Challenges and Solutions in Implementing Electronic Prescribing: A Qualitative Study

doi:10.21203/rs.3.rs-4812268/v1

Download PDF

Research Article

Challenges and Solutions in Implementing Electronic Prescribing: A Qualitative Study

https://doi.org/10.21203/rs.3.rs-4812268/v1

This work is licensed under a CC BY 4.0 License

You are reading this latest preprint version

Background

The use of electronic prescribing is recognized as a strategic tool for improving healthcare. Given the nationwide implementation of electronic prescribing systems initiated in 2020, this study aims to explore the challenges and solutions for implementing electronic prescribing in Iran's health system as a developing country.

Methods

This qualitative study was conducted through interviews with physicians, pharmacy staff, and electronic prescribing representatives in 2023. Initially, three in-depth interviews were conducted to develop the interview questions, resulting in three separate interview guides for each participant group (supplementary file no.1 ). Participants were purposively selected, including 12 physicians, 15 electronic prescribing representatives, and 9 pharmacy staff members. Interviews continued until data saturation was reached. The interviews were recorded, transcribed, and analyzed using content analysis with MAXQDA version 10 software. To identify challenges, sessions were held, and a final list of challenges was categorized. In the final stage, expert panels were formed to propose solutions.

Result

The challenges identified in this study were categorized into two main domains: "Organizational Challenges" and "Systemic Challenges." Organizational challenges included issues related to insurance (16 cases), patient referrals (4 cases), stakeholder education and communication (6 cases), and supervision (8 cases). Systemic challenges included infrastructure problems (18 cases), user interface (UI) issues (14 cases), and database issues (10 cases). The primary challenges in implementing electronic prescribing were system downtime and sluggishness, internet connectivity issues, and the existence of multiple insurance systems. Expert panel discussions resulted in proposed solutions, including the uniform design of software by the Ministry of Health, the establishment of an integrated electronic referral system, conducting practical training sessions for physicians, and implementing electronic signatures.

Conclusion

Electronic prescribing in Iran is still in its early stages and will inevitably face challenges and problems. Continuous monitoring of electronic prescribing systems is essential to address implementation issues promptly. Overall, improvements in infrastructure, integration of insurance systems, implementation of electronic signatures, adherence to electronic prescribing standards, and provision of practical training are recommended.

Electronic Prescribing

Challenges

Implementation

Physicians

Pharmacy

Implementation

Electronic prescribing (e-prescribing) has always been a topic of interest among other electronic health solutions for processing health-related data(1) and is considered a crucial component of health information technology infrastructure, improving patient safety, quality, and cost-effectiveness of care (2). The use of e-prescribing has been proposed as a significant strategic policy for enhancing healthcare in Europe. The United States and Europe represent the two major markets for e-prescribing systems globally, with Europe being the largest (3). Leading European countries in e-prescribing include Denmark, Sweden, Norway, Finland, and Iceland, with the world's first e-prescription implemented in Sweden in 1983(4).

The implementation of e-prescribing systems in healthcare is rapidly expanding, and improvements in both quantity and quality have been demonstrated. However, according to studies, the acceptance and use of e-prescribing do not always proceed smoothly. Therefore, user perspectives are crucial for the success of these systems (5). A 2019 study in Saudi Arabia found that 61% of physicians believed e-prescribing facilitates drug prescribing and patient detail retrieval(6).

A study in Kuwait highlighted the importance of e-prescribing in improving patient care quality, streamlining workflows, increasing productivity, and reducing medical errors from physicians' perspectives. However, the need for improved system design and infrastructure was also identified as a barrier(7). A study by the Social Security Organization (SSO) in Iran revealed that most physicians believed the SSO e-prescribing system was highly effective and efficient, improving patient safety and reducing costs. It emphasized the necessity of adequate financial, human, educational, and supportive resources for users(8, 9).

In Iran, the Social Security Organization first introduced e-prescribing in 2015, with a pilot program in Yazd province. The initiative to eliminate prescription booklets in Social Security medical centers commenced that same year(10). The comprehensive implementation of the e-prescribing project officially began in February 2019 and extended to 235 cities by November 2019. Since 2020, this initiative has been a priority for both the Ministry of Health and the Iranian Health Insurance Organization. In alignment with Clause 17 of the budget law, which mandated the cessation of paper prescriptions starting January 2022, the complete adoption of e-prescribing has been actively pursued. This mandatory shift is designed to integrate information systems, prevent erroneous drug prescriptions, regulate service provision, eliminate insurance overlaps, conserve paper, and ultimately facilitate the full implementation of the family physician's electronic health record system(11).

As with any technology, the outcomes of e-prescribing largely depend on its implementation(2). Poorly performing e-prescribing systems can negatively impact healthcare delivery. Therefore, healthcare information systems, especially electronic prescribing systems (EPS), must be carefully evaluated to ensure their performance and quality, encouraging use among users and policymakers(4, 12). Evaluating health information systems is essential to ensure proper functioning and minimize potential errors(13).

Given the mentioned importance of using and implementing e-prescribing systems, this study aims to investigate the challenges and solutions for implementing e-prescribing in Iran's health system as a developing country, to offer solutions for other countries with similar conditions in providing appropriate strategies to advance the country's therapeutic goals.

This study is an applied research in terms of its objective and a descriptive cross-sectional research in terms of its nature and method. Conducted in 2022, the study was carried out in two phases. A qualitative approach was employed to examine the challenges and solutions in implementing electronic prescribing (e-prescribing). The participants included 12 general and specialist physicians, 9 pharmacy staff, and 15 e-prescribing representatives who used the e-prescribing system in their service delivery. The inclusion criteria were experience with e-prescribing and willingness to participate in the interview.

To understand participants' experiences with existing challenges, the most common qualitative data collection method—interviews—was utilized. The primary researcher (who has been both a Staff and an Electronic Prescribing Representative) personally conducted all interviews. Prior to the main interviews, three in-depth, unstructured interviews were conducted with physicians and e-prescribing representatives to develop the interview questions. Following multiple discussions among researchers, the interview questions were finalized, resulting in 18 semi-structured questions for physicians and 7 questions each for pharmacy staff and e-prescribing representatives. The interviews were conducted in the first half of 2022.

The interviewer contacted participants via phone to schedule interviews if they were willing and had sufficient time to share their views. Interviews were preferably conducted at the participants' workplaces in a quiet room, lasting between 20 to 30 minutes. Before starting each interview, the interviewer introduced themselves, explained the study's purpose, interview duration, and the conditions for using the interview data. Consent was obtained for recording the interviews, and participants were assured of the confidentiality of all information shared during the sessions.

Interviews began with collecting personal information and establishing rapport, creating a conducive environment for the discussion. Participants were then asked open-ended and semi-structured questions to identify the challenges in implementing e-prescribing. The questions were designed to elicit participants' views and beliefs on the topic. Data were collected through 36 semi-structured interviews (12 with physicians, 15 with e-prescribing representatives, and 9 with pharmacy staff) until data saturation was reached.

The interviews were recorded, transcribed, and analyzed using MAXQDA software. Codes were reviewed and refined in five sessions with three researchers, revisiting the original interviews when necessary for clarity. The final codes were categorized, and the challenges were extracted. To enhance the scientific trustworthiness and validity of the results, methods proposed by Guba and Lincoln, including credibility, confirmability, dependability, and transferability, were employed(14).

For evaluating data analysis credibility, a session was held with researchers who had conducted similar studies, and the results were presented to them. Confirmability was achieved by sharing the analysis results with a group of participants and receiving their feedback. Transferability was ensured by selecting appropriate participants and promptly collecting and analyzing the data.

In the second phase, to propose solutions, a panel of experts was convened, including 3 researchers, 4 e-prescribing representatives, and 3 insurance experts. The researchers introduced themselves and stated the overall purpose of the session. After presenting the identified challenges, proposed solutions were discussed. During the focused group discussion, researchers took notes and, with participants' consent, recorded their views, which were transcribed after the session.

In this study, 12 physicians, 9 pharmacy staff members, and 15 e-prescribing representatives participated. The e-prescribing representatives included individuals directly involved in the e-prescribing system who were willing to participate in the interviews. The demographic characteristics of the participants are presented in Table 1.

Table 1

Demographic characteristics of study participants
Interviewing groups		Physician	pharmacy	Prescription Representative	Total
Demographic characteristics		Physician	pharmacy	Prescription Representative	Total
		No.	No.	No.	No.
Sex	female	4(33.3)	4 (44.4)	10 (66.6)	18 (50)
	male	8 (66.6)	5 (55.5)	5 (33.3)	18 (50)
Age	21–30	4 (33.3)	2 (22.2)	1 (6.6)	7 (19.4)
	31–40	6 (50)	4 (44.4)	11 (73.3)	21 (58.33)
	41 ≤ …	2 (16.6)	3 (33.3)	3 (20)	8 (22.2)
Education	Diploma	0 (0)	1 (11.1)	0 (0)	1 (2.7)
	BA*	0 (0)	4 (44.4)	7 (46.6)	11 (30.5)
	MA**	0 (0)	0 (0)	8 (53.3)	8 (22.2)
	GP***	5 (41.6)	4 (44.4)	0 (0)	9 (25)
	Specialist	7 (58.3)	0 (0)	0 (0)	7 (19.4)
Work experience	1–5	8 (66.6)	2 (22.2)	2 (13.3)	12 (33.3)
(year)	6–10	2 (16.6)	2 (22.2)	3 (20)	7 (19.4)
	11≤ …	2 (16.6)	5 (55.5)	10 (66.6)	17 (47.2)
Experience with electronic prescribing	…≤6	4 (33.3)	3 (33.3)	0 (0)	7 (19.4)
(month)	6–12	7 (58.3)	3 (33.3)	15 (100)	25 (69.4)
	12 ≤ …	1 (8.3)	3 (33.3)	0 (0)	4 (11.1)
Organizational Position	GP	5 (41.6)	0 (0)	0 (0)	5 (13.8)
	Specialist	7 (58.3)	0 (0)	0 (0)	7 (19.4)
	Pharmacy technician	0 (0)	4 (44.4)	0 (0)	4 (11.1)
	pharmacist	0 (0)	5 (55.5)	0(0)	5 (13.8)
	Health information technology expert	0 (0)	0 (0)	3 (20)	3 (8.3)
	Expert in charge of health information technology	0 (0)	0 (0)	12 (80)	(33.3)
*Bachelor of Arts
** Master of Arts
*** General Practitioner

The challenges in implementing electronic prescribing, extracted using MAXQDA version 10 software, are categorized into three main categories, subcategories, and codes from the perspectives of physicians, pharmacy staff, and e-prescribing representatives. These challenges are presented in the Table2.

Table 2

Challenges in Implementing Electronic Prescriptions from the Participants' Perspective
Themes	Sub Themes	Codes
Organizing Field	Challenges Related to Insurance	Weakness of insurance in terms of informing about changes in systems and instructions
		Lack of insurance coverage for some necessary tests
		Multiple systems for insurance
		The lack of an effective communication channel between Physician and insurance experts
		Lack of link between supplementary insurances and basic insurances and the requirement to provide a paper copy of supplementary insurance
		Lack of access to the rules of the electronic version
		Emphasis of insurance companies on not accepting paper prescriptions
		The need to submit a paper copy to supplementary insurance
		The need to approve some medicinal???? items
		Limited access of electronic prescribing representatives to insurance systems
		Incomplete reporting of insurance systems
		Creation of multiple plugins by the insurance organization
		Non-acceptance of paper prescriptions by pharmacies
		The need to physically send Physician documents to the insurance organization
	Challenges related to patient referrals	Absence of reference code at the time of drug prescription at the time of discharge of patients from hospital wards
		Absence of a specific mechanism in the field of referral
		The referral process is not electronic
		Submission of incorrect and illegible referral code by the patient
	Challenges related to training and informing stakeholders	Lack of knowledge of Physician about expense deductions and bills
		Failure to inform Physicians and patients about the ceiling of medicines and services
		Lack of sufficient training of beneficiaries for electronic prescribing
		Patients are not aware of the referral system
		Failure to inform patients and Physicians about the ceiling of medicines and services
		Not informing patients how to get medicine from the pharmacy
		Failure of Physicians to know the correct code of drugs
	Monitoring Challenges	Inability to guarantee the registration of prescriptions by Physicians
		Lack of supervision over drugs dispensed from pharmacies
		Lack of supervision over drugs dispensed from pharmacies
		Security issues and misuse of the electronic prescription system
		Problems accessing patient records
		Non-uniform pricing of drugs and other services across different systems
		Lack of use of electronic signatures
		Inability to monitor incorrect prescription registration by Physicians
		Lack of precision and sufficient mastery by Physicians when selecting drugs
System Field	Infrastructure Challenges	Inability to record prescriptions with a mobile phone
		Time-consuming electronic prescribing in busy emergency and clinic environments (lack of human resources)
		No designated individuals for 24-hour troubleshooting and system error handling
		Lack of necessary guidelines for prescribing during system or internet outages or slowdowns
		Absence of standardized codes for drugs and other services in the systems
		Issues with recording commercial drugs
		Delays in resolving some system defects
		Failure to send second authentication code SMS
		Incomplete display of alerts when necessary
		Prescriptions not displayed in the pharmacy due to data system slowdowns
		System and internet outages and slowdowns
		Presence of unspecified system errors
		Lack of an effective communication channel between pharmacy, Physician, and insurance expert
		Some Physician' unfamiliarity and lack of access to electronic prescriptions
		Issues with Physician registration in insurance systems
		Lack of integration between insurance systems and HIS (Hospital Information System)
		Eligibility check discrepancies in different systems
		Lack of integration between insurance systems and the comprehensive physician database
	User Interface Challenges	Inconsistent language used when recording drugs and services
		Inability to renew prescriptions
		Inability to record notes for certain medications when necessary
		Multiple usernames and passwords for different systems
		Difficulty in searching for drugs and para clinical services
		Multiple entries for different services in a single prescription
		Separate recording of prescriptions based on the physician's place of practice
		Inability to view tracking codes in the prescription list
		Failure to display frequently used prescriptions alphabetically
		Inability to edit prescriptions
		System interface not designed according to each specialty
		Ability to view the names of scheduled patients in specialized clinics
		Incorrect medication instructions recorded by Physician
		Lack of alphabetical search options
	Database Challenges	Lack of integration between laboratory and radiology results in the systems
		Incomplete family Physician database
		Missing certain drug, laboratory, and radiology codes
		Inability to record compound, herbal, and supplement medications
		Spelling errors in the systems
		Incomplete definition of drug dosages
		Mismatch between patient national ID and prescription
		Undefined certain medications
		Inability to change medication instructions
		Inability to view prescriptions when the tracking code is lost

The table, based on interviews conducted with 12 physicians, 9 pharmacy staff members, and 15 e-prescribing representatives working at Mashhad University of Medical Sciences, encompasses 2 main categories and 7 subcategories.

Main Concept: Organizational Domain

1–1) Insurance-Related Challenges: All participants highlighted the existence of multiple insurance platforms as a significant issue.

"It was decided that all insurances would use a common platform for prescribing to avoid issues with inquiries and registration. Unfortunately, each insurance currently has its own separate system, each with its own set of problems, and there is no comprehensive, integrated system that we can work with" (Participant 1).

Given that e-prescribing systems initially faced numerous challenges and required several adjustments over time, insurance organizations performed poorly in managing these changes effectively.

"There is no adequate response or support for technical deficiencies in the system. The system's electronic deficiencies are occasionally supported, albeit very weakly. However, in terms of scientific support for issues like the unavailability of drugs or services, I have yet to receive any satisfactory support" (Participant 5).

1–2) Challenges Related to Patient Referrals:

Several participants expressed concerns about the lack of referral codes at the time of patient discharge from inpatient wards, citing an absence of clear mechanisms for referrals. Despite the transition to e-prescribing, some participants mentioned that the referral process still involved paperwork. "The patient referral process should be integrated with other levels of electronic health insurance to eliminate paper-based referrals entirely" (Participant 8).

1–3) Challenges Related to Stakeholder Education and Information:

Many participants indicated that there was insufficient training when the e-prescribing process was initiated. Issues included physicians' lack of awareness about the prescription limits for certain medications and the inaccessibility of patients' medical and drug histories. "I received no training at the start of e-prescribing; I had to learn everything through trial and error and my own research. There were no recommendations or guidance provided" (Participant 5).

1–4) Challenges Related to Supervision:

Several participants noted that some physicians delegated the e-prescribing process to their assistants, making it difficult to supervise the medications dispensed to patients. Additionally, some physicians expressed concerns about the security and confidentiality of the e-prescribing system. "When we want to view a patient's previous records, a confirmation code must be sent, which can cause issues if the patient doesn't have their phone with them. We need to access these records in the patient's presence for their benefit, not to misuse their medical history" (Participant 4).

Main Concept 2: Systemic Domain

2 − 1) Infrastructure Challenges:

The most frequently mentioned infrastructure issues were system downtimes and internet slowdowns. All participants highlighted these problems. "System downtimes and slow internet are our biggest issues. When a patient comes to the pharmacy, we can't access their prescription or dispense their medication" (Participant 7).

Due to disruptions with mobile operators like MCI and Irancell, and occasional incorrect registration of physicians' phone numbers in the system, one-time passwords (OTPs) were not always received by physicians. Several interviewees mentioned: "Physicians sometimes forget their OTP, or their phone isn't with them, or the OTP is sent to a different number. This causes significant delays until the issue is resolved by colleagues in different locations" (Participant 10).

2–2) User Interface Challenges:

One issue was the lack of a consistent language for searching drugs and services within the e-prescribing systems. Some medications required additional explanations from the physician to the pharmacy staff to prevent confusion, which was not always possible. Physicians found it difficult to search for medications and services due to spelling errors, differing codes, and the abundance of drugs and services. "Finding the names of some tests is very difficult because many tests have similar names, and it opens a long list. In a busy emergency room, it's challenging for a tired physician to avoid making mistakes" (Participant 3).

Another problem highlighted by pharmacy staff was the incorrect entry of usage instructions by physicians. "Some physicians have their assistants enter prescriptions, leading to errors in drug entries and often incorrect usage instructions, like prescribing everything as 'once daily'" (Participant 8).

2–3) Database Challenges:

Physicians reported issues with spelling errors in the system and the absence of some drug codes. "Some drugs are incorrectly named in the insurance system; for example, 'cephalexin' is correctly spelled as 'cephalexin,' but in the system, it is entered as 'cephalexin'" (Participant 9).

Pharmacy staff mentioned that some drugs did not have codes, or only one code was assigned to a drug from various pharmaceutical companies, requiring the physician to write the prescription on paper. "Not all codes are registered in the systems, like some herbal syrups, supplements, etc., so the physician must write these separately on a paper alongside the e-prescription" (Participant 6).

Proposed Solutions in the Expert Panel:

The solutions session was held with 3 researchers, 4 e-prescribing representatives, and 3 insurance experts. Before the session, the researchers introduced themselves, explained the study's purpose, the duration of the session, and the conditions for using the proposed solutions. Consent for recording the session was also obtained. The representatives were then asked to propose suitable solutions based on the presented challenges which are presented in Table 3.

Table 3

Recommended Solutions in the Expert Panel
Challenges	Existing Solutions and Required Notifications	Proposed Solutions
Weakness of insurance companies in informing about changes in systems and guidelines	Conducting notifications through prescription websites
Multiple systems for insurance companies		Designing standardized software by the Ministry of Health
Absence of referral codes when prescribing medications at the time of patient discharge from hospital departments	The possibility for emergency users to write electronic prescriptions for rural insurance without referral codes at the time of patient discharge
Security issues and misuse of the electronic prescription system		The necessity of implementing electronic signatures
Inability to ensure that prescriptions are registered by Physician	Tracking prescription violations via the insurance dashboard
Inconsistent pricing of drugs and other services across different systems	The commercial nature of drugs as the reason for their price differences	More detailed segregation of actions in the systems
Missing codes for certain drugs, tests, and radiology services		The need for collaboration between the Food and Drug Administration and Physician regarding the design of the drug source in the systems
Lack of an effective communication channel between pharmacy, Physician, and insurance expert		Enabling chat access for communication between Physician and pharmacies/ the necessity for the Ministry to issue guidelines for a unified messaging system for notifying Physician
Inability to record prescriptions with a mobile phone	Capability to register prescriptions via mobile phone	The ability to record prescriptions with a mobile phone enhances the flexibility and efficiency of healthcare providers, improving the overall effectiveness of the healthcare system
No designated individuals for 24-hour troubleshooting and system error handling	24/7 national support available through phone number 1666 for health insurance and 1420 for social security insurance	Having designated individuals for 24-hour troubleshooting and system error handling ensures continuous support and minimizes downtime, enhancing the reliability and efficiency of healthcare services.
Failure to send second authentication code SMS	Creation of OTP codes for second login password to the system	Having the ability to successfully send a second authentication code via SMS ensures secure and reliable access to healthcare systems, thereby protecting sensitive patient information.
Inability to edit prescriptions	The ability to edit prescriptions up to 72 hours before the medication is collected from the pharmacy	The ability to edit prescriptions allows healthcare providers to make necessary adjustments to treatment plans, ensuring accuracy and improving patient outcomes. 4o
Inability to view tracking codes in the prescription list	The ability for patients to view tracking codes in the insurance system
Necessity for approval of certain drug items	Creating a medical record for the first visit to approve drug items
Patients and Physician not being informed about the limit on drugs and services	Displaying the list of insured drugs on the mdp.ihio.gov.ir system	Designing systems with short and comprehensible addresses for patients to access and view prescriptions
Lack of linkage between supplementary insurance and basic insurance, and the requirement for paper prescriptions for supplementary insurance		Creating web services for supplementary insurance
Lack of oversight on medications delivered from the pharmacy	The necessity for direct cooperation and continuous interaction with Physician, and following up with Physician/ using patient identification cards for medication delivery	Providing a platform for consultation with the responsible pharmacist or treating physician in the electronic prescription system
Inconsistent language used when recording drugs and services		Correct prescription registration during residency and internship periods
Issues with recording commercial drugs	The ability to deliver commercial drugs when prescribing medication generically
Non-electronic referral process		Eliminating paper forms in the referral system with user interfaces and adding a series of APIs and web services

This study is a qualitative research aimed at examining the challenges of implementing an electronic prescription system in hospitals affiliated with Mashhad University of Medical Sciences. Based on interviews conducted with three groups: physicians, pharmacy staff, and electronic prescription representatives, the challenges of implementing electronic prescriptions were categorized into two main groups: "organizational" and "systemic." Subcategories included "insurance-related challenges," "referral system," "supervision," "infrastructure," "user interface," and "database." Solutions proposed included "designing unified software by the Ministry of Health," "creating systems with short and comprehensible addresses for patients to access their prescriptions," "establishing web services for supplementary insurance," "providing a platform for consultation with the pharmacist or treating physician within the electronic prescription system," "correctly registering prescriptions during residency and internship," and "eliminating paper forms for the referral system by adding user interfaces and a series of APIs and web services."

Studies in Turkey, Finland, and the USA have emphasized the lack of integration between insurance systems and institutions(15–17). In the study by Zamzam Kalume et al. (2023), challenges in the paper-based referral system included delays in the referral process and incomplete paper-based referral forms(18). Craxford et al. found that training new physicians in the use of electronic prescriptions reduces errors and speeds up the process(19). Grossman and Odukoya OK emphasized the need for more training programs for prescribers to improve their skills and reduce the risk of medication errors(20, 21).

Another challenge highlighted in this study was related to supervision, including the inability to monitor incorrect prescriptions by physicians. In the study by RUPP and WARHOLAK, the need for pharmacist intervention was discussed to address issues in the electronic prescription process and incorrect medication or instructions from Physician' offices(22). In a study by Luiz Antonio in Brazil, data security and patient privacy were crucial concerns for electronic prescription systems, with fears of hacker intrusion and system insecurity causing significant worry among users(23). Other studies in Turkey, Kuwait, South Africa, and Brazil also reported better performance by physicians in using electronic signatures(7, 23–25).

The most frequently discussed challenge in this study was related to infrastructure, with almost all participants mentioning this issue. In the study by Abdulsalam M. Matuq and Almutairi, a lack of technical support and maintenance was noted(7, 26). Sinan Bulut et al. reported that more than a quarter (26.5%) of family physicians complained about system slowdowns, system outages, and internet-related problems(15). In Eija Kivekäs's study in Finland, physicians stated that weaknesses in telecommunications networks led to uncertainty about receiving electronic prescriptions(16).

One of the identified requirements in this study was an appropriate user interface. Findings by Myler and Sinan Bulut also emphasized the need for a suitable user interface for prescribing medications, which should have adequate, recognizable, and editable inputs(15, 27). The importance of users finding and selecting drug names, completing various prescription fields, and creating a customized set of medications has been highlighted in various studies(28, 29).

A challenge mentioned in this study was related to the database. Studies have emphasized using standard and common terminology among prescribers and implementers to avoid different interpretations and consequently reduce errors related to patient safety(30, 31). In Saudi Arabia and Lebanon, the lack of drug lists in the system affected physicians' willingness and ability to use electronic prescriptions(6, 26). One of the problems in the present study was the absence of some drug codes, which was also reported in the study by Zadeh PE, where the absence of some drug names, dosages, or diagnoses in the system and the inability to prescribe them were issues(32). Medication errors (both repetitive and omitted), prescription routes, frequencies, and dosages (both overuse and underuse) were among the most common electronic prescription errors. Additionally, the lack of a standardized electronic prescription format was one of the most frequently reported issues(32, 33).

The limitations of the present study include the small number of participants and the lack of access to more physicians, who are the primary users of electronic prescribing systems.

The electronic prescription system is complex, influenced by various stakeholders. This study identifies the challenges and proposes solutions for successful implementation. Addressing infrastructure, insurance, and monitoring issues, while considering stakeholders' expectations, is vital for the system's success. Continuous monitoring and immediate application of findings, along with practical training and standardization, are recommended for improvement.

Funding:

this research is supported by Mashhad University of medical sciences. (Grant no.4001257)

Author Contribution

Study concept and design: Borhani and Meraji. Analysis and interpretation of data: Hooshmand, Drafting of the manuscript: Borhani. Critical revision of the manuscript for important intellectual content: Zarqi, Meraji. All authors read and approved the final manuscript

Acknowledgements

This study is part of a master’s thesis on Health information Management approved by the School of Paramedical Sciences at Mashhad University of Medical Sciences registered under 4001257at the university’s Research Deputy. Hereby, the authors would like to express their gratitude to all the individuals who helped conduct this study.

Data Availability

data that support the findings of this study have been are available from the corresponding author on reasonable request.

Samadbeik M, Ahmadi M, Sadoughi F, Garavand A. A copmarative review of electronic prescription systems: Lessons learned from developed countries. J Res Pharm Pract. 2017;6(1):3.
Dhavle A, Corley S, Rupp M, Ruiz J, Smith J, Gill R, et al. Evaluation of a user guidance reminder to improve the quality of electronic prescription messages. Appl Clin Inf. 2014;5(03):689–707.
Kierkegaard P. E-prescription across Europe. Health Technol. 2013;3:205–19.
ePrescribing. An International Review. health information and standards. 2018.
Oktarlina RZ. E-prescribing: benefit, barrier, and adopting challenge in electronic prescribing. J Med. 2020;21(2):98.
Al-Kahtani NK, Ramzi OI, Subbarayalu AV, Almulhim JA, Almulhim B. Physicians perception toward an electronic prescribing system at an academic medical center (Amc) In Saudi Arabia: an exploratory study. Int J Sci Technol Res. 2019;8(10):358–63.
Almutairi BA, Potts HW, Al-Azmi SF. Physicians’ perceptions of electronic prescribing with electronic medical records in Kuwaiti primary healthcare centres. Sultan Qaboos Univ Med J. 2018;18(4):e476.
Raeesi A, Abbasi R, Khajouei R. Evaluating physicians’ perspectives on the efficiency and effectiveness of the electronic prescribing system. Int J Technol Assess Health Care. 2021;37(1):e42.
Alavi Amlashi SR, Kazemnejad Leyli E, Sheikhtaheri A. Physicians’ and Pharmacists’ viewpoint on ambulatory electronic prescription system. J Health Adm. 2022;25(3):108–24.
A M. Electronic prescription project of Social Security Organization. 1400.
History of electronic health insurance prescribing. https://ihio.gov.ir/#17758693
Bruthans J, Kofránek J, Vojtěch A. Concept and practice of electronic prescription. Medsoft. 2021;33:89–92.
Wrzosek N, Zimmermann A, Balwicki Ł. A survey of patients’ opinions and preferences on the use of e-prescriptions in Poland. Int J Environ Res Public Health. 2021;18(18):9769.
Polit DF, Beck CT. Nursing research: Principles and methods. Lippincott Williams & Wilkins; 2004.
Bulut S, Yıldız A, Kaya S. Evaluation of transition to electronic prescriptions in Turkey: perspective of family physicians. Int J health policy Manage. 2019;8(1):40.
Kivekäs E, Enlund H, Borycki E, Saranto K. General practitioners' attitudes towards electronic prescribing and the use of the national prescription centre. J Eval Clin Pract. 2016;22(5):816–25.
Pizzi LT, Suh D-C, Barone J, Nash DB. Factors related to physicians’ adoption of electronic prescribing: results from a national survey. Am J Med Qual. 2005;20(1):22–32.
Kalume Z, Jansen B, Nyssen M, Cornelis J, Verbeke F. Perception of Healthcare Providers on the Existing Patient Referral System and Recommendations on the Development of the Electronic Referral System in Rwanda. A Mixed Method Study; 2023.
Craxford S, Taylor L, Duguid A, Shivji F, Pickering S. The learning curve of electronic prescribing. Br J Hosp Med. 2015;76(9):538–40.
Grossman JM, Gerland A, Reed MC, Fahlman C. Physicians' experiences using commercial e-prescribing systems. Health Aff (Millwood). 2007;26(3):w393–404.
Odukoya OK, Stone JA, Chui MA. Barriers and facilitators to recovering from e-prescribing errors in community pharmacies. J Am Pharmacists Association. 2015;55(1):52–8.
Rupp MT, Warholak TL. Evaluation of e-prescribing in chain community pharmacy: best-practice recommendations. J Am Pharmacists Association. 2008;48(3):364–a91.
Joia LA, Magalhães C. Implementation of an electronic prescription system in a Brazilian general hospital: Understanding sources of resistance. Electron J Inform Syst Developing Ctries. 2009;39(1):1–18.
Cohen JF, Bancilhon J-M, Jones M. South African physicians' acceptance of e-prescribing technology: an empirical test of a modified UTAUT model. South Afr Comput J. 2013;50(1):43–54.
Gіder Ö, Ocak S, Top M. Evaluation of electronic prescription implications in Turkey: An investigation of the perceptions of physicians. Worldviews Evidence-Based Nurs. 2015;12(2):88–97.
Maatuk AM, Elghriani AM, Denna I, Werfalli AA, editors. Barriers and Opportunities to Implementing Electronic Prescription Software in Public Libyan Hospitals. 2022 International Conference on Engineering & MIS (ICEMIS); 2022: IEEE.
Miller RA, Waitman LR, Chen S, Rosenbloom ST. The anatomy of decision support during inpatient care provider order entry (CPOE): empirical observations from a decade of CPOE experience at Vanderbilt. J Biomed Inform. 2005;38(6):469–85.
Tamblyn R, Huang A, Kawasumi Y, Bartlett G, Grad R, Jacques A, et al. The development and evaluation of an integrated electronic prescribing and drug management system for primary care. J Am Med Inform Assoc. 2006;13(2):148–59.
Bell DS, Cretin S, Marken RS, Landman AB. A conceptual framework for evaluating outpatient electronic prescribing systems based on their functional capabilities. J Am Med Inform Assoc. 2004;11(1):60–70.
Schadow G, Fleck C, Nalkande M, Sangawar A, Rosenthal C, Carlson M et al. Value of New Drug Knowledge for e-Prescribing. United state: Agency for Healthcare Research and Quality 7p Report. (R01HS15377).
Merlin B, Chazard E, Pereira S, Serrot E, Sakji S, Beuscart R, et al. Can F-MTI semantic-mined drug codes be used for Adverse Drug Events detection when no CPOE is available? MEDINFO 2010. IOS; 2010. pp. 1025–9.
Zadeh PE, Tremblay MC. A review of the literature and proposed classification on e-prescribing: Functions, assimilation stages, benefits, concerns, and risks. Res Social Administrative Pharm. 2016;12(1):1–19.
Hor CP, O'Donnell JM, Murphy AW, O'Brien T, Kropmans TJ. General practitioners' attitudes and preparedness towards Clinical Decision Support in e-Prescribing (CDS-eP) adoption in the West of Ireland: a cross sectional study. BMC Med Inf Decis Mak. 2010;10(1):1–8.

No competing interests reported.

sup1.docx

Download PDF

Editorial decision: Revision requested
23 Sep, 2024
Reviews received at journal
22 Sep, 2024
Reviews received at journal
13 Sep, 2024
Reviewers agreed at journal
09 Sep, 2024
Reviewers agreed at journal
04 Sep, 2024
Reviewers invited by journal
23 Aug, 2024
Editor invited by journal
20 Aug, 2024
Editor assigned by journal
20 Aug, 2024
Submission checks completed at journal
20 Aug, 2024
First submitted to journal
27 Jul, 2024

You are reading this latest preprint version

Challenges and Solutions in Implementing Electronic Prescribing: A Qualitative Study

Status:

Version 1

Abstract

Background

Methods

Result

Conclusion

Introduction

Methodology

Results

Discussion

Conclusion

Declarations

Funding:

Author Contribution

Acknowledgements

Data Availability

References

Additional Declarations

Supplementary Files

Status:

Version 1