting safe dispensing of medications, 26% were neutral and 15% did not perceive it to support a safe dispensing. Most pharmacists (80%) had experienced problems with their dispensing system during the previous month. The pharmacists experienced problems included reliability issues, usability issues, and missing functionality.

CONCLUSION

In this case study exploring the implementation of new information systems for dispensing prescriptions at pharmacies in Sweden, weaknesses related to reliability, functionality and usability were identified and could affect patient safety. The weaknesses of the systems seem to result from the limited time for the development and implementation, the lack of comprehensive and evidence-based requirements for dispensing systems, and the unclear distribution of quality assurance responsibilities among involved stakeholders.

The effect of the electronic transmission of prescriptions on dispensing errors and prescription enhancements made in English community pharmacies: a naturalistic stepped wedge study

OBJECTIVES

To compare prevalence and types of dispensing errors and pharmacists' labelling enhancements, for prescriptions transmitted electronically versus paper prescriptions.

DESIGN

Naturalistic stepped wedge study.

SETTING

15 English community pharmacies.

INTERVENTION

Electronic transmission of prescriptions between prescriber and pharmacy.

MAIN OUTCOME MEASURES

Prevalence of labelling errors, content errors and labelling enhancements (beneficial additions to the instructions), as identified by researchers visiting each pharmacy.

RESULTS

Overall, we identified labelling errors in 5.4% of 16,357 dispensed items, and content errors in 1.4%; enhancements were made for 13.6%. Pharmacists also edited the label for a further 21.9% of electronically transmitted items. Electronically transmitted prescriptions had a higher prevalence of labelling errors (7.4% of 3733 items) than other prescriptions (4.8% of 12,624); OR 1.46 (95% CI 1.21 to 1.76). There was no difference for content errors or enhancements. The increase in labelling errors was mainly accounted for by errors (mainly at one pharmacy) involving omission of the indication, where specified by the prescriber, from the label. A sensitivity analysis in which these cases (n=158) were not considered errors revealed no remaining difference between prescription types.

CONCLUSIONS

We identified a higher prevalence of labelling errors for items transmitted electronically, but this was predominantly accounted for by local practice in a single pharmacy, independent of prescription type. Community pharmacists made labelling enhancements to about one in seven dispensed items, whether electronically transmitted or not. Community pharmacists, prescribers, professional bodies and software providers should work together to agree how items should be dispensed and labelled to best reap the benefits of electronically transmitted prescriptions. Community pharmacists need to ensure their computer systems are promptly updated to help reduce errors.

Towards creating the perfect electronic prescription

Significant strides have been made in electronic (e)-prescribing standards and software applications that have further fueled the adoption and use of e-prescribing. However, for e-prescribing to realize its full potential for improving the safety, effectiveness, and efficiency of prescription drug delivery, important work remains to be carried out. This perspective describes the ultimate goal of all e-prescribing stakeholders including prescribers and dispensing pharmacists: a clear, complete, and unambiguous e-prescription order that can be seamlessly received, processed, and fulfilled at the dispensing pharmacy without the need for additional clarification from the prescriber. We discuss the challenges to creating the perfect e-prescription by focusing on selected data segments and data fields that are available in the new e-prescription transaction as defined in the NCPDP SCRIPT Standard and suggest steps that could be taken to move the industry closer to achieving this vision.

Electronic prescribing: improving the efficiency and accuracy of prescribing in the ambulatory care setting

Electronic prescribing (e-prescribing) is an important part of the nation's push to enhance the safety and quality of the prescribing process. E-prescribing allows providers in the ambulatory care setting to send prescriptions electronically to the pharmacy and can be a stand-alone system or part of an integrated electronic health record system. The methodology for this study followed the basic principles of a systematic review. A total of 47 sources were referenced. Results of this research study suggest that e-prescribing reduces prescribing errors, increases efficiency, and helps to save on healthcare costs. Medication errors have been reduced to as little as a seventh of their previous level, and cost savings due to improved patient outcomes and decreased patient visits are estimated to be between $140 billion and $240 billion over 10 years for practices that implement e-prescribing. However, there have been significant barriers to implementation including cost, lack of provider support, patient privacy, system errors, and legal issues.

Recent trends in biomedical informatics: a study based on JAMIA articles

In a growing interdisciplinary field like biomedical informatics, information dissemination and citation trends are changing rapidly due to many factors. To understand these factors better, we analyzed the evolution of the number of articles per major biomedical informatics topic, download/online view frequencies, and citation patterns (using Web of Science) for articles published from 2009 to 2012 in JAMIA. The number of articles published in JAMIA increased significantly from 2009 to 2012, and there were some topic differences in the last 4 years. Medical Record Systems, Algorithms, and Methods are topic categories that are growing fast in several publications. We observed a significant correlation between download frequencies and the number of citations per month since publication for a given article. Earlier free availability of articles to non-subscribers was associated with a higher number of downloads and showed a trend towards a higher number of citations. This trend will need to be verified as more data accumulate in coming years.

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

OBJECTIVE

We conducted a systematic review identifying users groups' perceptions of barriers and facilitators to implementing electronic prescription (e-prescribing) in primary care.

METHODS

We included studies following these criteria: presence of an empirical design, focus on the users' experience of e-prescribing implementation, conducted in primary care, and providing data on barriers and facilitators to e-prescribing implementation. We used the Donabedian logical model of healthcare quality (adapted by Barber et al) to analyze our findings.

RESULTS

We found 34 publications (related to 28 individual studies) eligible to be included in this review. These studies identified a total of 594 elements as barriers or facilitators to e-prescribing implementation. Most user groups perceived that e-prescribing was facilitated by design and technical concerns, interoperability, content appropriate for the users, attitude towards e-prescribing, productivity, and available resources.

DISCUSSION

This review highlights the importance of technical and organizational support for the successful implementation of e-prescribing systems. It also shows that the same factor can be seen as a barrier or a facilitator depending on the project's own circumstances. Moreover, a factor can change in nature, from a barrier to a facilitator and vice versa, in the process of e-prescribing implementation.

CONCLUSIONS

This review summarizes current knowledge on factors related to e-prescribing implementation in primary care that could support decision makers in their design of effective implementation strategies. Finally, future studies should emphasize on the perceptions of other user groups, such as pharmacists, managers, vendors, and patients, who remain neglected in the literature.

From physician intent to the pharmacy label: prevalence and description of discrepancies from a cross-sectional evaluation of electronic prescriptions

OBJECTIVE

The objectives of this cross-sectional study were to estimate the prevalence of unintended discrepancies between three sources of prescription information and to describe the types of electronic prescribing system vulnerabilities identified.

METHODS

Staff from community pharmacies identified approximately 200 new prescriptions written at three participating ambulatory care clinics (2 adult, 1 paediatric). Unintended discrepancies were identified by comparing three sources of prescription information: (1) the prescriber's note as documented in the patient's chart; (2) the electronic prescription (e-prescription) entered into the clinic's electronic prescribing software; (3) the medication that was ultimately dispensed by the pharmacy as indicated on the prescription label. The discrepancy rate was calculated by dividing the number of discrepancies identified by the number of prescriptions evaluated.

RESULTS

A total of 602 prescriptions written by 33 prescribers were evaluated from the 3 ambulatory care clinics. The discrepancy rate between the prescriber's note and the e-prescription was 1.7%, 0.6% and 3.9% for the three clinics. The discrepancy rate between the e-prescription (clinic) and the prescription label (pharmacy) was 4.2%, 0.9% and 1.5%. Differences between directions for administration was the most common type of discrepancy identified.

CONCLUSIONS

Discrepancy rates between the prescriber's note and the e-prescription were similar to the discrepancy rates between the e-prescription and pharmacy label. To reduce outpatient medication errors, a better understanding is needed of the sources of discrepancies that occur within the prescriber's clinic, and those that occur between the clinic and pharmacy.

The fungibility of time in claims of efficiency: the case of making transmission of prescriptions electronic in English general practice

OBJECTIVES

This paper presents a study of the effects of the implementation of the NHS Electronic Prescription Service (EPS) on time spent on repeat prescribing in English general practice. EPS is a new network service for the electronic transmission of primary care prescriptions, principally between GP practices and community pharmacies. This service is promoted on the basis of the importance of safe and timely supply of medicines, and the level of medicines use by many patients with treatable chronic conditions. The service is also based on presumptions of significant time-savings and efficiency gains for general practices and GPs. Our objective was to assess the time-related changes (including time savings) conditioned by digital transmission of prescriptions, specifically for repeat prescribing activity in primary care practices.

METHODS

As part of the official evaluation of EPS in the English NHS we undertook a qualitative research design with field studies in four of the first GP practices adopting EPS. This research was based on interviews with clinical and administrative staff, and non-participant observation of repeat prescribing related activities.

RESULTS

We found that the use of EPS reduced turnaround time and conditioned changes in the workflow, with time-savings found mainly in relation to administrative tasks. But the use of this technology also created additional tasks and shifted existing tasks and responsibilities. Thus elimination of tasks did not automatically correspond to potential staff savings or cost savings. Tasks that were eliminated and new tasks that were created were not equivalent in terms of time spent, quality of attention required, and roles involved.

CONCLUSIONS

The wider claim that healthcare information technology saves time and increases efficiency is often based on assumptions of the fungibility of time and people - i.e. that units of time added or saved on different steps of the workflow can be summed up as if they were all of the same kind, and thus reveal any net efficiency gain. But workflow time savings involve changes in the quality of tasks, redistribution of work and responsibility that mean that time can hardly be added or subtracted to obtain 'efficiency totals'.

A typology of electronic health record workarounds in small-to-medium size primary care practices

OBJECTIVE

Electronic health record (EHR) use in ambulatory care can improve safety and quality; however, problems with design, implementation, and poor interface with other systems lead users to develop 'workarounds', or behaviors users adopt to overcome perceived limitations in a technical system. We documented workarounds used in independent, community-based primary care practices, and developed a typology of their key features.

MATERIALS AND METHODS

Comparative case study of EHR use in seven independent primary care practices. Field researchers spent approximately 1 month in each practice to observe EHR use, conduct patient pathways, and interview clinicians and staff.

RESULTS

We observed workarounds addressing a wide range of EHR-related problems, including: user interface issues (eg, insufficient data fields, limited templates), barriers to electronic health information exchange with external organizations, and struggles incorporating new technologies into existing office space. We analyzed the observed workarounds inductively to develop a typology that cuts across specific clinical or administrative processes to highlight the following key formal features of workarounds in general: temporary/routinized, which captures whether the workaround is taken for granted as part of daily workflow or is understood as a short-term solution; avoidable/unavoidable, referring to the extent to which the workaround is within the practice's power to eliminate; and deliberately chosen/unplanned, which differentiates strategically chosen adaptations from less thoughtful workarounds.

CONCLUSIONS

This workaround typology provides a framework for EHR users to identify and address workarounds in their own practices, and for researchers to examine the effect of different types of EHR workarounds on patient safety, care quality, and efficiency.

Technical support and delegation to practice staff - status quo and (possible) future perspectives for primary health care in Germany

BACKGROUND

Primary health care in industrialized countries faces major challenges due to demographic changes, an increasing prevalence of chronic diseases and a shortage of primary care physicians. One approach to counteract these developments might be to reduce primary care physicians' workload supported by the use of health information technology (HIT) and non-physician practice staff. In 2009, the U.S. Commonwealth Fund (CWF) conducted an international survey of primary care physicians which the present secondary descriptive analysis is based on. The aim of this analysis was twofold: First, to explore to what extend German primary care physicians already get support by HIT and non-physician practice staff, and second, to show possible future perspectives.

METHODS

The CWF questionnaire was sent to a representative random sample of 1,500 primary care physicians all over Germany. The data was descriptively analyzed. Group comparisons regarding differences in gender and age groups were made by means of Chi Square Tests for categorical variables. An alpha-level of p < 0.05 was used for statistical significance.

RESULTS

Altogether 715 primary care physicians answered the questionnaire (response rate 49%). Seventy percent of the physicians use electronic medical records. Technical features such as electronic ordering and access to laboratory parameters are mainly used. However, the majority does not routinely use technical functions for drug prescribing, reminder-systems for guideline-based interventions or recall of patients. Six percent of surveyed physicians are able to transfer prescriptions electronically to a pharmacy, 1% use email communication with patients regularly. Seventy-two percent of primary care physicians get support by non-physician practice staff in patient care, mostly in administrative tasks or routine preventive services. One fourth of physicians is supported in telephone calls to the patient or in patient education and counseling.

CONCLUSION

Within this sample the majority of primary care physicians get support by HIT and non-physician practice staff in their daily work. However, the potential has not yet been fully used. Supportive technical functions like electronic alarm functions for medication or electronic prescribing should be improved technically and more adapted to physicians' needs. To warrant pro-active health care, recall and reminder systems should get refined to encourage their use. Adequately qualified non-physician practice staff could play a more active role in patient care. Reimbursement should not only be linked to doctors', but also to non-physician practice staff services.