Perceptions of standards-based electronic prescribing systems as implemented in outpatient primary care: a physician survey

Electronic prescription system requirements: a scoping review

Background

An electronic prescription system is a mechanism that has long been implemented in many countries around the world. In the present study, we reviewed the requirements, standards, and features of an electronic prescription system for its correct and accurate execution.

Methods

This scoping review was conducted according to the PRISMA-SCR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews). A comprehensive literature search was performed with the related keywords in Web of Science, PubMed, Scopus, and ProQuest with no time limit. The selection of papers was based on inclusion criteria. After removing duplicates, reviewing titles, abstracts, and full-text, 13 articles were included in the analysis.

Results

Electronic prescription system requirements extracted from the studies: Patient data, Patient selection or identification and data access, Drug Selection, Security, Privacy and administration, Transparency and accountability, Interoperability and communication, Monitoring, report, reminder, and renewals, Feedback at the prescriber level, Infrastructure: Computer equipment, Awareness of physicians and System support, Patient education and information, Usability, Standards, History of Medications / Current Medications, Data transfer and storage, Alerts and other messages to prescribers, and filtering of user-selectable alerts for possible prescription problems and Decision support.

Conclusions

The results of this study showed that the electronic prescription systems have several functional and technical capabilities that can provide significant benefits to all system’s stakeholders, including service providers, drug distributors, patients, and insurance organizations if used correctly.

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.

How Physicians Renew Electronic Prescriptions in Primary Care: Therapeutic Decision or Technical Task?

In long-term pharmacotherapies, the renewal of prescriptions is part of the medication use process. Although the majority of medicines are used with renewed prescriptions, little research has focused on renewal practices. The aim of this study was to explore current renewal practices from a primary care physician’s perspective to identify system-based challenges and development needs related to the renewal practices. This qualitative study was conducted in two phases in public primary health care centres of Kirkkonummi, Finland. First, five physicians were shadowed on-site while they renewed prescriptions. The findings of the shadowing phase were further discussed in two focus group discussions with seven other physicians than in the shadowing phase. Inductive content analysis was used for data analysis utilizing Reason’s risk management theory as a theoretical framework. Due to problems in the renewal process, including impractical information systems, a lack of reconciled medication lists, and a lack of time allocated for renewing prescriptions, physicians felt that monitoring and reviewing each patients’ medications for renewal was complicated. Therefore, they felt that renewing, at times, became a technical task rather than a therapeutic decision. The physicians suggested information system improvements, enhanced interprofessional cooperation, and patient involvement as strategies to ensure rational pharmacotherapy and patient safety in the renewal of prescription medicines.

Electronic Medication Management System Introduction and Deprescribing Practice in Post-Acute Care

OBJECTIVE

To determine the effect of introducing an electronic medication management system (EMMS) on deprescribing practice in a post-acute hospital setting.

DESIGN

This study used a before-after study design.

SETTING AND PARTICIPANTS

This study examined the admission and discharge medications prescribed to patients admitted to an Australian post-acute hospital before and after the introduction of an EMMS.

METHODS

Data were collected over a 1-month period before and after the introduction of an EMMS and included summary measures of drug burden including Potentially Inappropriate Medications and the Drug Burden Index. We calculated and compared admission and discharge medication prescription as well as change in medication use before and after the introduction of an EMMS.

RESULTS

Medication prescription data were available for 121 people before and 107 people after EMMS introduction. In both phases, when compared with admission, those discharged were prescribed fewer medications (mean reduction pre-EMMS = 2.9, P < .001, post-EMMS = 2.6, P < .001), fewer Potentially Inappropriate Medications (mean reduction pre-EMMS = 0.4, P < .001, post-EMMS = 0.6, P < .001) and had lower Drug Burden Index (mean reduction pre-EMMS = 0.1, P < .001, post-EMMS = 0.2, P < .001). The degree of reduction in each measure was similar before and after EMMS introduction.

CONCLUSIONS AND IMPLICATIONS

The introduction of an EMMS did not affect deprescribing practice in a post-acute hospital setting. Future work is required to explore the potential for clinical decision support within an EMMS to further improve the safety and effectiveness of deprescribing within post-acute care.

Digital Health in Physicians' and Pharmacists' Office: A Comparative Study of e-Prescription Systems' Architecture and Digital Security in Eight Countries

e-Prescription systems are key components and drivers of digital health. They can enhance the safety of the patients, and are gaining popularity in health care systems around the world. Yet, there is little knowledge on comparative international analysis of e-Prescription systems' architecture and digital security. We report, in this study, original findings from a comparative analysis of the e-Prescription systems in eight different countries, namely, Canada, United States, United Kingdom, Australia, Spain, Japan, Sweden, and Denmark. We surveyed the databases related to pharmacies, eHealth, e-Prescriptions, and related digital health websites for each country, and their system architectures. We also compared the digital security and privacy protocols in place within and across these digital systems. We evaluated the systems' authentication protocols used by pharmacies to verify patients' identities during the medication dispensing process. Furthermore, we examined the supporting systems/services used to manage patients' medication histories and enhance patients' medication safety. Taken together, we report, in this study, original comparative findings on the limitations and challenges of the surveyed systems as well as in adopting e-Prescription systems. While the present study was conducted before the onset of COVID-19, e-Prescription systems have become highly relevant during the current pandemic and hence, a deeper understanding of the country systems' architecture and digital security that can help design effective strategies against the pandemic. e-Prescription systems can help reduce physical contact and the risk of exposure to the virus, as well as the wait times in pharmacies, thus enhancing patient safety and improving planetary health.

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.

Conceptual Framework of the Impact of Health Technology on Healthcare System

The World Health Organization (WHO) promotes health systems strengthening as a means of improving population health, especially in low- and middle-income countries. The United Nations Sustainable Development Goals highlight the importance of investing in workforce development to improve population health and economic well-being. In relation to pharmaceuticals, health systems face challenges in terms of i) guaranteeing access to needed drugs, ii) rationalizing medicines use, and iii) avoiding harm from adverse events. There is a pressing need to better understand the relationships between technology and pharmacy practice when strengthening pharmaceutical care systems. In response, this paper examines ways in which harnessing new technologies can change pharmacy practice and strengthen pharmaceutical systems for the benefit of patients. The paper will present a conceptual framework as well as exploring case studies.

A Prescription For Enhancing Electronic Prescribing Safety

While electronic prescribing has been shown to reduce medication errors and improve prescribing safety, it is vulnerable to error-prone processes. We review six intersecting areas in which changes to electronic prescribing systems, particularly in the outpatient setting, could transform medication ordering quality and safety. We recommend incorporating medication indications into electronic prescribing, establishing a single shared online medication list, implementing the transmission of electronic cancellation orders to pharmacies (CancelRx) to ensure that drugs are safely and reliably discontinued, implementing standardized structured and codified prescription instructions, reengineering clinical decision support, and redesigning electronic prescribing to facilitate the ordering of nondrug alternatives.

Patient factors associated with the initiation of telehealth services among heart failure patients at home

Telehealth is an intervention that can assist patients with heart failure to manage their symptoms at home. However, it is reported that between 24-70% of eligible patients do not receive telehealth. This study aimed to explore factors associated with the initiation of telehealth among home care patients with heart failure using the Outcome and Assessment Information Set data (N = 2,832). The findings indicate patients who received high-risk drugs education by visiting nurses had an 80% increase in the odds of receiving telehealth, and patients who received no assistance from caregivers had a 46% decrease in odds compared to those who were assisted at least daily.

Privacy protection laws and public perception of data privacy

Purpose

The move toward e-health care in various countries is envisaged to reduce the cost of provision of health care, improve the quality of care and reduce medical errors. The most significant problem is the protection of patients’ data privacy. If the patients are reluctant or refuse to participate in health care system due to lack of privacy laws and regulations, the benefit of the full-fledged e-health care system cannot be materialized. The purpose of this paper is to investigate the available e-health data privacy protection laws and the perception of the people using the e-health care facilities.

Design/methodology/approach

The researchers used content analysis to analyze the availability and comprehensive nature of the laws and regulations. The researchers also used survey method. Participants in the study comprised of health care professionals (n=46) and health care users (n=187) who are based in the Dubai, United Arab Emirates. The researchers applied descriptive statistics mechanisms and correlational analysis to analyze the data in the survey.

Findings

The content analysis revealed that the available health data protection laws are limited in scope. The survey results, however, showed that the respondents felt that they could trust the e-health services systems offered in the UAE as the data collected is protected, the rights are not violated. The research also revealed that there was no significance difference between the nationality and the privacy data statements. All the nationality agreed that there is protection in place for the protection of e-health data. There was no significance difference between the demographic data sets and the many data protection principles.

Originality/value

The findings on the users’ perception could help to evaluate the success in realizing current strategies and an action plan of benchmarking could be introduced.

Comprehensive process model of clinical information interaction in primary care: results of a "best-fit" framework synthesis

Objective

To describe a new, comprehensive process model of clinical information interaction in primary care (Clinical Information Interaction Model, or CIIM) based on a systematic synthesis of published research.

Materials and Methods

We used the "best fit" framework synthesis approach. Searches were performed in PubMed, Embase, the Cumulative Index to Nursing and Allied Health Literature (CINAHL), PsycINFO, Library and Information Science Abstracts, Library, Information Science and Technology Abstracts, and Engineering Village. Two authors reviewed articles according to inclusion and exclusion criteria. Data abstraction and content analysis of 443 published papers were used to create a model in which every element was supported by empirical research.

Results

The CIIM documents how primary care clinicians interact with information as they make point-of-care clinical decisions. The model highlights 3 major process components: (1) context, (2) activity (usual and contingent), and (3) influence. Usual activities include information processing, source-user interaction, information evaluation, selection of information, information use, clinical reasoning, and clinical decisions. Clinician characteristics, patient behaviors, and other professionals influence the process.

Discussion

The CIIM depicts the complete process of information interaction, enabling a grasp of relationships previously difficult to discern. The CIIM suggests potentially helpful functionality for clinical decision support systems (CDSSs) to support primary care, including a greater focus on information processing and use. The CIIM also documents the role of influence in clinical information interaction; influencers may affect the success of CDSS implementations.

Conclusion

The CIIM offers a new framework for achieving CDSS workflow integration and new directions for CDSS design that can support the work of diverse primary care clinicians.

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.

Pharmacy Use in the First Year of the Veterans Choice Program: A Mixed-methods Evaluation

BACKGROUND

The Veterans Choice Program (VCP) was created to ensure timely access to health care in the Department of Veterans Affairs (VA). Under this program, medications may be ordered by select non-VA clinicians to be dispensed by VA pharmacies, creating new challenges in ensuring medication safety.

OBJECTIVES

To examine pharmaceutical use during the first year of the VCP and to understand barriers and facilitators for VA pharmacists to dispensing medications under the VCP.

STUDY DESIGN

Mixed-methods evaluation.

METHODS

We captured all prescriptions dispensed through the VCP and described the demographics of VCP users and their medications. We also conducted semistructured interviews of VA pharmacists, focusing on VA formulary management and experiences dispensing opioid and hepatitis C (HCV) medications. Codebook development and coding followed iterative qualitative methods.

RESULTS

Overall, 17,346 Veterans received 56,426 VCP prescriptions from November 7, 2014 through November 7, 2015. The total medication cost was $27 million, 90% of which was for only 2772 HCV prescriptions. Topical eye drops and opioids represented the most commonly dispensed prescriptions (15.6% and 9.2% of all prescriptions, respectively). Pharmacists reported numerous challenges to dispensing VCP medications, including time required to contact non-VA clinicians about formulary issues, requiring controlled substance prescriptions to be hand delivered to VA pharmacies, and lack of access to laboratory data required to safely dispense medications.

CONCLUSIONS

HCV-related medication costs predominated the first year of VCP, but this is likely to change going forward. The safe use of opioids, efficient management of nonformulary medications, and unintended new barriers to access created by the VCP must be addressed.

Impact of the introduction of electronic prescribing on staff perceptions of patient safety and organizational culture

BACKGROUND

Electronic prescribing (EP) systems are online technology platforms by which medicines can be prescribed, administered, and stock controlled. The actual impact of EP on patient safety is not truly understood. This study seeks to assess the impact of the implementation of an EP system on safety culture, as well as assessing differences between clinical respondent groups and considering their implications.

METHODS

Staff completed a modified Safety Attitudes Questionnaire survey, 6 weeks following the introduction of EP across surgical services in a hospital in Dorset, England. Responses were assessed and differences between respondent groups compared. Rates of self-reported adverse events were compared before and after implementation.

RESULTS

Overall response rate was 34.5%. There was no significant difference between usage patterns and previous experience with EP between user groups. Overall safety was felt to have been reduced by the introduction of EP. Significant differences between clinician and nonclinicians were seen in ability to discuss errors (3.23 ± 0.5 versus 2.8 ± 0.69, P = 0.004), drug chart access, and ease of medication prescribing. Regression analysis did not identify any confounding factors. Despite a significant reduction in the adverse event rate in other divisions of the hospital that did not implement EP at the same time, this same reduction was not seen in the surgical department.

CONCLUSIONS

This is the first study to assess the impact of EP on safety culture using a validated assessment tool (Safety Attitudes Questionnaire). Overall safety culture deteriorated following introduction of EP. Problems with system usability/intuitiveness, nonstandardized implementation, and competence assessment strategies may have all contributed to this result. Centers seeking to implement EP in future must consider these factors to ensure a positive impact on patient safety and outcomes.

A Copmarative Review of Electronic Prescription Systems: Lessons Learned from Developed Countries

This review study aimed to compare the electronic prescription systems in five selected countries (Denmark, Finland, Sweden, England, and the United States). Compared developed countries were selected by the identified selection process from the countries that have electronic prescription systems. Required data were collected by searching the valid databases, most widely used search engines, and visiting websites related to the national electronic prescription system of each country and also sending E-mails to the related organizations using specifically designed data collection forms. The findings showed that the electronic prescription system was used at the national, state, local, and area levels in the studied countries and covered the whole prescription process or part of it. There were capabilities of creating electronic prescription, decision support, electronically transmitting prescriptions from prescriber systems to the pharmacies, retrieving the electronic prescription at the pharmacy, electronic refilling prescriptions in all studied countries. The patient, prescriber, and dispenser were main human actors, as well as the prescribing and dispensing providers were main system actors of the Electronic Prescription Service. The selected countries have accurate, regular, and systematic plans to use electronic prescription system, and health ministry of these countries was responsible for coordinating and leading the electronic health. It is suggested to use experiences and programs of the leading countries to design and develop the electronic prescription systems.

Physicians' Voices: What Skills and Supports Are Needed for Effective Practice in an Integrated Delivery System? A Case Study of Kaiser Permanente

Payers are demanding that US health care become more accountable and integrated, posing new demands for physicians and the organizations that partner with them. We conducted focus groups with 30 physicians in a large integrated delivery system who had previous experience practicing in less integrated settings and asked about skills they need to succeed in this environment. Physicians identified 3 primary skills: orienting to teams and systems, engaging patients as individuals and as a panel, and integrating cost awareness into practice. Physicians also expressed a high level of trust that the system was designed to help them provide better care. This belief appeared to make the new demands and mental shifts tolerable, even welcome, standing in contrast to research showing widespread physician distrust of their institutional settings. Physicians' new skills and the system features that promote trust are described in the article and should be a focus for systems transitioning to a more integrated, accountable model.

How Physician Perspectives on E-Prescribing Evolve over Time. A Case Study Following the Transition between EHRs in an Outpatient Clinic

BACKGROUND

Physicians are expending tremendous resources transitioning to new electronic health records (EHRs), with electronic prescribing as a key functionality of most systems. Physician dissatisfaction post-transition can be quite marked, especially initially. However, little is known about how physicians' experiences using new EHRs for e-prescribing evolve over time. We previously published a qualitative case study about the early physician experience transitioning from an older to a newer, more robust EHR, in the outpatient setting, focusing on their perceptions of the electronic prescribing functionality.

OBJECTIVE

Our current objective was to examine how perceptions about using the new HER evolved over time, again with a focus on electronic prescribing.

METHODS

We interviewed thirteen internists at an academic medical center-affiliated ambulatory care clinic who transitioned to the new EHR two years prior. We used a grounded theory approach to analyze semi-structured interviews and generate key themes.

RESULTS

We identified five themes: efficiency and usability, effects on safety, ongoing training requirements, customization, and competing priorities for the EHR. We found that for even experienced e-prescribers, achieving prior levels of perceived prescribing efficiency took nearly two years. Despite the fact that speed in performing prescribing-related tasks was highly important, most were still not utilizing system short cuts or customization features designed to maximize efficiency. Alert fatigue remained common. However, direct transmission of prescriptions to pharmacies was highly valued and its benefits generally outweighed the other features considered poorly designed for physician workflow.

CONCLUSIONS

Ensuring that physicians are able to do key prescribing tasks efficiently is critical to the perceived value of e-prescribing applications. However, successful transitions may take longer than expected and e-prescribing system features that do not support workflow or require constant upgrades may further prolong the process. Additionally, as system features continually evolve, physicians may need ongoing training and support to maintain efficiency.

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.

Research note

Purpose

The purpose of the paper is to present a framework for moving cross-border ePrescription (eP) and Patient Summary (PS) services forward, bearing in mind the needs and requirements of the European e-health space for cross-border eP and PS services, the limitations of the already developed solutions, as well as outcomes available from other domains.

Design/methodology/approach

The outcomes of previous and current large-scale pilot projects, aiming toward the delivery of electronic cross-border services, are examined. Integration of generic building blocks (BBs) is considered for the further development of cross-border eP and PS, in line with the European Directive on patients’ rights in cross-border health care.

Findings

The e-health domain is expected to greatly benefit from mitigating non-domain concerns such as those for electronic identification, end point detection, non-repudiation and the use of electronic signatures and trust establishments for basic cross-border public services in Europe.

Research limitations/implications

Research limitations are related to the fact that electronic identification, electronic signature and semantic issues have not been fully addressed yet at a European level to support cross-border services.

Practical implications

Practical implications are related to the cooperation, European level compatibility and sustainability of the underlying national infrastructures required to support reliable and secure exchange of medical data, as well as the readiness to address continuously evolving interoperability, legal and security requirements in a cross-border setting.

Originality/value

The need for consolidating the existing outcomes of non-health specific BBs is examined for two high-priority e-health services. Ongoing progress is presented, together with related issues that need to be resolved for improving technical certainty and making it easier to use health-care services abroad in cases of emergency.

Health information exchange in the wild: the association between organizational capability and perceived utility of clinical event notifications in ambulatory and community care

OBJECTIVE

Event notifications are real-time, electronic, automatic alerts to providers of their patients' health care encounters at other facilities. Our objective was to examine the effects of organizational capability and related social/organizational issues upon users' perceptions of the impact of event notifications on quality, efficiency, and satisfaction.

MATERIALS AND METHODS

We surveyed representatives (n = 49) of 10 organizations subscribing to the Bronx Regional Health Information Organization's event notification services about organizational capabilities, notification information quality, perceived usage, perceived impact, and organizational and respondent characteristics. The response rate was 89%. Average item scores were used to create an individual domain summary score. The association between the impact of event notifications and organizational characteristics was modeled using random-intercept logistic regression models.

RESULTS

Respondents estimated that organizations followed up on the majority (83%) of event notifications. Supportive organizational policies were associated with the perception that event notifications improved quality of care (odds ratio [OR] = 2.12; 95% CI, = 1.05, 4.45), efficiency (OR = 2.06; 95% CI = 1.00, 4.21), and patient satisfaction (OR = 2.56; 95% CI = 1.13, 5.81). Higher quality of event notification information was also associated with a perceived positive impact on quality of care (OR = 2.84; 95% CI = 1.31, 6.12), efficiency (OR = 3.04; 95% CI = 1.38, 6.69), and patient satisfaction (OR = 2.96; 95% CI = 1.25, 7.03).

CONCLUSIONS

Health care organizations with appropriate processes, workflows, and staff may be better positioned to use event notifications. Additionally, information quality remains critical in users' assessments and perceptions.

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.

Accuracy of pharmacy benefit manager medication formularies in an electronic health record system and the Epocrates mobile application

BACKGROUND

Physicians commonly use formulary medication coverage information generated by electronic heath records (EHRs) and the Epocrates mobile drug database application when making medication selection decisions. Nonformulary selections may lead to higher out-of-pocket patient costs and nonadherence with prescribed regimens. Nonformulary selections also contribute to higher overall health plan spending. However, the accuracy of these systems compared with actual insurance coverage is not known. 

OBJECTIVE

To assess the accuracy of formulary status icons generated by an EHR system and the Epocrates mobile application for patients with Alabama Medicaid and Blue Cross Blue Shield of Alabama (BCBS), the primary insurance providers in the state of Alabama.

METHODS

Patients of all ages who had a chart review performed at the outpatient family medicine or pediatric clinics at the University of Alabama at Birmingham Huntsville Medical Regional Campus from May to October 2013 were included in this retrospective analysis. Patients who were not insured by either Alabama Medicaid or BCBS were excluded. Patients who did not have new medications added at the time of the visit were also excluded. For each medication prescribed, the formulary status provided in the EHR system and Epocrates was compared with the actual Medicaid and BCBS formularies published online, and the accuracy of the 2 databases was determined. 

RESULTS

A total of 1,529 medication records were analyzed. The EHR and Epocrates provided accurate formulary information for 93.1% and 89.4% of medications, respectively. Formulary information generated by the EHR was 96.3% accurate for Medicaid patients and 80.1% accurate for BCBS patients. Epocrates was 88.2% accurate for Medicaid patients and 94.4% accurate for BCBS patients. A total of 936 medication records from the pediatric clinic were analyzed, and the majority of these patients (88.4%) had Medicaid insurance. In this population, the EHR was more accurate (96.9%) than Epocrates (86.6%). Of the small number of pediatric medication records (n = 109) associated with patients who had BCBS, Epocrates was more accurate (92.7%) than the EHR (83.5%). In family medicine, 593 medication records were analyzed. Again, for Medicaid patients, the EHR was more accurate (95.3%) than Epocrates (91.5%). For those with BCBS, Epocrates was more accurate (95.3%) than the EHR (78.2%). When over-the-counter (OTC) medications (n = 232) were analyzed separately from prescription medications, it was found that overall the EHR was 90.5% accurate, and Epocrates was 41.4% accurate. It is important to note that when only prescription medications were analyzed, the accuracy rates were high (93.6% for the EHR and 98.0% for Epocrates).

CONCLUSIONS

Formulary information generated by the EHR system and the Epocrates mobile application is a useful tool for physicians when prescribing medications, but neither source is completely accurate. Prescribers should be particularly cautious when making OTC formulary decisions using the Epocrates mobile application, since the formulary information provided for these medications was found to be the least accurate.

Evaluation of electronic prescription implications in Turkey: an investigation of the perceptions of physicians

BACKGROUND

Electronic prescribing (e-prescribing) is an evolving area of healthcare information technology that aims to support physician decision-making by capturing, reviewing, and issuing medical prescriptions with high potential for improving the quality and safety of the process.

PURPOSE

To describe physician perception of e-prescription use in healthcare organizations that work with social security and to evaluate their infrastructures for MEDULA (an information system for billing and other health informatics) in healthcare organizations in Turkey.

METHODS

A cross-sectional survey design was used for this study. A convenience sample of physicians in eight general hospitals and in two oral and dental health centers of the Ministry of Health in Turkey were surveyed.

RESULTS

Survey response rate was 47% (248/425). The majority of physicians (62%) support e-prescribing but have not used an electronic signature for prescriptions (78.2%). Almost half of them believe that e-prescriptions would positively contribute to patient safety (43%)

LINKING EVIDENCE TO ACTION

Our study provides a first look at the perceptions of physicians regarding the implications of e-prescriptions, which became mandatory on January 15, 2013, in Turkey. Advocates of e-prescribing have suggested that additional efforts are needed to strengthen clinical decision systems. Physicians and nurses are better able to adopt e-prescribing systems and to view them positively if they recognize the limitations of paper-based prescribing and understand the utility of electronic systems in addressing some of these limitations. This study represents a starting point for government and related organizations to improve their knowledge on how well the implied benefits of e-prescriptions are realized in their acquisition, appraisal, and use in health policy decision-making and health systems.

The impacts of second generation e-prescribing usability on community pharmacists outcomes

BACKGROUND

The results from past studies about the effects of second-generation e-prescribing systems on community pharmacists' outcomes and practices are inconclusive, and the claims of effectiveness and efficiency of such systems have not been supported in all studies. There is a strong need to study the factors that lead to positive outcomes for the users of these systems.

OBJECTIVE

This paper intends to bridge the above gaps by empirically examining the impacts of user interface usability on the community pharmacists' outcomes.

METHODS

A quantitative survey research method was used and the data was collected from the community pharmacists, who use an e-prescribing system. Data from 152 questionnaires collected in a national survey were used to for the study. Partial Least Squares (PLS) path modeling was used to examine scale reliability, validity and hypotheses.

RESULTS

The scale was found to test well for reliability and validity. Examining the hypotheses illustrated that ease of use (P < 0.01, t = 5.79) and information quality (P < 0.01, t = 6.24) of an e-prescribing system improved pharmacists' outcomes (including communication, facilitation of care, reduction of workload and medical errors) while ease of use of the system was influenced by user interface consistency (P < 0.01, t = 7.35) and system error prevention (P < 0.01, t = 5.29).

CONCLUSION

To improve community pharmacists' outcomes and practices, the ease of use, information quality, consistency and error prevention features of e-prescribing systems should be improved. It was found that information quality had a stronger impact on the outcomes and hence improving the quality of the generated information would have higher impacts on users' outcomes.

Computerized prescriber order entry in the outpatient oncology setting: from evidence to meaningful use

BACKGROUND

Chemotherapy is an effective treatment in the fight against many cancers. Medication errors in oncology can be particularly serious given the narrow therapeutic window of antineoplastic drugs and their high toxicities. Computerized prescriber order entry (cpoe) has consistently been shown to reduce medication errors and adverse drug events in various settings, but its use in the oncology setting has not been well established. To gain a better understanding of the meaningful use of cpoe systems in the outpatient chemotherapy setting, we undertook a systematic review of systemic therapy cpoe.

METHODS

A province-wide expert panel consisting of clinical experts, health information professionals, and specialists in human factors design provided guidance in the development of the research questions, search terms, databases, and inclusion criteria. The systematic review was undertaken by a core team consisting of a medical oncologist, nurse, pharmacist, and methodologist. The medline, embase, cinahl, and compendex databases were searched for relevant evidence.

RESULTS

The database searches resulted in 5642 hits, of which 9 met the inclusion criteria and were retained. In the oncology setting, cpoe systems generally reduce chemotherapy medication errors; however, specific types of errors increase with the use of cpoe. These systems affect practice both positively and negatively with respect to time, workload, and productivity.

CONCLUSIONS

Despite the paucity of oncology-specific research, cpoe should be used in outpatient chemotherapy delivery to reduce chemotherapy-related medication errors. Adoption by clinicians will be enhanced by cpoe processes that complement current practice and workflow processes.

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.

User experiences with different regional health information exchange systems in Finland

PURPOSE

The interest in cross-organizational Health Information Exchange (HIE) is increasing at regional, national and cross-European levels. The purpose of our study was to compare user experiences (usability) of different regional health information exchange system (RHIE) types as well as the factors related to the experienced level of success of different RHIE system types.

METHODS

A web-based questionnaire was sent to 95% of Finnish physicians aged between 25 and 65 years of age. RHIE systems were mainly available in the public sector and only in certain regions. Those 1693 physicians were selected from the 3929 respondents of the original study, who met these criteria. The preferred means (paper/fax vs. electronic) of cross-organizational HIE, and replies to the 11 questions measuring RHIE success were used as the main dependent variables.

RESULTS

Two thirds (73%) of the primary care physicians and one third (33%) of the specialized care physicians replied using an electronic RHIE system rather than paper or fax as a primary means of cross-organizational HIE. Respondents from regions where a regional virtual EHR (type 3) RHIE system was employed had used electronic means rather than paper HIE to a larger extend compared to their colleagues in regions where a master patient index-type (type 1) or web distribution model (type 2) RHIE system was used. Users of three local EHR systems preferred electronic HIE to paper to a larger extend than users of other EHR systems. Experiences with an integrated RHIE system (type 3) were more positive than those with other types or RHIE systems.

CONCLUSIONS

The study revealed User preferences for the integrated virtual RHIE-system (type 3) over the master index model (type 1) or web distribution model (type 2). Success of individual HIE tasks of writing, sending and reading were impacted by the way these functionalities were realized in the EHR systems. To meet the expectations of increased efficiency, continuity, safety and quality of care, designers of HIE systems also need to take into account the different HIE needs of primary care clinicians and their secondary care colleagues in hospitals. Both national legislation and local interpretations of data protection possibly hinder the full use of any RHIE systems. These findings should be taken into account when designing usable HIE systems. More qualitative research is needed on specific features of those local systems that are associated with positive or negative user experience.

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.

A theoretical approach to electronic prescription system: lesson learned from literature review

CONTEXT

The tendency to use advanced technology in healthcare and the governmental policies have put forward electronic prescription. Electronic prescription is considered as the main solution to overcome the major drawbacks of the paper-based medication prescription, such as transcription errors. This study aims to provide practical information concerning electronic prescription system to a variety of stakeholders.

EVIDENCE ACQUISITION

In this review study, PubMed, ISI Web of Science, Scopus, EMBASE databases, Iranian National Library Of Medicine (INLM) portal, Google Scholar, Google and Yahoo were searched for relevant English publications concerning the problems of paper-based prescription, and concept, features, levels, benefits, stakeholders and standards of electronic prescription system.

RESULTS

There are many problems with the paper prescription system which, according to studies have jeopardized patients' safety and negatively affected the outcomes of medication therapy. All of these problems are remedied through the implementation of e-prescriptions.

CONCLUSIONS

The sophistication of electronic prescription and integration with EHR will become a reality, if all its stakeholders collaborate in developing fast and secure electronic prescription systems. It is plausible that the required infrastructure should be provided for implementation of the national integrated electronic prescription systems in countries without the system. Given the barriers to the implementation and use, policymakers should consider multiple strategies and offer incentives to encourage e-prescription initiatives. This will result in widespread adoption of the system.

Impacts of second-generation electronic prescriptions on the medication management process in primary care: a systematic review

OBJECTIVE

To describe second-generation electronic prescription (eRx) technologies and identify their impacts on the medication management process in primary care. Second-generation eRx technologies have focused on networking various stakeholders so that they can communicate electronically.

METHOD

Using key words, a search was conducted of the relevant databases up to January 2011. A manual search was conducted of the bibliographies of the studies as well as the prior systematic reviews found. The tables of contents of the major periodicals in the field were also searched. This included studies of the impacts of eRx technologies that allow electronic circulation of information between prescription sites and dispensing sites, independent of the methodology used. A structured form was used to extract the data. The studies' impacts were classified by stage in the medication management process (prescription, transmission of the prescription, execution of the prescription and use of the medication).

RESULTS

Nineteen observational studies were included in this review. Most of them (10/19) have evaluated users' perceptions using interviews, focus groups or questionnaires. Two technology models stand out: the push model, under which the prescriber directs the prescription toward a specific pharmacy, and the pull model, under which any authorized pharmacy can download a given prescription into its system. The push model is the most widely used, particularly in the United States. Communication between prescribers and dispensers is usually unidirectional, and communications standards have to be refined. The only demonstrated impacts of second-generation eRx technologies were found at two levels: positive impacts on the quality of the pharmacological profile available to professionals, and negative impacts on the execution of prescriptions in pharmacies. Stakeholders' perceptions were mixed and reflected considerable differences according to context, the type of technology used, the intensity of its use and its maturity. Electronic transmission of prescriptions provides a new way to monitor patient compliance.

CONCLUSION

There is little empirical data demonstrating benefits to second-generation eRx technologies, even if it is a highly promoted model for improving primary care quality. More research is required, with studies that measure the impacts of second-generation technologies using empirical data and conducted in the context of actual use. Future studies should also employ the same terminology and provide full descriptions of context, type of technology and intensity of use.

Factors that physicians find encouraging and discouraging about electronic prescribing: a quantitative study

To determine factors that physicians find encouraging and discouraging about e-prescribing and to compare these factors based on physicians' adoption status, a cross-sectional study was conducted using an internet-based survey administered to a national convenience sample of primary care physicians. A scale was developed to measure factors related to the adoption of e-prescribing. Analysis procedures included exploratory factor analysis, multivariate analysis of variance, and Tukey's post-hoc tests. 443 surveys were received and seven e-prescribing factors were identified. Pre-implementation and cost factors were found to be most discouraging, while software features were found to be most encouraging. The fact that current e-prescribers found e-prescribing factors to be more encouraging than future or non-e-prescribers suggests that 'fear of the unknown' may play a role in prescribers' perceptions of e-prescribing and associated software. These findings will enable consultants, vendors, and policymakers to facilitate the adoption of e-prescribing by directly targeting the factors that are most salient to physicians.

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

OBJECTIVE

A core feature of e-prescribing is the electronic exchange of prescription data between physician practices and pharmacies, which can potentially improve the efficiency of the prescribing process and reduce medication errors. Barriers to implementing this feature exist, but they are not well understood. This study's objectives were to explore recent physician practice and pharmacy experiences with electronic transmission of new prescriptions and renewals, and identify facilitators of and barriers to effective electronic transmission and pharmacy e-prescription processing.

DESIGN

Qualitative analysis of 114 telephone interviews conducted with representatives from 97 organizations between February and September 2010, including 24 physician practices, 48 community pharmacies, and three mail-order pharmacies actively transmitting or receiving e-prescriptions via Surescripts.

RESULTS

Practices and pharmacies generally were satisfied with electronic transmission of new prescriptions but reported that the electronic renewal process was used inconsistently, resulting in inefficient workarounds for both parties. Practice communications with mail-order pharmacies were less likely to be electronic than with community pharmacies because of underlying transmission network and computer system limitations. While e-prescribing reduced manual prescription entry, pharmacy staff frequently had to complete or edit certain fields, particularly drug name and patient instructions.

CONCLUSIONS

Electronic transmission of new prescriptions has matured. Changes in technical standards and system design and more targeted physician and pharmacy training may be needed to address barriers to e-renewals, mail-order pharmacy connectivity, and pharmacy processing of e-prescriptions.

Evaluation of RxNorm in Ambulatory Electronic Prescribing

Drug prescriptions need to accurately identify the medications that prescribers intend for pharmacists to dispense. However, the set of computer-interpretable identifiers currently used in electronic prescribing (e-prescribing) does not support the specific needs of the prescribers and pharmacists who conduct e-prescribing transactions. RxNorm, a drug nomenclature from the National Library of Medicine, assigns a rigorously derived, centrally maintained, and publicly available unique identifier to each clinically distinct drug. It therefore has the potential to greatly improve drug identification in e-prescribing transactions. Through laboratory research and pilot testing, the authors evaluated RxNorm's potential to improve how medications are represented in e-prescribing transactions. They found that RxNorm is highly complete for prescription drugs used in ambulatory practice that are within its scope and that it offers substantial efficiency and parsimony gains for communicating health plan formulary information to prescribers. The errors that arose during use were of low clinical significance. In live pilot testing, RxNorm identifiers were successfully added to prescription transactions sent between participating prescribers and pharmacies, and the pharmacies were able to use this information to check for dispensing errors or to disambiguate prescriptions. The authors found that RxNorm appears to provide drug identifiers that more accurately reflect the prescriber's intent than the drug identifier set currently used.

Errors associated with outpatient computerized prescribing systems

OBJECTIVE

To report the frequency, types, and causes of errors associated with outpatient computer-generated prescriptions, and to develop a framework to classify these errors to determine which strategies have greatest potential for preventing them.

MATERIALS AND METHODS

This is a retrospective cohort study of 3850 computer-generated prescriptions received by a commercial outpatient pharmacy chain across three states over 4 weeks in 2008. A clinician panel reviewed the prescriptions using a previously described method to identify and classify medication errors. Primary outcomes were the incidence of medication errors; potential adverse drug events, defined as errors with potential for harm; and rate of prescribing errors by error type and by prescribing system.

RESULTS

Of 3850 prescriptions, 452 (11.7%) contained 466 total errors, of which 163 (35.0%) were considered potential adverse drug events. Error rates varied by computerized prescribing system, from 5.1% to 37.5%. The most common error was omitted information (60.7% of all errors).

DISCUSSION

About one in 10 computer-generated prescriptions included at least one error, of which a third had potential for harm. This is consistent with the literature on manual handwritten prescription error rates. The number, type, and severity of errors varied by computerized prescribing system, suggesting that some systems may be better at preventing errors than others.

CONCLUSIONS

Implementing a computerized prescribing system without comprehensive functionality and processes in place to ensure meaningful system use does not decrease medication errors. The authors offer targeted recommendations on improving computerized prescribing systems to prevent errors.

Electronic prescriptions and disruptions to the jurisdiction of community pharmacists

The practice of community pharmacists is being challenged by the appearance of electronic prescription (e-Rx) technology. This article examines the disruptions caused by e-Rx technology to the jurisdiction of community pharmacists based on a model developed from work by Abbott (1988). The main disruptions to professional activities were investigated by qualitative methods in a series of interviews with pharmacists and physicians separated in two groups: practitioners who tested a typical e-Rx technology and stakeholders involved in the implementation of this large-scale e-Rx project in Quebec, Canada. The findings suggest that the technology may disrupt the jurisdiction of community pharmacists, mainly by changing the distribution of information among physicians and community pharmacists. More specifically, the technology represents both a threat to community pharmacists - by supporting the dominant position held by physicians if it gives them access to information held exclusively by pharmacists - and an opportunity - by redistributing information to the pharmacists' benefit, allowing them to improve the quality of their inferences about medication. However, it would appear that the opportunities offered by the technology generate concerns and tensions, both between physicians and pharmacists and between the pharmacists themselves. This phenomenon may well work against the implementation and use of available tools.

Electronic prescriptions are slowly spreading in the European Union

OBJECTIVE

This study investigated whether the adoption of electronic prescriptions (e-prescriptions) had increased in the 27 member countries of the European Union (EU) in the beginning of this decade. Our previous study in 2002 concerning the old union with 15 countries had discovered that e-prescriptions were rare in daily practice and that there was only slight interest for their future use. Since the internal market with free movement of people, goods, services, and capital is a central issue in the Union, we took a cross-border view of the use of the e-prescriptions.

MATERIALS AND METHODS

A semiopen questionnaire on the use of e-prescriptions, chosen systems, the process itself, investments, and the acceptance of non-national European prescriptions was e-mailed to community pharmacy associations of the 27 EU member countries that were members of or otherwise identified by the Pharmaceutical Group of the EU.

RESULTS

Five countries were using e-prescriptions as a part of their daily practice, but only Denmark and Sweden reported nationwide use. These countries were the same that used e-prescriptions nationally already in 2002. Pilots presented in 2002 had not yet advanced into daily practice. Some new pilots/projects were prepared in the old and new member countries. E-prescription models and systems used were divergent between the countries and sometimes even within a country.

CONCLUSIONS

Nationwide use of e-prescriptions was not more common than in 2002. Several countries had piloted or were piloting projects on e-prescriptions. Interoperability of different systems is a challenge to which EU-funded projects might offer a solution.

Electronic prescribing improves medication safety in community-based office practices

BACKGROUND

Although electronic prescribing (e-prescribing) holds promise for preventing prescription errors in the ambulatory setting, research on its effectiveness is inconclusive.

OBJECTIVE

To assess the impact of a stand-alone e-prescribing system on the rates and types of ambulatory prescribing errors.

DESIGN, PARTICIPANTS

Prospective, non-randomized study using pre-post design of 15 providers who adopted e-prescribing with concurrent controls of 15 paper-based providers from September 2005 through June 2007.

INTERVENTION

Use of a commercial, stand-alone e-prescribing system with clinical decision support including dosing recommendations and checks for drug-allergy interactions, drug-drug interactions, and duplicate therapies.

MAIN MEASURES

Prescribing errors were identified by a standardized prescription and chart review.

KEY RESULTS

We analyzed 3684 paper-based prescriptions at baseline and 3848 paper-based and electronic prescriptions at one year of follow-up. For e-prescribing adopters, error rates decreased nearly sevenfold, from 42.5 per 100 prescriptions (95% confidence interval (CI), 36.7-49.3) at baseline to 6.6 per 100 prescriptions (95% CI, 5.1-8.3) one year after adoption (p < 0.001). For non-adopters, error rates remained high at 37.3 per 100 prescriptions (95% CI, 27.6-50.2) at baseline and 38.4 per 100 prescriptions (95% CI, 27.4-53.9) at one year (p = 0.54). At one year, the error rate for e-prescribing adopters was significantly lower than for non-adopters (p < 0.001). Illegibility errors were very high at baseline and were completely eliminated by e-prescribing (87.6 per 100 prescriptions at baseline for e-prescribing adopters, 0 at one year).

CONCLUSIONS

Prescribing errors may occur much more frequently in community-based practices than previously reported. Our preliminary findings suggest that stand-alone e-prescribing with clinical decision support may significantly improve ambulatory medication safety.

TRIAL REGISTRATION

ClinicalTrials.gov, Taconic Health Information Network and Community (THINC), NCT00225563, http://clinicaltrials.gov/ct2/show/NCT00225563?term=Kaushal&rank=6 .

Adoption and use of stand-alone electronic prescribing in a health plan-sponsored initiative

OBJECTIVES

To quantify rates of stand-alone e-prescribing (SEP) adoption and use among primary care physicians (PCPs) participating in a SEP initiative and to determine which physician and patient characteristics were associated with higher rates of each.

STUDY DESIGN

Using records from an insurer-led SEP initiative, we compared the characteristics of 297 PCPs who adopted SEP through the initiative with the characteristics of 1892 eligible PCPs who did not. Among 297 adopters, we studied the extent of SEP use.

METHODS

Dependent variables included each physician's adoption of SEP and his or her e-prescribing use ratio (the ratio of electronic prescriptions to pharmacy claims in the same period). Independent variables included characteristics of PCPs (specialty, practice size, and prescribing volume) and their patients (patient age, sex, race/ethnicity, and household income).

RESULTS

Solo practitioners, pediatricians, and physicians with more patients from predominantly African American zip codes were underrepresented among SEP adopters. The mean (SD) e-prescribing use ratio among adopters was 0.23 (0.28). Twenty percent of physicians maintained e-prescribing use ratios above 0.50. Available physician characteristics explained little of the variance in use, but physicians in smaller practices had greater use (P = .02).

CONCLUSIONS

Certain categories of physicians may need more tailored incentives to adopt SEP. On average, adopters used the SEP system for only about one-quarter of their prescriptions. Some adopters achieved high levels of SEP use, and further research is needed to elucidate the factors that enabled this.

Physicians' attitudes towards ePrescribing--evaluation of a Swedish full-scale implementation

Background

The penetration rate of Electronic Health Record (EHR) systems in health care is increasing. However, many different EHR-systems are used with varying ePrescription designs and functionalities. The aim of the present study was to evaluate experienced ePrescribers' attitudes towards ePrescribing for suggesting improvements.

Methods

Physicians (n = 431) from seven out of the 21 Swedish health care regions, using one of the six most widely implemented EHR-systems with integrated electronic prescribing modules, were recruited from primary care centers and hospital clinics of internal medicine, orthopaedics and surgery. The physicians received a web survey that comprised eight questions on background data and 19 items covering attitudes towards ePrescribing. Forty-two percent (n = 199) of the physicians answered the questionnaire; 90% (n = 180) of the respondents met the inclusion criteria and were included in the final analysis.

Results

A majority of the respondents regarded their EHR-system easy to use in general (81%), and for the prescribing of drugs (88%). Most respondents believed they were able to provide the patients better service by ePrescribing (92%), and regarded ePrescriptions to be time saving (91%) and to be safer (83%), compared to handwritten prescriptions. Some of the most frequently reported weaknesses were: not clearly displayed price of drugs (43%), complicated drug choice (21%), and the perception that it was possible to handle more than one patient at a time when ePrescribing (13%). Moreover, 62% reported a lack of receipt from the pharmacy after successful transmission of an ePrescription. Although a majority (73%) of the physicians reported that they were always or often checking the ePrescription a last time before transmitting, 25% declared that they were seldom or never doing a last check. The respondents suggested a number of improvements, among others, to simplify the drug choice and the cancellation of ePrescriptions.

Conclusion

The Swedish physicians in the group studied were generally satisfied with their specific EHR-system and with ePrescribing as such. However, identified weaknesses warrant improvements of the EHR-systems as well as of their implementation in the individual health care organisation.