The electronic prescribing system of the Social Security Organization (SSO)
The electronic prescribing system of SSO’s medical centers and hospitals is the most extensive and the only electronic prescribing system implemented countrywide in Iran. This system is used in all medical centers affiliated to SSO, including 70 hospitals and 279 general and specialized clinics throughout the country [21].
The electronic prescribing system implemented in SSO health centers and hospitals works as part of the hospital information system in hospitals and as a separate system in clinics for the registration of medications and para-clinical procedures by physicians and is only available to physicians within these centers. Figure 1 illustrates the professional process of using the electronic prescribing system. In this system, medications can be selected and registered by the physician through both a search and from the list of medications registered as a package (Figure 2). Figure 3 illustrates the medications registered as a package in this system. The medication package is a list of medications that has been arranged first by medication type and then alphabetically and can be selected from an approved box.
This system allows the physician to select the intended medications and then register their order, method of administration and dosage. Medications are then automatically registered in the patient's medication history. Para-clinical measures, including tests, imaging and other procedures, can also be registered. In addition to the registration of medications and procedures, the patient's vital signs, main complaint and current illness, disease history, physical examination results, diagnosis and diagnosis explanation and treatment plan can also be registered in this system. The system warns physicians of any medication interactions or if a certain medication has already been prescribed to the patient by other physicians at a recent time. At the present time, this system only registers the medications available in the relevant health center and other medications not available in the same center are registered as paper prescriptions.
Study design
This descriptive-analytical study was conducted in 2018 on all the physicians using the electronic prescribing system of the SSO in Sistan and Baluchistan Province. Sistan and Baluchistan Province is one of the southeastern provinces of Iran, and its provincial SSO has five general and specialized clinics and two hospitals. This study was conducted a year after the implementation of the electronic prescribing system in this province.
Data collection
Data were collected using a self-administered questionnaire based on the review of relevant scientific literature. The validity of this questionnaire was confirmed by two medical informatics experts and two health information management experts, and its reliability was measured through a study of 20 of the participants and its Cronbach's alpha was reported as α=94%.
The questionnaire consisted of three sections:
1) Six items related to demographic data and clinical experience, computer skills, mean number of hours of computer use per shift and site of using the electronic prescribing system by the participant.
2) Questions related to physicians' perspectives on the efficiency (19 questions) and effectiveness (13 questions) of the electronic prescribing system. The efficiency was in three dimensions, including time (7 questions), costs (5 questions) and other efficiency-related questions (7 questions). The effectiveness was in two dimensions, including patient safety (6 questions) and other effectiveness-related items (7 questions). The items were answered based on a five-point Likert scale (including ‘totally disagree’, ‘disagree’, ‘ineffective’, ‘agree’ and ‘totally agree’).
3) Open-ended questions related to the most positive and negative aspects of the electronic prescribing system.
Data were collected by the researcher through a visit to the physicians' workplace while using the electronic prescribing system and asking them to complete the questionnaire. Before completing the questionnaire, the participants were briefed on the study and how to complete the questionnaire, and informed verbal consent was obtained from them and completing the questionnaire indicated the participant’s consent.
Data analysis
Data were analyzed using SPSS-18. Descriptive statistics were used to calculate frequency and percentage of the responses. the ‘totally agree’ and ‘agree’ options were reported together and the ‘disagree’ and ‘totally disagree’ options also reported together. For the analytical statistics, each option on the Likert scale was given a score from one (‘totally disagree’) to five (‘totally agree’), and their mean values were taken as the efficiency and effectiveness scores. The mean value of 3 was considered the cut-off point for the efficiency and effectiveness scores, and scores higher than 3 were taken to indicate a good efficiency and effectiveness [22].
The relationship between efficiency and effectiveness was then assessed by the Chi-square test. Normality was assessed using the Kolmogorov-Smirnov test. Given the normal distribution of the data, Pearson’s analytical test was used to assess the relationship of age and work experience with efficiency and effectiveness, the relationship of the efficiency dimensions with the effectiveness dimensions, and also the relationship of efficiency with effectiveness. The analytical independent t-test was used to assess the relationship of gender, the site of using the electronic prescribing system and specialization with efficiency and effectiveness. The relationship of computer skills with efficiency and effectiveness was also assessed using the ANOVA.