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- PMC10746557
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Explor Res Clin Soc Pharm. 2023 Dec; 12: 100375.
Published online 2023 Nov 25. doi:10.1016/j.rcsop.2023.100375
PMCID: PMC10746557
PMID: 38145236
Amina Hareem,a,⁎ Joshua Lee,b Ieva Stupans,a Joon Soo Park,c and Kate Wanga
Author information Article notes Copyright and License information PMC Disclaimer
Associated Data
- Supplementary Materials
Abstract
Background
The utilization of electronic prescribing is growing, prompted by lockdown measures during the COVID-19 pandemic. However, despite this increasing adoption, there is a notable dearth of consolidated evidence regarding the challenges and opportunities associated with the integration of electronic prescribing systems within the daily clinical practices of community pharmacists.
Objective
This paper aims to systematically review the community pharmacists' perspectives on barriers and facilitators to electronic prescribing, addressing the significant need for understanding how electronic prescribing impacts the workflow and decision-making processes of pharmacists, ultimately influencing the quality of patient care.
Methods
PubMed, Embase, and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases were searched from January 1, 2000, to October 25, 2022, using search terms related to electronic prescribing, computerised physician order entry, community/retail pharmacies, and pharmacists.
Results
A total of 28 studies were included in the systematic review. In these studies, community pharmacists perceived that design, interoperability, attitude towards e-prescribing technology, information quality, workflow, productivity, and accessible resources facilitated e-prescribing. In addition, the included studies emphasized the importance of technological support for the successful implementation of electronic prescribing systems. The system's design characteristics significantly improve e-prescribing technology's favourable effects. According to our review, it has been proposed that a poorly designed e-prescribing system can have a negative impact on the quality of care, implementation, and user satisfaction. In contrast, a well-designed system can significantly contribute to improvements.
Conclusions
The review highlighted that e-prescribing has both barriers and facilitators, with the quality of the system and its implementation influencing these factors. Technical issues and user acceptance (patient/prescribers/pharmacists) can act as barriers or enablers, highlighting the need for comprehensive consideration and monitoring of e-prescribing to identify and address potential issues.
Keywords: Community pharmacist, Electronic prescribing system, Systematic review, Implementation factors, User perspective, Primary care
Highlights
•
Review examines electronic prescribing's profound impact on community pharmacies.
•
TDF framework sheds light on e-prescribing dynamics for community pharmacists.
•
Environmental context & resources: dual barriers and facilitators in e-prescribing.
•
Focused interventions can transform perceptions on e-prescribing practices.
•
Article guides policymakers in refining e-prescribing across healthcare systems.
1. Introduction
Ensuring patient safety and providing high-quality care requires accurate and complete patient information, which can often be challenging due to the fragmented nature of health settings. To address this, there is a need for innovative technologies to manage patients' health records better and support medical decision-making.1 Implementing digital health services (telehealth, electronic health records, remote monitoring) and technologies (wearable health trackers and health applications) has revolutionised healthcare delivery, focusing on safety, quality improvement, privacy, and confidentiality.2 These new technologies have emerged as a response to traditional methods' limitations and can potentially improve clinical care.3
During the 2019 coronavirus pandemic (COVID-19), there was a greater need to modify how general practices provide healthcare due to the demand for social distancing. This led to an increase in telehealth services, expedited electronic prescribing and home delivery of medications to support vulnerable individuals and reduce the transmission of COVID-19 infection among patients and healthcare providers.4 Electronic prescriptions emerged as one of the crucial digital health innovations that played a critical role in ensuring uninterrupted healthcare services during the pandemic. For example, the number of electronic prescriptions in the United States increased to 1.91 billion in 2020, while telehealth consultations increased by 154% compared to March 2019.5 By May 2020, nearly all general practices in England provided telehealth services, with 80% of prescriptions going paperless.6 Similarly, in Australia, there has been a significant increase in the utilization of telehealth services and electronic prescriptions. Between March 13, 2020, and July 31, 2022, approximately 118.2 million telehealth services were delivered to 18 million patients. Moreover, over 95,000 practitioners utilised telehealth, and between May 2020 and March 2023, around 130 million electronic prescriptions were issued.7,8
E-prescribing is an essential aspect of modern healthcare systems and has been adopted by many countries worldwide to improve the quality, safety, and efficiency of medication management. E-prescribing is a process whereby healthcare professionals, such as doctors or nurse practitioners, use a secure electronic system to create, transmit and store patient prescription information.9 Rather than traditional paper prescriptions, e-prescribing enables healthcare professionals to electronically generate and send prescriptions directly to pharmacies, where they can be quickly and accurately filled.10E-prescribing systems can also provide healthcare professionals with up-to-date information on medication interactions, allergies, and dosing guidelines, reducing the risk of medication errors and improving patient safety.11
Electronic prescriptions have revolutionised prescription handling, leading to significant advancements in healthcare systems. They are recognised as a crucial reform in pharmaceutical policies worldwide, with evaluations conducted across multiple countries in recent decades.12 In countries like Australia, from 2020 to 2021, >314.8 million prescriptions were dispensed under the Pharmaceutical Benefits Scheme and Repatriation Pharmaceutical Benefits Scheme13; medication errors have been identified as a significant public health issue, causing 250,000 medication-related hospital admissions and an annual cost of AUD 1.4 billion to the healthcare system.14 Similarly, in the United States, the Centres for Disease Control and Prevention (CDC) reported that nearly half of the population used at least one prescription medication within 30days from 2015 to 2018.15 The annual cost of medication errors is estimated at $40 billion.16 Nearly two-thirds of Canadians over 65 take at least five distinct prescription medications, with medication errors resulting in 1 in 143 hospitalisations and costing an estimated CAD 140 million annually.17 Meanwhile, England reported that approximately 1.1 billion prescription items were dispensed in the community, with preventable medication errors costing the National Health Service approximately £98.5 million annually and contributing to approximately 1700 fatalities.18 These statistics from Australia, England, USA and Canada show that medication errors are a serious problem that can significantly impact public health and healthcare costs.14,16, 17, 18.E-prescription benefits patients in two ways. Firstly, it minimizes the chances of prescription misplacement or loss. Secondly, it reduces the dispensing time, leading to shorter wait times and higher satisfaction levels with pharmacies.19,20 Electronic prescriptions can streamline the dispensing process at pharmacies,21 reducing the need for clarification calls, speeding up refill operations, maintaining organised data, and providing updated information on pharmaceutical formularies and pre-authorisations.22 In essence, e-prescribing services aim to enhance patient access to medications and bolster the efficiency and efficacy of healthcare services, positioning it as a pivotal component of contemporary healthcare systems.23
Digital health technologies have transformed the healthcare industry by improving the planning, organisation, and delivery of services. However, the success and sustainability of these technologies largely depend on user satisfaction.24 As community pharmacists are the primary users of e-prescribing applications, their input is critical for improving the effectiveness and efficiency of the process. Therefore, evaluating their satisfaction with this service is crucial to ensure optimal care delivery.
This systematic review aims to explore the experiences of community pharmacists with electronic prescribing systems, focusing on their daily use and the associated barriers and facilitators. By using the Theoretical Domains Framework (TDF) to analyse the data in-depth, we aim to identify factors that influence the implementation and use of these systems. Ultimately, this review aims to provide insights that can be used to improve the efficacy and user experience of e-prescribing systems, thus enhancing patient care and medication management.
2. Methods
2.1. Protocol and registration
This study was conducted according to PRISMA guidelines for systematic review.25 The protocol for this systematic review was registered with PROSPERO International Prospective Register of Systematic Reviews (registration number: CDR42022370501). It is available at: [https://www.crd.york.ac.uk/prospero/display_record.php?ID=CRD42022370501].
2.2. Eligibility criteria
To be included in the review, studies had to:
1.
Be original research articles published in English and subjected to peer review.
2.
Report on community pharmacists' perspectives regarding e-prescription or computerised physician order entry systems. In cases where multiple stakeholders, such as physicians, pharmacy personnel, and nurses, were involved, community pharmacists' perspectives had to be distinctly highlighted and included.
The exclusion criteria were as follows:
1.
Non-original articles, including review articles, grey literature, and studies published in languages other than English.
2.
Articles that did not include the community pharmacist's perspective.
3.
Studies exclusively focused on secondary and tertiary care settings within hospitals.
4.
Studies where the full text was unavailable.
2.3. Search strategy
A complete literature search was conducted on the following databases: PubMed, Embase and Cumulative Index to Nursing and Allied Health Literature (CINAHL) databases from January 1st, 2000, to October 25, 2022, in order to focus on contemporary systems. We conducted a comprehensive search using a combination of relevant keywords and MeSH headings, such as “e-prescription,” “e-prescribing,” “computerised physician order entry,” and “community/retail pharmacies and pharmacists,” to identify relevant studies. Both OR and AND Boolean operators were utilised to combine these terms. In addition, we manually searched the reference lists of eligible studies to identify any relevant articles that may have been missed during the electronic database search. Please refer to Table S1 in the Supplementary Material document for the detailed search strategy.
2.4. Study selection
All identified studies were imported into Endnote, and duplicates were deleted. Two investigators independently screened the title and abstracts and then reviewed the full text of potentially relevant studies. Any discrepancies were resolved through discussion with other investigators.
2.5. Data extraction
Two investigators independently extracted data from the selected studies through manual extraction. Extracted data includes study design, country of origin, year of publication, study focus, study setting, participants, and outcomes regarding barriers and facilitators to e-prescribing services. The data related to barriers and facilitators were systematically analysed and categorised according to the domains of the Theoretical Domains Framework (TDF),26 which provides a comprehensive and structured approach to understanding the factors influencing behaviour change in healthcare settings. This mapping process involved identifying the relevant TDF domains that each barrier or facilitator aligned with, thus enabling a more nuanced and in-depth analysis of the underlying factors impacting the uptake and implementation of e-prescribing systems by community pharmacists.
2.6. Quality and risk of bias assessment
Two investigators independently assessed the quality of each included study using Mixed Method Appraisal Tools (MMAT) for qualitative, quantitative, and mixed-method studies.27 Each paper was evaluated using the MMAT quality appraisal tool, and a score was assigned based on the percentage of criteria that were met for the relevant study design. For example, if the paper met 4 out of 5 criteria, it was assigned a score of 80%. Three sets of criteria (qualitative, quantitative, and mixed methods) were used for mixed methods studies to determine the final score. We assessed the quality of the included studies to ensure that they were methodologically rigorous and relevant to our research questions. We examined the research design, sampling strategy, data collection methods, data analysis techniques, validity and reliability measures for each study. For mixed methods studies, we evaluated how qualitative and quantitative data were integrated and complemented each other. The quality assessment provided valuable insights into the strengths and limitations of each study, contributing to the overall credibility and validity of our research synthesis.
3. Results
3.1. Article selection
A total of 3558 studies were initially retrieved through the database search, which were reduced to 3383 articles after removing duplicates (n=175). Among these, 3331 records were excluded based on title and abstract, resulting in 52 articles that could be considered for inclusion. A manual search of the reference lists of full-text articles led to an additional 11 papers that were screened for eligibility. After a thorough review of the full-text articles, a total of 28 relevant papers were included for synthesis, as shown in Fig. 1. Please refer to Table S3 in the Supplementary Material document for the list of excluded articles.
3.2. Assessment of quality
All 28 papers were assessed using at least one of the study designs listed in the MMAT.27 The most common criteria used to evaluate the quality were questions pertinent to a qualitative study (15/28), followed by quantitative studies (9/28) and mixed method studies (4/28). Most studies (25 out of 28) demonstrated strong methodological quality, meeting the predefined standards and guidelines. These studies provided robust and reliable evidence for our research synthesis. No paper was excluded from the review based on its quality. A summary of the quality assessment results can be found in Table S2 in the Supplementary Material document to enhance transparency.
3.3. Study characteristics
The characteristics of the included studies are summarised in the data extraction table (Table 1). The studies included in this review were published between 2007 and 2021. Most of the included studies (32%) were carried out in the United States of America (USA) (n=9). European countries, including England, Sweden, Belgium, and Finland, accounted for 39% of the studies (n=11). Canada was the location for 17% of the studies (n=5), while New Zealand contributed 4% of the research (n=1). One study was conducted in Turkey (4%) and another in Malaysia (4%). Seven research papers (25%) reported the outcomes of studies involving pharmacists and physicians. Conversely, twenty-one (75%) articles centred on research exclusively involving community pharmacists, with the potential inclusion of pharmacy staff. Out of the 28 studies analysed, 53% were carried out using a qualitative research method (n=15),28., 29, 30, 31, 32, 33, 34, 35, 36, 37., 38, 39, 40, 41, 42. 33% studies incorporated a quantitative approach (n=9),43, 44, 45, 46, 47, 48, 49, 50, 51 while 14% of the included studies utilised mixed method design (n=4).52., 53, 54, 55
Table 1
Representing data extraction details.
First Author Time Country | Study Design(Data Collection method) | Research focus | Participants | Barriers | Facilitator | Analysis technique |
---|---|---|---|---|---|---|
Gagnon et al. 28 (2015) Canada | Qualitative design (telephone and in-person interviews) | The study focus was barriers and facilitators concerning the adoption of nationwide e-prescribing implementation | 33 community pharmacists, 2 pharmacy technicians, 11 physicians and 3 clinic managers |
|
|
|
Motulsky et al.52 (2019) Canada | Mixed method- Descriptive analysis+ exploratory descriptive studies(Interviews and observation) | The focus was on adoption issues. | There were 11 pharmacists, 8 pharmacy technicians, 9 prescribers, 7 physicians and 2 nurses. |
|
|
|
Motulsky et al.29 (2015) Canada | Qualitative Method (Interviews) | The focus was on adoption issues | 49 participants, including 12G.P.s, 2 managers, 33 community pharmacists, 2 pharmacy staff members |
|
|
|
Motulsky et al.30 (2008) Canada | Qualitative Study (Interviews) | The focus was to determine e-prescribing technology's effect on pharmacists' professionalisation | 12 community pharmacists |
|
|
|
Motulsky et al.31 (2011) Canada | Qualitative study (interviews) | The focus was to determine disruption in the pharmacist's professional role by electronic prescribing technology | 21 participants, including 14 community pharmacists and 7G.P.s |
|
|
|
Clauson et al.43 (2011) United States of America | Quantitative (Surveys) | The study focus was to determine pharmacists' perception regarding e-prescribing | 438 community pharmacists |
|
|
|
Odukoya et al.32 (2012a) United States America | Qualitative (think-aloud protocol + observation) | The study focus was to determine the community pharmacists' staff perception of e-prescription design | 7 pharmacies, including 10 pharmacists and 24 technicians. |
|
|
|
Odukoya et al.33 (2012b) United States of America | Cross-sectional Qualitative (think-aloud protocol + pharmacy group interviews) | The study focused on determining the workflow challenges encountered while using e-prescribing technology. | 7 community pharmacies (16 pharmacists and 14 pharmacy technicians) |
|
|
|
Odukoya et al.34 (2013) United States of America | Cross-sectional Qualitative design(Direct observation + Think Aloud Protocol + Team interviews) | The study focused on determining the factors that may increase the potential for medication errors with e-prescribing. | 7 community pharmacies(14 pharmacists and 16 Technicians) |
|
|
|
Odukoya et al.35 (2015b) United States of America | Cross-sectional Qualitative Design (direct observation + interviews+ focus group) | The study focus was to determine the factors affecting e-prescribing error recovery | 5 Community pharmacies (13 Pharmacists, 14 Pharmacy Technicians) |
|
|
|
Rupp et al.44 (2007) United States of America | Descriptive cross-sectional Quantitative (Questionnaire) | Study findings focussed on the attitude and beliefs towards e-prescribing and the processing of e-prescription | 1086 participants, including 446 pharmacists, 605 technicians and 35 interns |
|
|
|
Grossman et al.36 (2012) United States of America | Qualitative study (Interviews) | The study focused on identifying facilitators and barriers to electronic transmission and e-prescription processing. | 97 facilities, including 24 physician practices, 48 community pharmacies, and three mail-order pharmacies |
|
|
|
Lander et al.53 (2012) United States of America | Mixed method (open-ended and structured questionnaire, interviews over telephone) | Study findings focus primarily on impediments to e-prescribing system adoption. | 23 Pharmacies, including 11 pharmacists, 10 owner/pharmacists, 2 pharmacy managers |
|
|
|
Terri et al.41 (2011) United States of America | Qualitative Studies Focus Group | Focus on pharmacists' opinions and perspectives regarding utilising Health Information Technology (HIT), including Electronic Prescribing (eRx). | 32 pharmacists participated from the following care settings: 19 retail, 3 hospitals, 4 outpatient care, and 6 others |
|
|
|
Rahimi et al.45 (2011) Sweden | Cross-sectional Quantitative (survey) | The study examines the e-prescribing impact on pharmacists' practice concerning work efficiency and pharmacological safety | 52 community pharmacists |
|
| Descriptive analysis t-test correlation between area indices analysed using Spearman correlation |
Hammar et al.54 (2010) Sweden | Mixed method (Survey) | The study evaluated Swedish pharmacist attitudes towards e-prescribing technology | 259 community pharmacists |
|
|
|
Franklin et al.46 (2013) England | Exploratory Quantitative Data collection form) | This study compared the number and type of interventions made by community pharmacists using EPSR2 with those originating from prescriptions without EPSR2. | 8 community pharmacies |
|
|
|
Jasmine et al.37 (2011) England | Qualitative (interviews+ nonparticipating observation) | The study examined how the enhanced EPS (EPS2) can affect workflow and workload in community pharmacies. | 8 Community pharmacies, including community pharmacists and other staff |
|
| Qualitative methods were employed that used an ethnographic framework. |
Sara et al.40 (2013) England | Qualitative (interviews) | This study explored pharmacists' experience with the new system and their perceptions of its benefits and any. associated problems. | 13 community pharmacists |
|
|
|
Jasmine et al.38 (2014a) England | Qualitative (interviews + observation) | This study explored community pharmacists' initial perceptions of the advanced version of the Electronic Prescriptions Service in England | 8 community pharmacies |
|
|
|
Jasmine et al.39 (2014b) England | Qualitative (interviews + observation) | The study aimed to explore initial user experiences of Community Pharmacists using EPS2 in England. | 8 community pharmacies |
|
|
|
Van Laere et al.49 (2020) Belgium | Descriptive Cross-sectional Quantitative study (survey-based) | This study examined the pharmacist's perspective of e-prescription implementation in Belgium's community pharmacy software and the frequency and severity of problems. | 246 community pharmacists |
|
|
|
Van Laere et al.48 (2019a) Belgium | Cross-sectional Quantitative study (survey-based) | This study focused on pharmacists' perception of the implementation of the e-prescription within the software package and what other factors influence it. | 246 community pharmacists |
|
|
|
Timonen et al.47 (2018) Finland | Quantitative study (Data collected through a report form) | Aim of this study was to explore the experiences of pharmacists regarding the impact of e-prescriptions on the medicine dispensing process in Finnish community pharmacies | 54 community pharmacies |
|
|
|
Kauppinen et al.50 (2017) Finland | Cross-sectional Quantitative study (postal survey) | The study explored the impact of electronic prescriptions on the dispensing process in Finnish community pharmacies | 778 participants, including 143 community pharmacists and 635 dispensers |
|
|
|
Campbell et al.42 (2021) New Zealand | Qualitative Study Data were collected through face-to-face semi-structured interviews | Study findings focused on the e-prescription effect on pharmacists' professional workflow, interprofessional interactions and communication with prescribers and patients | 4 GPs and 4 Community pharmacists |
|
|
|
Bilgener et al.55 (2021) Turkey | Mixed method (Questionnaire) | To determine the opinion of pharmacists about e-prescribing | 378 community pharmacists |
|
|
|
Peikari et al.51 (2015) Malaysia | Cross-sectional quantitative design (Survey) | The study investigated the extent to which second-generation e-prescribing usability leads to positive outcomes for community pharmacists | 152 community pharmacists |
|
|
|
3.4. Key findings
A comprehensive overview of the study's findings is shown in 4 tables. Table 1 presents the data extraction details for all included studies. Table 2 depicts the overall e-prescribing exchange process of the countries included in this systematic review. Table 3, Table 4 describe the barriers and facilitators of e-prescribing identified in each study, including their TDF domains. Through data extraction and tabulation, community pharmacists' perspectives on the factors influencing their experience with e-prescribing systems were identified. Facilitators refer to factors that support the successful integration and use of electronic prescribing, as reported by the included studies. In contrast, barriers in our review are the elements that negatively impact pharmacists' interactions with the electronic prescribing system. The collected data on facilitators and challenges were subsequently mapped to the Theoretical Domains Framework (TDF) for classification and analysis.26 All authors analysed the mapping of domains to the TDF and reached a consensus on the most accurate categorisations. This rigorous approach ensures a comprehensive analysis of the factors influencing community pharmacists' experience with e-prescribing and provides valuable insights for optimising e-prescribing practises in community pharmacy settings.
Table 2
Representing e-prescription exchange system.
Country | Centralised/decentralised | Prescription database | Identifiers (physician/patient/pharmacy) | e-prescription exchange system | Prescription Tracking (dispensing notification to prescriber) | Prescription Renewal (refill from prescriber to pharmacy) |
---|---|---|---|---|---|---|
Sweden | Centralised | National Pharmacy Database | Patient=Personal identity number (PIN) along with e-ID system Physician=Personal License number Pharmacy=Registered Pharmacy number |
| Yes, e-prescriptions can be tracked through the system | The e-prescribing system directly facilitates prescription refills from prescriber to pharmacy. |
England | Centralised | National Spine | Patient=NHS number Prescriber=General medical council number(GMC) Pharmacy=ODS (Organisational data service code) or GPhC (General Pharmaceutical Council number)/smartcard used for login. |
| Yes, e-prescriptions can be tracked through the system | The e-prescribing system directly facilitates prescription refills from prescriber to pharmacy. |
Belgium | Decentralised | Recip-e | Patient=National registration number (NRN) Physician=(unique identification number) Pharmacy=PIN (Pharmaceutical inspection number) |
| Yes, e-prescriptions can be tracked through the system | The e-prescribing system directly facilitates prescription refills from prescriber to pharmacy. |
United States of America | Decentralised | Surescripts | Physician=National provider identifier(NPI) Pharmacy=Providers ID NCPDP(National Council for Prescription Drug Programs) |
| Yes, e-prescriptions can be tracked through the system | The e-prescribing system directly facilitates prescription refills from prescriber to pharmacy. |
Canada | Centralised | Drug Information System | Physician=Prescriber identification number (PIN) Pharmacy=NAPRA (National Association of Pharmacy Regulatory Authorities number) |
| Yes, e-prescriptions can be tracked through the system | The e-prescribing system directly facilitates prescription refills from prescriber to pharmacy. |
Turkey | Centralised | Electronic Prescription System | Patient=Patient's Turkish identification number Physician=Physician Turkish identification number Pharmacy=Pharmacy registry number | Prescription exchange via MEDULA system (primary care physician generates prescription code, SSI sends and controls prescription code, pharmacist uses prescription code to dispense). | Yes, e-prescriptions can be tracked through the system | The e-prescribing system directly facilitates prescription refills from prescriber to pharmacy. |
New Zealand | Centralised | New Zealand e-script service (NZePS) | Patient identifier=National Health Index (NHI) number Physician identifier=Practitioner Index Number |
| Yes, e-prescriptions can be tracked through the system | The system does not facilitate refills directly between the prescriber and pharmacy. However, prescribers and pharmacists have communication options to coordinate prescription renewals. |
Malaysia | Centralised | MyRx System | Patient=MyKad number Physician=Malaysian Medical Council(License number) Pharmacy=PBM (Pharmacy Board Malaysia number) | The National Electronic Health Record (NEHR) system allows providers to generate and transmit e-prescriptions to pharmacies. | Not Clear - | The e-prescribing system directly facilitates prescription refills from prescriber to pharmacy. |
Finland | Centralised | Prescription Centre | Patient=Personal identity code (PIC) Physician=Personal license number Pharmacy=Registered pharmacy number |
| Yes, e-prescriptions can be tracked through the system | The e-prescribing system directly facilitates prescription refills from prescriber to pharmacy. |
Table 3
Representing barriers to e-prescribing with TDF domains.
TDF Domain | First author | Barriers to e-prescribing |
---|---|---|
Environmental Context and Resources | Gagnon et al.28 Motulsky et al.29,52 Clauson et al.43 Odukoya et al.32,33,35 Rupp. et al.44 Grossman et al.36 Lander et al.53 Rahimi et al.45 Hammar et al.54 Franklin et al.46 Harvey et al.37., 38, 39 Sara et al.40 Van Laere et al.48,49 Kauppinen et al.50 Campbell et al.42 Bilgener et al.55 Terri et al.41 |
|
Professional Role and Identity | Motulsky et al.31 Terri et al.41 |
[E-prescribing technology allows for information sharing and benefits for pharmacists, but tensions arise between physicians and pharmacists due to the inadequate sharing of therapeutic indications. Physicians express reservations about pharmacists' involvement in medical decisions and believe that pharmacists may not have adequate patient information and clinical training to utilise therapeutic indications effectively. These tensions relate to the domains of professional role and identity and social influence, as differences in roles and perceptions of authority, as well as community attitudes and norms, contribute to the challenges faced in properly using e-prescribing features.] |
Social Influence | ||
Belief about Consequences | Rupp. et al.44 Timonen et al.47 Bilgener et al.55 Terri et al.41 Campbell et al.42 |
|
Belief About Capabilities | Clauson et al.43 |
|
Interpersonal and Professional Relationship | Motulsky et al.31 Odukoya et al.34 Terri et al.41 Campbell et al.42 |
|
Memory Attention and Decision Process | Odukoya et al.34 Bilgener et al.55 |
[The loss of the e-prescription code may be attributed to issues such as forgetting where it was stored or misplacing the physical document.] |
Reinforcement | Lander et al.53 Bilgener et al.55 |
|
Knowledge | Lander et al.53 Hammar et al.54 Terri et al.41 |
[Patients and prescribers being unaware of the benefits of e-prescribing can hinder its adoption and usage. Lack of knowledge leads to resistance to change, reliance on outdated practices, and misconceptions about complexity. Limited access to information contributes to the barrier. Educating stakeholders through awareness campaigns and providing clear information can help overcome this barrier.] |
Table 4
Represents the e-prescribing facilitators with the TDF domain.
TDF Domain | Study (First Author) | Facilitators to E-Prescribing |
---|---|---|
Environmental Context and Resources | Motulsky et al.30 Clauson et al.43 Odukoya et al. 32,33,35 Rupp et al.44 Grossman et al.36 Rahimi et al.45 Hammar et al.54 Harvey et al.37,38 Garfield et al.40 Bilgener et al.55 Peikari, et al.51 Terri et al.41 Campbell et al.42 |
|
Social Professional Role and Identity | Motulsky et al.30 |
|
Belief About Consequences | Motulsky et al.30 Clauson et al.43 Grossman et al.36 Rahimi et al. 45 Hammar et al.54 Garfield et al.40 Kauppinen et al.50 Bilgener et al.55 Peikari et al.51 Terri et al.41 |
|
Knowledge | Odukoya et al.35 Van Laere et al.48,49 Terri et al.41 |
[Having a comprehensive grasp of the E-Prescription workflow, combined with sound clinical knowledge, enables identifying and resolving system-related issues and prescription errors that may occur during the process. This understanding fosters effective communication, reduces the likelihood of prescription inaccuracies, and enhances user satisfaction with the system.] |
Skills | ||
Interpersonal and Professional Relationship | Clauson et al.43 Odukoya et al.35 Hammar et al.54 Garfield et al.40 Terri et al.41 |
|
3.5. E-prescribing process
Electronic prescribing systems can vary across countries. In the United States, some systems allow prescribers to request patients' medication history and formulary information directly from pharmacies and reimbursem*nt authorities. A central repository is used in Canada and England, but prescribers may need to manually enter the patient's information. Within the scope of this review, in the countries under consideration, prescribers enter prescription details into their clinical system, which checks medication history and drug allergies. Prescribers sign the prescription electronically, and it's securely transmitted to the patient's preferred pharmacy or a designated one directly or via an intermediatory, with confirmation sent to the prescriber once the medication is dispensed. Table 2 summarises the e-prescribing processes for the studied countries.
3.6. Barriers to e-prescribing
A total of twenty-five papers discussed the barriers to the e-prescribing process (Table 3). Barriers were mapped to the following eight TDF domains. Environmental context and resources accounted for the highest proportion, representing 50% of the studies,28,29,32,33,35,36,41, 42., 43, 44, 45, 46,52., 53, 54 followed by knowledge 11%,41,53,54 professional role and identity 3%,31 social influence 7%,31,41 interpersonal and professional relationship 14%,31,34,41,42 belief about consequences 18%,41,42,44,47,55 memory attention and decision Process 7%,34,55 belief about capabilities 3%,43 and reinforcement 7%.53,55 It's important to note that the percentages may exceed 100% due to some studies addressing multiple domains within their discussions of barriers.
3.7. Facilitators to e-prescribing
A total of 17 papers discussed the facilitators to the e-prescribing process (Table 4). Facilitators were categorised into the following six TDF domains. 3% of the studies accounted for social professional role and identity,30 57% accounted for environmental context and resources,30,32,33,35, 36, 37., 38,40, 41, 42., 43, 44, 45,51,54,55 35% accounted for belief about consequences,30,36,40,41,43,45,50,51,54,55 17% accounted for interpersonal and professional relationship,35,40,41,43,54 14% accounted for knowledge and skills.35,41,48,49 It's important to note that the percentages may exceed 100% due to some studies addressing multiple domains within their discussions of facilitators.
4. Discussion
From the pharmacists' perspective, the most frequently referenced barrier to e-prescribing is associated with the environmental context and resources domain of the TDF framework. The facilitators most frequently referenced were, again, environmental context and resources, suggesting that focused rather than multi-faceted interventions would improve pharmacists' perceptions of e-prescribing.
4.1. Environmental context and resources
System-related issues were the most cited, being mentioned in 22 of our included studies.28,29,31, 32, 33, 34, 35, 36, 37.,39, 40, 41,44, 45, 46, 47, 48, 49,52,54,55 They were mainly considered a barrier to e-prescribing technology because system-related problems appeared to reduce work efficacy.28,29,32,33,35,40,44,45,48, 49, 50,52 Concerns about system reliability35,45 and content appropriateness for user needs —such as a lack of visual aids or codes for ordered drugs— make e-prescribing time consuming and thus considered a barrier.28 Interoperability issues further complicate the scene, sometimes causing prescription errors.32 Specific issues like duplicate prescriptions and barriers associated with electronically prescribing controlled medications presented more challenges.40,41,44,46 However, it should be noted that the e-prescribing of controlled substances is now allowed in the USA.56
Pharmacists appreciated the improved security, legibility, and patient privacy offered by e-prescribing,31,32,41,43, 44, 45,54 perceiving these as facilitators for its implementation. The quality of the information provided by the system was perceived as a facilitating aspect, as it can reduce pharmacists' workload and enhance patient care.45,51 Nevertheless, certain limitations did temper these benefits. Slow processing, system freezes, data entry errors, and other associated challenges often frustrate users. When e-prescribing systems align well with existing processes, they enhance workflow efficiency.33,37,40,45,50,54 However, several studies reported workflow disruptions, such as system problems and e-prescription errors, as barriers.33,45,47,53 Incorporating workflow analysis into system design and minimizing workflow interruptions could resolve these issues.
Where e-prescribing systems seamlessly integrate with existing processes, a substantial improvement in efficiency emerges. However, recent studies have evidenced persistent system-related issues.42,49,50,52 This longevity of issues underscores the need for persistent attention and improvement in e-prescribing systems.
To ensure an effective e-prescribing system, community pharmacists require accessible support systems that address their professional needs. Pharmacists' input during development is crucial.29 Vendors should prioritise user-friendliness, incorporate real users in the design, provide guides and technical support, and ensure seamless integration with other systems. Neglecting these factors may lead to unintentional usage and compromise system efficacy.39 In essence, while e-prescriptions are primarily perceived as facilitating and time-saving, especially with adequate training and support,30,32,35, 36, 37.,40,45,50,51,54 the environmental context and available resources must be meticulously considered and refined to realize the full potential of this technology. These recommendations align with previous literature, which emphasized the importance of user-centric design in healthcare informatics solutions.57,58
4.2. Memory attention and decision support, interpersonal and professional relationships, and reinforcement
Within memory, attention, and decision support domains, e-prescribing may pose challenges that increase pharmacists' cognitive burden.34 In traditional paper-based prescriptions, pharmacists can annotate or highlight crucial information on the prescription. However, with e-prescribing, this vital information may be scattered across multiple screens or menus, necessitating pharmacists to actively search for and cross-reference details, ultimately leading to an elevated cognitive load.34 This emphasizes the need for system designs that centralize essential details, reducing the cognitive strain on pharmacists.
Interpersonal dynamics, particularly relationships with other healthcare professionals and patients, emerge as key facilitators in the e-prescribing landscape.33,38,39,41,52 Enhanced patient-pharmacist interactions, characterized by reduced wait times, are notable benefits.31 However, miscommunication or a lack of communication can lead to confusion and misunderstandings.29,32,39,40 Addressing these concerns requires streamlined communication interfaces and protocols, supplemented by continual education for healthcare providers and patients.
The costs associated with e-prescribing also featured as significant considerations.43,53E-prescribing streamlines the prescription process, saving staff time, yet its implementation can present challenges. Physicians are eligible for bonuses for electronic prescriptions, while pharmacists have to bear transaction fees for the service.53 Concerns about increased costs29,37,40,52 served as significant barriers. Without appropriate incentives, pharmacists may not have the motivation to invest in the technology or fully utilise its features. The potential increase in dispensing costs and resource requirements can affect the reinforcement domain by reducing sustained use. The recommendation includes incentivizing pharmacists, minimizing implementation costs, and ensuring access to necessary tools for effective system utilization. Our review aligns with another study that explored barriers and facilitators to implementing complex innovations in primary care settings. This literature review underscored the significance of policies and incentives, robust infrastructure, resource availability, engaging key stakeholders, organisational readiness, individual knowledge and beliefs, and the integration of innovations within existing workflows and systems.59
4.3. Belief about consequences, social influence and social/professional role and identity
Pharmacists largely view e-prescribing positively, citing benefits such as increased efficiency, heightened patient safety, reduced paperwork, and professional growth.29,30,32,33,36, 37., 38,40,43, 44, 45,48,54,55 However, it depended on the quality and completeness of the information provided by the system to community pharmacists, enabling them to make suitable decisions.51
However, e-prescribing errors can be a significant risk and negate the benefits. According to the literature, e-prescriptions have an inherent error rate,44,47 which may increase due to inadequate physician training.41 Standardisation in drug names and prescription instructions can help reduce incomplete prescriptions.47 These errors negatively impact patient safety and affect pharmacy efficiency by disrupting the usability and workflow due to complicated procedures involved in correcting e-prescriptions or flipping between multiple screens (integration issues) and increasing pharmacists' workload. To address these issues, pharmacy staff should be adequately trained to recover from e-prescription errors more efficiently.35
Further complications arise from communication breakdowns between healthcare professionals and patients. Increased calls for prescription clarification disrupt workflow. Additionally, a general misconception among patients that e-prescriptions ensure immediate availability of medications increases pharmacists' pressures to try to manage these unrealistic expectations.33,44
E-prescribing technology presents an opportunity for pharmacist involvement in medication management, but it could lengthen the prescription filling time because pharmacists are required by law and professional ethics to double-check prescription facts before dispensing medication to a patient.30 Some studies31,41 also identified physicians' reluctance to disclose therapeutic indications that create tensions between physicians and pharmacists.31 Interventions management and building collaborative relationships between healthcare providers, highlighting the benefits of pharmacist involvement in medication management, and addressing concerns or misconceptions regarding pharmacist competence or scope of practice to address barriers related to professional role and identity in e-prescribing. By promoting the value of the pharmacist's role in medication management and addressing any concerns or misconceptions, healthcare providers can collaborate more effectively to ensure patients' safe and effective medication use.
The integration of e-prescribing systems enhances pharmacists' professional role and image by showcasing their ability to effectively utilise technology, exercise professional judgment, and engage in advanced medication management practices. This elevates their status as healthcare professionals and increases awareness among physicians about the valuable contributions pharmacists bring to the healthcare team, fostering collaboration and improving interprofessional relationships.30
4.4. Knowledge, skill and belief about capabilities
A thorough understanding of the e-prescription workflow, coupled with strong clinical expertise, facilitates the identification and resolution of system-related issues and prescription errors that may arise during the process.35,41,48,49 This comprehensive understanding promotes effective communication, diminishes the probability of prescription inaccuracies, and augments user satisfaction with the system.44,48 The low adoption rates among prescribers have resulted in significant implementation issues, hindering the broader acceptance of e-prescribing.52 This lack of adoption may be attributed to stakeholders' unawareness of the potential benefits associated with e-prescribing.53,54 As a result, pharmacists often encounter the challenge of simultaneously handling both traditional paper prescriptions and electronic prescriptions. This dual system can introduce inefficiencies and inconsistencies, particularly in regions where e-prescribing is not mandated. This further complicates the workflow, potentially diminishing the intended benefits of e-prescribing. The implementation issues should be addressed along with more training programs for prescribers.
User acceptance is crucial for the success of any technology, including e-prescribing. Factors such as attitude, perceived usefulness, ease of use, professional growth, patient safety, awareness, productivity, I.T. skills, training, patient attitude, and self-efficacy impact the outcomes. Attitudes have a significant impact on acceptance, and a favourable attitude towards e-prescribing is crucial for its success. On the other hand, people who perceive little value in e-prescribing are less likely to use the technology. Most of the studies in our review indicated that pharmacists were receptive to the e-prescription system,29,44,45,48,49,55 nevertheless, this catalyses its meaningful and efficient utilization. However, resistance to technology was reported as a barrier to e-prescribing implementation43; for instance, experienced pharmacists who have been practising for a long time may be more accustomed to traditional paper-based methods or may feel comfortable with their existing workflows, leading to resistance or less interest in adopting new technologies like e-prescribing. Resistance to change, especially in long-practising professionals, is a well-documented challenge in healthcare technology adoption.60 However, it's essential to note that even in these situations, the gradual transition process, practical training, and continuous support can help ease the utilization and familiarization of the new system.
5. Strength
This systematic review aims to provide a comprehensive and up-to-date analysis of the positive and negative aspects associated with electronic prescribing (e-prescribing) in the context of community pharmacy practice. By examining the relevant literature, this review establishes a solid framework for enhancing the effectiveness and efficiency of community pharmacy practice through the adoption of e-prescribing. Additionally, this study provides empirically substantiated suggestions for community pharmacists. These recommendations facilitate informed decision-making and promote the integration of electronic prescribing systems within their professional domain. The findings of this study possess the capacity to greatly enhance the efficacy and user satisfaction of e-prescribing systems, thus leading to an improvement in patient care and medication management.
6. Limitation
Findings from this review should be evaluated with caution due to some of the limitations of this study. The literature search utilised only three databases (PubMed, Embase, and CINAHL). Thus, it is possible that relevant studies published in journals that are not indexed in these databases are not included. However, this systematic review employed a meticulous and detailed approach to the literature search, thereby ensuring the inclusion of a wide range of relevant studies on community pharmacists' perspectives of e-prescribing. Using this specific method improves the dependability of our findings. The reported results only pertain to content that has been published.
The different time periods and geographic locations of the included studies could be considered a limitation of the review. The studies encompass an extensive range of e-prescribing implementation and utilization stages, spanning the years 2000 to 2022 and multiple jurisdictions. Some studies describe the early adoption and implementation of e-prescribing, while others describe the experiences after its mandated use. Since e-prescribing is not universally mandated, the outcomes may not encapsulate all scenarios. The broad temporal and geographical scope, although lending comprehensiveness, compromises the depth of analysis for specific contexts. Only English-language studies were included in the review. This suggests that the results may not accurately reflect pharmacists' experiences in countries where English is not the primary language. The review comprised studies from numerous nations, however, a significant number of studies were conducted in countries with high incomes.
7. Conclusion
In recent years, electronic prescription systems have shown substantial promise in enhancing the quality, safety, and efficacy of pharmaceutical prescribing and dispensing. To harness the full potential of these systems within community pharmacies, it is vital to implement the following recommendations:
Address Design and Technical Issues: This review highlighted factors, such as design and technical issues, interoperability, attitude towards e-prescribing, productivity, and resources that play a crucial role in the effective utilization of e-prescribing by community pharmacists. Policymakers should address these issues, and the design process should involve community pharmacists and other users for a user-centric approach.
Optimize Productivity: Strategies should be identified to boost community pharmacists' productivity with electronic prescription systems, including streamlining workflows, providing tools to increase efficiency and acknowledging that electronic prescription systems might necessitate changes to current workflows. Formulate strategies and provide support to ensure pharmacists adapt seamlessly and the systems meet users' needs.
Promote Positive Attitudes: Develop initiatives to raise a positive attitude towards e-prescribing among community pharmacists. Education and training programs can be beneficial in this regard.
Allocate Sufficient Resources: Ensure community pharmacies have access to the necessary hardware and software resources to utilise electronic prescription systems effectively.
Stakeholder Education and Support: Provide ongoing education and support to all stakeholders involved in using electronic prescription systems. This can include training, troubleshooting assistance, and regular updates on system improvements. Workspace evaluation, user requirements definition, and stakeholder education and support are essential preparations.
Strengthen Collaboration: Collaboration among all system stakeholders is required to strengthen and support the electronic prescription system.
Incorporating these recommendations into practice facilitates the seamless integration of electronic prescription systems into the daily routines of community pharmacists, maximizing the benefits they offer in improving pharmaceutical prescribing and dispensing. This multifaceted approach ensures that the potential of electronic prescription systems is harnessed to its fullest, ultimately resulting in safer and more efficient healthcare practices.
Funding
This research did not receive any specific grant from funding agencies in the public, commercial, or not-for-profit sectors.
CRediT authorship contribution statement
Amina Hareem: Data curation, Investigation, Methodology, Project administration, Resources, Validation, Writing – original draft, Writing – review & editing. Joshua Lee: Data curation, Investigation, Methodology, Project administration, Resources, Validation, Writing – review & editing. Ieva Stupans: Conceptualization, Investigation, Methodology, Project administration, Supervision, Resources, Validation, Writing – review & editing. Joon Soo Park: Data curation, Investigation, Methodology, Project administration, Supervision, Resources, Validation, Writing – review & editing. Kate Wang: Conceptualization, Data curation, Investigation, Methodology, Project administration, Supervision, Resources, Validation, Writing – review & editing.
Declaration of Competing Interest
The authors declare that they have no known competing financial interests or personal relationships that could have appeared to influence the work reported in this paper.
Footnotes
Appendix ASupplementary data to this article can be found online at https://doi.org/10.1016/j.rcsop.2023.100375.
Appendix A. Supplementary data
Supplementary material:
: Table S1: Search strategy, Table S2: Quality assessment, and Table S3: List of excluded studies.
Click here to view.(195K, docx)Supplementary material
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