The results of the study were classified into two main themes based on the interviews, including implementation challenges and software challenges with E-prescribing. Each theme included the sub-themes, which we will describe following (Table 2).
Table 2
Themes | Sub-themes |
Challenges in Electronic prescribing Implementation | Physician’s inadequate training |
The Ministry of Health and Medical Education's ineffective position as an executor |
The adoption of various software by basic insurance companies |
Physicians' unwillingness to collaborate |
Health insurers' insufficient assistance in providing computer hardware and software |
Inadequate Internet connection |
Increased pharmacy workload |
Failing to take into account the unique peculiarities of deprived provinces. It is more difficult |
Software problems with E – prescribing | Coding |
Non-coverage of some medicines. |
Lack of a scientific basis for prescription pharmaceuticals |
low user-friendliness of the existing system |
1) Challenges in electronic prescribing implementation
1–1 Physician’s inadequate training
The majority of interviewees stated that one of the primary factors for the electronic prescribing program's delayed development was not providing physicians with the appropriate training. They claim that another problem in the E-prescribing process is the use of an obligatory strategy for the physicians and pharmacists without any attempt to train and develop the required culture and knowledge among them. According to one of the policymakers:
"For the most brilliant members of society, we adopted a compulsory strategy. They'll ultimately figure it out. The language of force is therefore ineffective. This is the cause of the widespread misuse of the nation's electronic prescribing scheme."
1-2- The Ministry of Health and Medical Education's ineffective position as an executor
One of the key drawbacks of the E-prescribing process, which was often noted by different interviewees, is the Ministry of Health and Medical Education (MOHME)'s weak role as the program's executor. Some interviewees seemed to think that the Insurance Organizations' dominant role in this program's administration and supervision highlighted the MOHME's inadequacies. An administrator said:
"Currently, platforms for electronic prescriptions are provided by insurance companies, and the Ministry of Health Medical Education has not developed any special platforms! This organization's conflict of interests could be at the root of this problem."
However, some interviewees claimed that the MOHME had overlooked the main objective of putting in place the E-prescribing plan. A physician said:
"I believe that one of the difficulties with prescription is that the Ministry of Health has lost concentration. In fact, over time, the precise prescription that must be brought to light has changed."
Some of the interviewees argued that the MOHME's frequent management changes hindered it from concentrating on E-prescribing. Another problem presented by the respondents regarding the MOHME's minor role was the absence of a comprehensive perspective and a documented road map. In other words, one of the factors contributing to the program's unsatisfactory implementation over the past several years has been the presence of a short-term, non-permanent attitude toward it.
1–3 The adoption of various software by basic insurance companies
According to the interviews, confusion, and dissatisfaction among physicians, pharmacists, and other users of E-prescribing have resulted from the deployment of various software programs by health insurance and social security agencies. An additional aspect impacting the inappropriate implementation of the program has been some technical difficulties with various kinds of software.
1-4- Health insurers' insufficient assistance in providing computer hardware and software to healthcare organizations.
According to interviews, the E-prescribing plan's deployment has caused health service providers more costs. These expenses comprise the price of the internet, the cost of computer system upgrades, and the expenses associated with purchasing printers, papers, and other requirements.
1–5 Physicians' unwillingness to collaborate
Some of the interviewees believed that the physicians' lack of sufficient collaboration in the electronic prescribing program was the source of the program's recent slow development. Another respondent noted that as the physicians were inexperienced with the existing software, they were unable to pick the most suitable interface software, which resulted in their dissatisfaction and delays in the adoption of the electronic prescribing program. Some pharmacists claim that since some physicians don't have enough training in medical terminology, improper medicines, and services are chosen by them, which leads to patients receiving the wrong medications or inadequate and inaccurate medical diagnoses and therapy services. Software developers have been sluggish to implement electronic prescriptions because they think that physicians prefer the paper approach and aren't interested in using computers.
The reality that physicians prefer writing prescriptions on paper than using computers is one of our most deep concerns.
1–6 - Inadequate Internet connection
The poor internet connection in the country, according to several interviewees, hinders the proper implementation of the program regardless of whether it's well-designed. Also, some interviewees thought that the demolition of the infrastructure of the social security organization and the slow performance of its servers, in addition to the inappropriate internet, represented the additional issue with E-prescribing.
1–7 Increased pharmacy workload
Some interviewees claimed that numerous E-prescribing portals have raised pharmacy procedures and placed unnecessary processes on them. Additionally, some of the interviewees assumed that the lengthened screw prescription process as a result of the service providers' incorrect registration of the prescription or the internet outage had increased their workload, extended the patients' wait times, and as a result, their dissatisfaction.
Also, some of the interviewees suggested that this program might not be adequately implemented across the country because of the excessive investments made by medical sciences universities in the field of IT, particularly because of the constraints placed on deprived provinces of the country.
1–8 Failing to take into account the unique peculiarities of deprived provinces.
It is more difficult to use E-prescribing due to the restricted availability of information technology and the absence of basic amenities in many underdeveloped areas of the country. One of the major problems in these areas is poor internet connectivity, which is a major barrier to the program's proper implementation.
2- Software problems with E – prescribing
2 − 1 Coding
A) Lack of a standard code
The absence of consistent and thorough coding is one of the biggest problems, per interviews. According to some interviewees, organizations engaged in electronic prescriptions ought to be able to interact with one another in a common language, but this tongue has not yet been developed. To put it another way, insurance organizations have different classifications for medicines or services that create problems for users.
"When the same coding is not used, it indicates that the received information does not match," said one of the interviewers. Data is indeed transferred, but according to different standards, consequently, there is no information aggregation.
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b) Non-assignment of codes to some services/medicines: According to doctors, many medicines, radiology imaging, and tests do not yet have codes entered into the system, leading to a misunderstanding between the doctor and the patient resulting in an improper use of the prescription system.
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c) The discrepancy between the coding that the physicians want and the coding that the software offers: the respondents claimed that the prior coding was based on the relative value book and was only based on payment, however, the coding required for prescribing medical conditions has to be different. The 'coding' needs to be tailored according to the doctor's order.
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d) Lack of an appropriate code for imaging and laboratory procedures: According to the individuals who participated in the interviews, the codes for radiology imaging and laboratory procedures need to be modified, and in many cases, standard codes have not been established for them. The main problem with laboratory services is that there isn't an appropriate service code. Doctors struggle to find the codes because there are so many of them, which causes them to lose time from performing other crucial tasks.
Furthermore, some laboratory services call for extra tests, but since these tests are not offered by the system, the physician is unable to choose them. The laboratory is forced to charge the patient an additional cost for the test in such a case. Another problem with laboratory services is that the levels of the tests are not specified in the system, and the healthcare provider just records the results of the primary test.
2–2. Non-coverage of some medicines.
A number of drugs, according to those who participated in the interviews, are not listed in the electronic prescribing system. As a result, patients have to shell out more out of pocket for the prescriptions. Additionally, a number of physicians report that they frequently waste a lot of time looking for medicines that are not listed in the database, which leaves patients dissatisfied and frustrated. A patient reported:
"Yesterday, I went to the doctor, he said that your drug has not registered in the system and you should go and get medicine without any insurance payment!!"
2-3- Lack of a scientific basis for prescription pharmaceuticals
Some interviewees believed that the computerized prescribing software's logic and way of prescribing drugs are unclear, which makes physicians doubt the efficacy of the current software. Not paying attention to the timing and importance of pharmaceutical regulation is another problem.
2-4- low user-friendliness of the existing system
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System difficulty: Many of the interviewees reported that the current iteration of the social security electronic prescribing system is not user-friendly, making it challenging for users to apply it and, frequently, wasting their time.
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The long drop-down list of medications/tests and increased risk of error: According to some physicians, the risk of selecting the incorrect medication is very significant as a result of the long drop-down list, and it is important to address this problem as swiftly as possible.
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The tedious procedure of manually entering a medicine's name into the database. Additionally, several medical professionals felt that because it takes so long to input a medication's name into the system, they are unable to spend as much time interacting with patients. Some medical professionals believed the physician was focusing much of his efforts and attention on finishing the system rather than performing his primary duties, which include carefully examining the patient and developing an altruistic relationship. As a result of this, an effective professional relationship between the physician and the patient cannot be established, which leads to patient dissatisfaction.
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Inadequacy of the system's decision-making support: According to the individuals who took part in the interviews, the system's capacity to recommend treatments and medications based on the chosen primary diagnosis is very limited, and this capability needs to be improved. This is due to the fact that it cannot make the right recommendations for a number of diagnoses. Additionally, a few physicians agreed that the current approach did not adequately address the likelihood of medicine interaction warnings and various prescription tests.