Prescriber and staff perceptions of an electronic prescribing system in primary care: a qualitative assessment

The impact of eHealth use on general practice workload in the pre-COVID-19 era: a systematic review

BACKGROUND

In recent years, eHealth has received much attention as an opportunity to increase efficiency within healthcare organizations. Adoption of eHealth might consequently help to solve perceived health workforce challenges, including labor shortages and increasing workloads among primary care professionals, who serve as the first point of contact for healthcare in many countries. The purpose of this systematic review was to investigate the impact of general eHealth use and specific eHealth services use on general practice workload in the pre-COVID-19 era.

METHODS

The databases of CINAHL, Cochrane, Embase, IEEE Xplore, Medline ALL, PsycINFO, Web of Science, and Google Scholar were searched, using combinations of keywords including 'eHealth', 'workload', and 'general practice'. Data extraction and quality assessment of the included studies were independently performed by at least two reviewers. Publications were included for the period 2010 - 2020, before the start of the COVID-19 pandemic.

RESULTS

In total, 208 studies describing the impact of eHealth services use on general practice workload were identified. We found that two eHealth services were mainly investigated within this context, namely electronic health records and digital communication services, and that the largest share of the included studies used a qualitative study design. Overall, a small majority of the studies found that eHealth led to an increase in general practice workload. However, results differed between the various types of eHealth services, as a large share of the studies also reported a reduction or no change in workload.

CONCLUSIONS

The impact of eHealth services use on general practice workload is ambiguous. While a small majority of the effects indicated that eHealth increased workload in general practice, a large share of the effects also showed that eHealth use reduced workload or had no impact. These results do not imply a definitive conclusion, which underscores the need for further explanatory research. Various factors, including the study setting, system design, and the phase of implementation, may influence this impact and should be taken into account when general practices adopt new eHealth services.

STUDY REGISTRATION NUMBER

PROSPERO (International Prospective Register of Systematic Reviews) CRD42020199897; https://www.crd.york.ac.uk/prospero/display_record.php?RecordID=199897 .

Exploring the role of professional identity in the implementation of clinical decision support systems-a narrative review

BACKGROUND

Clinical decision support systems (CDSSs) have the potential to improve quality of care, patient safety, and efficiency because of their ability to perform medical tasks in a more data-driven, evidence-based, and semi-autonomous way. However, CDSSs may also affect the professional identity of health professionals. Some professionals might experience these systems as a threat to their professional identity, as CDSSs could partially substitute clinical competencies, autonomy, or control over the care process. Other professionals may experience an empowerment of the role in the medical system. The purpose of this study is to uncover the role of professional identity in CDSS implementation and to identify core human, technological, and organizational factors that may determine the effect of CDSSs on professional identity.

METHODS

We conducted a systematic literature review and included peer-reviewed empirical studies from two electronic databases (PubMed, Web of Science) that reported on key factors to CDSS implementation and were published between 2010 and 2023. Our explorative, inductive thematic analysis assessed the antecedents of professional identity-related mechanisms from the perspective of different health care professionals (i.e., physicians, residents, nurse practitioners, pharmacists).

RESULTS

One hundred thirty-one qualitative, quantitative, or mixed-method studies from over 60 journals were included in this review. The thematic analysis found three dimensions of professional identity-related mechanisms that influence CDSS implementation success: perceived threat or enhancement of professional control and autonomy, perceived threat or enhancement of professional skills and expertise, and perceived loss or gain of control over patient relationships. At the technological level, the most common issues were the system's ability to fit into existing clinical workflows and organizational structures, and its ability to meet user needs. At the organizational level, time pressure and tension, as well as internal communication and involvement of end users were most frequently reported. At the human level, individual attitudes and emotional responses, as well as familiarity with the system, most often influenced the CDSS implementation. Our results show that professional identity-related mechanisms are driven by these factors and influence CDSS implementation success. The perception of the change of professional identity is influenced by the user's professional status and expertise and is improved over the course of implementation.

CONCLUSION

This review highlights the need for health care managers to evaluate perceived professional identity threats to health care professionals across all implementation phases when introducing a CDSS and to consider their varying manifestations among different health care professionals. Moreover, it highlights the importance of innovation and change management approaches, such as involving health professionals in the design and implementation process to mitigate threat perceptions. We provide future areas of research for the evaluation of the professional identity construct within health care.

Developing a Multifaceted Evaluation Tool for Electronic Prescribing System: A Study from a Developing Country

: Evaluation of electronic prescribing systems (EPS) can contribute to their quality assurance, and motivate users and policy-makers to implement these systems, directly influencing the health of society. An appropriate evaluation tool plays a determining role in the identification of proper EPS. The present study aimed to develop a multifaceted evaluation tool for assessing the EPS. This study was conducted in two main steps in 2018. In the first step, we conducted a literature review to find the main features and capabilities of the prosperous EPS. In the second step, a Delphi method was used for determining the final criteria for evaluating EPS. After preparing a primary questionnaire based on the first step results, 27 expert stakeholders from related fields participated in this 3-phase Delphi study. The narrative content analysis and descriptive statistics were used for data analysis. The final evaluation tool consists of 61 questions in 10 main dimensions, including practical capabilities of the process/user and patient safety, data storage and transfer, prescription control and renewal, technical functions, user interfaces, security and privacy, reporting, portability, hardware and infrastructure, and system failure/recovery. The evaluation tool developed in this study can be used for the critical appraisal of features of EPS. It is recommended that this multifaceted evaluation tool be employed to help buyers compare different systems and assist EPS software vendors in prioritizing their activities regarding the system development. By using this tool, healthcare organizations can also choose a system that improves many aspects of health care.

Key factors of clinicians' acceptance of CPOE system and their link to change management

The successful implementation of a Computerized Provider Order Entry (CPOE) system is a challenging process for any healthcare organization. It requires a dramatic change not only to the way the care is provided but also to the way clinicians work. Because of the required change complexity, organizations must consider key factors of clinicians' acceptance to avoid resistance and maximize chances of success. This paper aims to identify the different factors that affect clinicians' acceptance of CPOE systems and their relation to existing change management models. A systematic literature review was conducted to identify barriers and recommendations to the clinicians' acceptance of CPOE systems. Then, a comparative analysis was used to explain the relationship between the discovered factors and change management, with a focus on Kotter's model. The review included 23 articles. A total of 28 barriers and 25 recommendations have been identified. In conclusion, factors of clinicians' acceptance fall into two categories: one related to the used implementation strategy and the other related to how the system was designed. Most of the factors are similar to change management principles. The systematic incorporation of change management principles during CPOE implementation would likely improve clinicians' acceptance of the system.

Evaluating physicians' perspectives on the efficiency and effectiveness of the electronic prescribing system

BACKGROUND

The implementation of the electronic prescribing system follows certain objectives, and users' perspectives can contribute to understanding the efficiency and effectiveness of this system. This study aimed to evaluate physicians' perspectives on the efficiency and effectiveness of the electronic prescribing system.

METHODS

This study was conducted on all physicians using the electronic prescribing system in clinics and hospitals affiliated with the treatment deputy of the Social Security Organization (SSO) in Sistan and Baluchistan Province in Iran. Data were collected using a self-administered questionnaire containing three sections: (i) Six items related to demographic data and clinical experience, (ii) Specific questions based on a five-point Likert scale-related physicians' perspectives about efficiency (19 questions) and effectiveness (13 questions), and (iii) Open-ended questions about the positive and negative aspects of using the electronic prescribing system.

RESULTS

The mean and standard deviation of the efficiency and effectiveness of the electronic prescribing system were 3.68 ± 0.67 and 3.84 ± 0.65, respectively. Patient safety had the highest mean score among all dimensions (4.0 ± 0.64). Most participants (n = 55, 79%) considered the efficiency and effectiveness of this system high. More than 90 percent of the physicians (n = 63) believed that the electronic prescribing system enables a better medication prescription by providing alerts and access to patients' medication history.

CONCLUSION

The findings showed that most physicians believed that the electronic prescribing system of Iran's SSO has high efficiency and effectiveness. In particular, physicians believed that using this system improves patient safety and reduces costs.

Clinical decision support systems-based interventions to improve medication outcomes: A systematic literature review on features and effects

Background: Clinical decision support systems (CDSSs) interventions were used to improve the life quality and safety in patients and also to improve practitioner performance, especially in the field of medication. Therefore, the aim of the paper was to summarize the available evidence on the impact, outcomes and significant factors on the implementation of CDSS in the field of medicine. Methods: This study is a systematic literature review. PubMed, Cochrane Library, Web of Science, Scopus, EMBASE, and ProQuest were investigated by 15 February 2017. The inclusion requirements were met by 98 papers, from which 13 had described important factors in the implementation of CDSS, and 86 were medicated-related. We categorized the system in terms of its correlation with medication in which a system was implemented, and our intended results were examined. In this study, the process outcomes (such as; prescription, drug-drug interaction, drug adherence, etc.), patient outcomes, and significant factors affecting the implementation of CDSS were reviewed. Results: We found evidence that the use of medication-related CDSS improves clinical outcomes. Also, significant results were obtained regarding the reduction of prescription errors, and the improvement in quality and safety of medication prescribed. Conclusion: The results of this study show that, although computer systems such as CDSS may cause errors, in most cases, it has helped to improve prescribing, reduce side effects and drug interactions, and improve patient safety. Although these systems have improved the performance of practitioners and processes, there has not been much research on the impact of these systems on patient outcomes.

Healthcare professionals' attitudes of implementing a chemotherapy electronic prescribing system: A mixed methods study

PURPOSE

Recent research has investigated the attitudes of healthcare professionals when implementing electronic healthcare systems such as electronic medical records or electronic prescribing in primary care. There is limited research on implementation of electronic prescribing in secondary care and no published research exploring implementation of systemic-anticancer therapy (includes chemotherapy, TKIs, monoclonal antibodies, etc) electronic prescribing. By considering what attitudes healthcare professionals had towards the implementation of systemic-anticancer therapy (SACT) electronic prescribing systems, recommendations could be developed and used to aid successful future implementations.

METHODS

This mixed methods study was in three phases. The first phase was a qualitative exploration of attitudes of healthcare professionals towards the implementation of a systemic-anticancer therapy electronic prescribing system, with the development of a questionnaire based on these findings. This was followed by a quantitative second phase where the results from the questionnaire were used to assess if the qualitative results could be generalised to a larger population. Further progression in phase three looked at developing recommendations based on the factors found in order to aid future implementations for hospitals.

RESULTS

Thirteen factors were found relating to attitudes of healthcare staff when implementing systemic-anticancer therapy electronic prescribing. Nine of these factors were cited by other researchers when implementing other electronic healthcare systems. Four factors appeared to be specific to systemic-anticancer therapy electronic prescribing implementations. Nineteen recommendations were proposed when implementing a systemic-anticancer therapy electronic prescribing system.

CONCLUSION

This is the first study, to our knowledge, to examine the attitudes of healthcare professionals when implementing a systemic-anticancer therapy electronic prescribing system and the first to define important factors and list recommendations to manage these.

An evaluation of the TARGET (Treat Antibiotics Responsibly; Guidance, Education, Tools) Antibiotics Toolkit to improve antimicrobial stewardship in primary care-is it fit for purpose?

BACKGROUND

The TARGET (Treat Antibiotics Responsibly; Guidance, Education, Tools) Antibiotics Toolkit aims to improve antimicrobial prescribing in primary care through guidance, interactive workshops with action planning, patient facing educational and audit materials.

OBJECTIVE

To explore GPs', nurses' and other stakeholders' views of TARGET.

DESIGN

Mixed methods.

METHOD

In 2014, 40 UK GP staff and 13 stakeholders participated in interviews or focus groups. We analysed data using a thematic framework and normalization process theory (NPT).

RESULTS

Two hundred and sixty-nine workshop participants completed evaluation forms, and 40 GP staff, 4 trainers and 9 relevant stakeholders participated in interviews (29) or focus groups (24). GP staffs were aware of the issues around antimicrobial resistance (AMR) and how it related to their prescribing. Most participants stated that TARGET as a whole was useful. Participants suggested the workshop needed less background on AMR, be centred around clinical cases and allow more action planning time. Participants particularly valued comparison of their practice antibiotic prescribing with others and the TARGET Treating Your Infection leaflet. The leaflet needed greater accessibility via GP computer systems. Due to time, cost, accessibility and competing priorities, many GP staff had not fully utilized all resources, especially the audit and educational materials.

CONCLUSIONS

We found evidence that the workshop is likely to be more acceptable and engaging if based around clinical scenarios, with less on AMR and more time on action planning. Greater promotion of TARGET, through Clinical Commissioning Group's (CCG's) and professional bodies, may improve uptake. Patient facing resources should be made accessible through computer shortcuts built into general practice software.

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.

Patient and clinician perspectives of an integrated electronic medication prescribing and dispensing system: A qualitative study at a multisite Australian hospital network

BACKGROUND:

While clinician attitudes towards electronic prescribing (e-prescribing) systems have been widely studied, little is known about the perspectives of patients, despite being the primary beneficiaries of these systems.

OBJECTIVE:

The objective of this study is to explore and compare patient and clinician attitudes towards an integrated e-prescribing and dispensing system, in order to guide improvements in system implementation, service delivery and enhancements to system functionality.

METHOD:

A cross-sectional survey was developed and administered to patients and multidisciplinary clinicians at a multisite Australian metropolitan teaching hospital network in all areas where e-prescribing was fully implemented. Participants' views on perceived impact and valued features of the e-prescribing system were elucidated.

RESULTS:

Overall, 783 participants (400 patients and 383 clinicians) completed the survey. Although 98% of clinicians were aware of the transition to e-prescriptions, only 36% of patients were aware prior to the study. Over 80% of patients and clinicians perceived improvements in prescribing and dispensing safety and clinician workflow; 90% of patients were comfortable with information privacy associated with e-prescriptions; and 86% of patients preferred e-prescriptions to handwritten prescriptions. Although over 80% of patients valued features that improved access to information and medication safety, clinicians were more discerning about valued system features.

CONCLUSION:

The majority of patients and clinicians reported a positive impact of e-prescribing on safety and efficiency. Both groups valued safe and effective use of medicines, although differences existed in the importance placed on key system features. A greater focus on patient engagement and communication is needed to optimise the delivery of patient-centred care.

Medication Errors in Injured Patients

Trauma patients are vulnerable to medication error given multiple handoffs throughout the hospital. The purpose of this study was to assess trends in medication errors in trauma patients and the role these errors play in patient outcomes. Injured adults admitted from 2009 to 2015 to a Level I trauma center were included. Medication errors were determined based on a nurse-driven, validated, and prospectively maintained database. Multivariable logistic regression modeling was used to control for differences between groups. Among 15,635 injured adults admitted during the study period, 132 patients experienced 243 errors. Patients who experienced errors had significantly worse injury severity, lower Glasgow Coma Scale scores and higher rates of hypotension on admission, and longer lengths of stay. Before adjustment, mortality was similar between groups but morbidity was higher in the medication error group. After risk adjustment, there were no significant differences in morbidity or mortality between the groups. Medication errors in trauma patients tend to occur in significantly injured patients with long hospital stays. Appropriate adjustment when studying the impact of medical errors on patient outcomes is important.

Adoption of e-health technology by physicians: a scoping review

OBJECTIVE

The goal of this scoping review was to summarize the current literature identifying barriers and opportunities that facilitate adoption of e-health technology by physicians.

DESIGN

Scoping review.

SETTING

MEDLINE, EMBASE, and PsycINFO databases as provided by Ovid were searched from their inception to July 2015. Studies captured by the search strategy were screened by two reviewers and included if the focus was on barriers and facilitators of e-health technology adoption by physicians.

RESULTS

Full-text screening yielded 74 studies to be included in the scoping review. Within those studies, eleven themes were identified, including cost and liability issues, unwillingness to use e-health technology, and training and support.

CONCLUSION

Cost and liability issues, unwillingness to use e-health technology, and training and support were the most frequently mentioned barriers and facilitators to the adoption of e-health technology. Government-level payment incentives and privacy laws to protect health information may be the key to overcome cost and liability issues. The adoption of e-health technology may be facilitated by tailoring to the individual physician's knowledge of the e-health technology and the use of follow-up sessions for physicians and on-site experts to support their use of the e-health technology. To ensure the effective uptake of e-health technologies, physician perspectives need to be considered in creating an environment that enables the adoption of e-health strategies.

Can utilizing a computerized provider order entry (CPOE) system prevent hospital medical errors and adverse drug events?

Computerized provider order entry (CPOE) systems allow physicians to prescribe patient services electronically. In hospitals, CPOE essentially eliminates the need for handwritten paper orders and achieves cost savings through increased efficiency. The purpose of this research study was to examine the benefits of and barriers to CPOE adoption in hospitals to determine the effects on medical errors and adverse drug events (ADEs) and examine cost and savings associated with the implementation of this newly mandated technology. This study followed a methodology using the basic principles of a systematic review and referenced 50 sources. CPOE systems in hospitals were found to be capable of reducing medical errors and ADEs, especially when CPOE systems are bundled with clinical decision support systems designed to alert physicians and other healthcare providers of pending lab or medical errors. However, CPOE systems face major barriers associated with adoption in a hospital system, mainly high implementation costs and physicians' resistance to change.

Can the theoretical domains framework account for the implementation of clinical quality interventions?

BACKGROUND

The health care quality improvement movement is a complex enterprise. Implementing clinical quality initiatives requires attitude and behaviour change on the part of clinicians, but this has proven to be difficult. In an attempt to solve this kind of behavioural challenge, the theoretical domains framework (TDF) has been developed. The TDF consists of 14 domains from psychological and organisational theory said to influence behaviour change. No systematic research has been conducted into the ways in which clinical quality initiatives map on to the domains of the framework. We therefore conducted a qualitative mapping experiment to determine to what extent, and in what ways, the TDF is relevant to the implementation of clinical quality interventions.

METHODS

We conducted a thematic synthesis of the qualitative literature exploring clinicians' perceptions of various clinical quality interventions. We analysed and synthesised 50 studies in total, in five domains of clinical quality interventions: clinical quality interventions in general, structural interventions, audit-type interventions, interventions aimed at making practice more evidence-based, and risk management interventions. Data were analysed thematically, followed by synthesis of these themes into categories and concepts, which were then mapped to the domains of the TDF.

RESULTS

Our results suggest that the TDF is highly relevant to the implementation of clinical quality interventions. It can be used to map most, if not all, of the attitudinal and behavioural barriers and facilitators of uptake of clinical quality interventions. Each of these 14 domains appeared to be relevant to many different types of clinical quality interventions. One possible additional domain might relate to perceived trustworthiness of those instituting clinical quality interventions.

CONCLUSIONS

The TDF can be usefully applied to a wide range of clinical quality interventions. Because all 14 of the domains emerged as relevant, and we did not identify any obvious differences between different kinds of clinical quality interventions, our findings support an initially broad approach to identifying barriers and facilitators, followed by a "drilling down" to what is most contextually salient. In future, it may be possible to establish a model of clinical quality policy implementation using the TDF.

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.

Impact of an electronic medication management system on hospital doctors' and nurses' work: a controlled pre-post, time and motion study

OBJECTIVE

To quantify and compare the time doctors and nurses spent on direct patient care, medication-related tasks, and interactions before and after electronic medication management system (eMMS) introduction.

METHODS

Controlled pre-post, time and motion study of 129 doctors and nurses for 633.2 h on four wards in a 400-bed hospital in Sydney, Australia. We measured changes in proportions of time on tasks and interactions by period, intervention/control group, and profession.

RESULTS

eMMS was associated with no significant change in proportions of time spent on direct care or medication-related tasks relative to control wards. In the post-period control ward, doctors spent 19.7% (2 h/10 h shift) of their time on direct care and 7.4% (44.4 min/10 h shift) on medication tasks, compared to intervention ward doctors (25.7% (2.6 h/shift; p=0.08) and 8.5% (51 min/shift; p=0.40), respectively). Control ward nurses in the post-period spent 22.1% (1.9 h/8.5 h shift) of their time on direct care and 23.7% on medication tasks compared to intervention ward nurses (26.1% (2.2 h/shift; p=0.23) and 22.6% (1.9 h/shift; p=0.28), respectively). We found intervention ward doctors spent less time alone (p=0.0003) and more time with other doctors (p=0.003) and patients (p=0.009). Nurses on the intervention wards spent less time with doctors following eMMS introduction (p=0.0001).

CONCLUSIONS

eMMS introduction did not result in redistribution of time away from direct care or towards medication tasks. Work patterns observed on these intervention wards were associated with previously reported significant reductions in prescribing error rates relative to the control wards.

A comprehensive e-prescribing model to allow representing, comparing, and analyzing available systems

BACKGROUND

Even though ePrescribing systems are now available in many healthcare systems and have been a crucial milestone of the roadmaps towards eHealth in the last years, there is still a large heterogeneity among functionalities and performances of different systems.

OBJECTIVE

In this paper, we propose an updated comprehensive model for the ePrescribing process able to represent, analyze, and compare current systems and to support the design of new, more general, systems suitable also to sustain the ePrescription process in National Healthcare Systems.

METHODS

After a preliminary literature review, we identified six main phases of the ePrescribing process, namely Assign, Transmit, Dispense, Administer, Monitor, and Analysis Decision. Each phase produces a digital object characterized by formal properties that ensure the collection of appropriate data and information and works as input for the next one. The impact, in terms of benefits, of ePrescribing on governance, drug surveillance, and quality of care at the individual, territorial, and governmental levels are related to the formal properties of the digital objects created at the end of each phase.

RESULTS AND CONCLUSIONS

The model-based implementation of each phase has an impact on the quality of care, the access to care, and the effectiveness of care delivery. The model does not cover cost evaluation, but the benefits identified can be used as basis for cost-benefit or cost-effectiveness analysis of heterogeneous systems.