Pharmacy customers' experiences with the national online service for viewing electronic prescriptions in Finland

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2017

Pharmacy customers' experiences with the national online service for viewing electronic prescriptions in Finland

Lämsä Elina

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PHARMACY CUSTOMERS’ EXPERIENCES WITH THE NATIONAL ONLINE SERVICE FOR VIEWING ELECTRONIC PRESCRIPTIONS IN FINLAND

Elina Lämsä^a*, Johanna Timonen^a, Pekka Mäntyselkä^b,c, Riitta Ahonen^a

a School of Pharmacy / Social Pharmacy, Faculty of Health Sciences, Kuopio Campus, University of Eastern Finland, P.O.B. 1627, FI-70211 Kuopio, Finland

b School of Public Health and Clinical Nutrition, Faculty of Health Sciences, Kuopio Campus, University of Eastern Finland, P.O.B. 1627, FI-70211 Kuopio, Finland

c Primary Health Care Unit, Hospital District of Northern Savo, P.O.B. 100, 70029 Kuopio University Hospital, Kuopio, Finland

*Corresponding author

E-mail: Elina Lämsä – elina.lamsa@uef.fi; Johanna Timonen – johanna.timonen@uef.fi; Pekka Mäntyselkä – pekka.mantyselka@uef.fi; Riitta Ahonen – riitta.ahonen@uef.fi

ABSTRACT Objectives

To investigate (1) Finnish pharmacy customers’ familiarity with My Kanta, the national online service for viewing electronic prescriptions (ePrescriptions), (2) how commonly My Kanta is used, (3) who the typical users are, and (4) users’ experiences of the usability of My Kanta.

Method

A survey was conducted among pharmacy customers (aged ≥18) purchasing medicines for themselves.

Questionnaires (N=2915) were distributed from 18 community pharmacies across Finland in autumn 2015.

The data obtained was stored in SPSS for Windows and subjected to descriptive analysis, chi-square tests and logistic regression analysis.

Results

In total, 1288 respondents were included (response rate 44%). Most (62%) of the customers were familiar with My Kanta. The majority of them (78%) were using it to view their ePrescriptions. My Kanta was perceived as clear, easy to use and to provide a good overall picture of the prescribed medications. Familiarity with My Kanta was associated with a higher education than basic school, regular use of prescription medicines, and sufficient information received about ePrescriptions. Men used My Kanta more often than women.

Respondents aged 75 or older were less likely to be familiar with and to use the service compared to 18 to 34 year olds.

Conclusions

Most of the Finnish pharmacy customers were familiar with the national online service, My Kanta, for viewing ePrescriptions. Service users perceived it as easy to use and beneficial in managing their overall medication.

Customers under 75, those educated beyond basic school, those using prescription medicines regularly, and those who had obtained sufficient information about ePrescriptions were most likely to be familiar with My Kanta. Men and customers under 75 were the typical users of the service. Some customers, however, were unaware of the service, or unable or reluctant to use it.

Keywords

Patient access to records; electronic prescription; pharmacy customer; survey

1 INTRODUCTION

Digitization in healthcare (eHealth) has been one of the leading ambitions of health policy worldwide in the 21^st century [1,2]. According to the World Health Organization’s definition, eHealth is the use of information and communication technologies for health at the universal, national and regional levels [3]. The eHealth practice includes electronic patient records, electronic identification of patients and healthcare professionals, and telehealth services (provision of health services via remote telecommunications). eHealth aims to improve the quality and availability of healthcare services [1,2]. Electronic storing of medical data has also enabled patients to access their personal records via online portals [4-8]. Patient portals are rarely nationwide [7] but rather administered by single organizations or regions [4-6,9-11]. In pursuit of patient-centered care, portals offer the possibility to communicate with the provider by secure messaging, to book appointments or request prescription renewals [5-11]. Electronic exchange of information between the healthcare provider and the patient may benefit the patient’s medication adherence and satisfaction with the quality of care [4,8,12,13].

Moreover, having access to records can save patients time and money and, importantly, help them better manage their personal health [13, 14].

Implementation of electronic prescriptions (ePrescriptions) is included in eHealth strategies [1]. In Europe, an ePrescription is defined as a medical prescription that is issued with a data processor by a healthcare professional and then electronically transmitted to the pharmacy for electronic dispensation of the medicine to the patient [2]. However, the definition varies, in some countries comprising only the electronic issuing and transfer of data. Fully operational ePrescription systems are currently in nationwide use in only a few European countries, among them Sweden, Denmark, Estonia, and Finland [15]. On the other hand, ePrescriptions are widely used in the United States [16] and regional or nationwide pilot projects are being introduced or under consideration in many European countries [15].

Introduction of ePrescriptions leads to significant changes for prescribers, pharmacists and patients. From the patients’ perspective, ePrescriptions have simplified the purchasing of prescription medicines from pharmacies [17-19]. Electronic data transfer renders the storing of paper documents by patients unnecessary. However, without tangible paper prescriptions patients’ may be less aware of their prescribed medicines [19,20].

According to the country reports of European Union Member States, patients rarely have access to their ePrescriptions [2]. Patients’ medical histories are generally incorporated into online patient portals [4,11,21], but up-to-date ePrescription information for patients is lacking. This may make it more difficult for patients to manage their overall medication.

Sweden, Norway, Denmark, Estonia, and Finland have national online services for citizens to view their own personal health data, including ePrescriptions (services respectively called Mina Vårdkontakter, Mine resepter, Sundhed.dk, Eesti.ee, and My Kanta) [22-26]. These services also provide overviews of users’ medication and the validity of their prescriptions. No previous study focusing on patients’ experiences with keeping up to date with their ePrescriptions by these nationwide online services has been published internationally.

This study aims to investigate (1) Finnish pharmacy customers’ familiarity with My Kanta, (2) how commonly the service is used, (3) who the typical users are, and (4) users’ experiences of the usability of My Kanta pages.

2 MATERIALS AND METHODS 2.1 Study context

In Finland, the nationwide introduction of ePrescriptions by law began in 2012 [27] and Finnish pharmacies started to dispense ePrescriptions in the same year. The issuing of ePrescriptions was made obligatory in public healthcare in 2013 and in private healthcare in 2015. In 2015, nearly 56 million prescriptions were dispensed in Finnish pharmacies, of which over 90% were electronic [28,29]. All prescriptions should be electronic by 2017 and conventional prescriptions (for example paper, telephone) will only be used in exceptional situations such as blackouts. The implementation of ePrescriptions aims to improve patient and medication safety as well as facilitate and streamline the prescribing and dispensing of medicines [27].

In Finland, ePrescriptions are issued, transferred, stored and dispensed electronically. Once issued, ePrescriptions are stored in a centralized database (the Prescription Centre) from which they can be retrieved and dispensed in any Finnish pharmacy. The Prescription Centre is one part of the national electronic data

system service for healthcare, pharmacies, and citizens called the National Archive of Health Information (also referred to as Kanta services: www.kanta.fi/en/). In addition to ePrescriptions, Kanta services comprise the Pharmaceutical Database, the Patient Data Repository, the Prescription Archive, and My Kanta pages. The Pharmaceutical Database includes information necessary for prescribing and dispensing (such as prices of medicines and reimbursement status). The Patient Data Repository includes patient health records from all healthcare units in a uniform format. The Patient Data Repository is currently being introduced and the information will accumulate in the archive gradually. Prescriptions are stored in the Prescription Centre for 2.5 years, after which they are transferred to the Prescription Archive and stored for 20 years. The data contained in the Prescription Archive is only available to the authorities and is used for purposes such as research and the compilation of statistics.

Patients can get up-to-date information about their ePrescriptions by asking pharmacy or healthcare staff, or via the My Kanta pages. My Kanta is an online service accessible to all adults aged ≥18 [22]. By logging into the service, the user can view all his or her personal data which has been entered by any Finnish private or public healthcare unit, or pharmacy. My Kanta gives an overview of the user’s ePrescription details: how long prescriptions are valid, whether there is any medicine left, logs and dispensations made by healthcare units and pharmacies. Those wishing to have a hard-copy document can print out a summary of their ePrescriptions on My Kanta. Patients can also request the printout from healthcare or pharmacy staff. The features available in My Kanta pages are presented in Table 1. A bank log-in ID or other form of verification is required for logging into the service.

In Finland, medicines (except for nicotine replacement therapy) are sold to the public only from community pharmacies. Finland has a privately owned pharmacy system regulated by the Finnish Medicines Agency.

There are approximately 600 community pharmacies and 200 subsidiary pharmacies, at least one pharmacy in almost every municipality [30]. There are also two university-owned community pharmacies: the University Pharmacies of Helsinki, with 17 branches across Finland, and the University Pharmacy of Eastern Finland in Kuopio. University pharmacies operate in the same way as privately owned community pharmacies.

Table 1.

Features of My Kanta

Viewing ePrescriptions and medicines purchased

The data is shown for 2.5 years from the date the prescriptions were issued

Paper, telephone or fax prescriptions are not shown

 Brand name, dose, indication, and refills

 Date of prescribing, prescriber’s name and organization

 How long the ePrescription is valid

 Whether or not any medicine is outstanding

Printing off a summary of ePrescriptions Users can choose whether to print one or more ePrescriptions

The printout has the same information as that included in paper prescriptions

The printout can be used as proof of personal medication when travelling abroad

Submitting a request to renew an ePrescription to healthcare units

Restricting healthcare unit and pharmacy access to an ePrescription

A restricted ePrescription is only shown

 to the prescriber of that ePrescription

 in the case of CNS agents with abuse potential or narcotic agents, to the prescriber who is prescribing other CNS agents with abuse potential or narcotic agents to the patient

A restricted ePrescription can be dispensed only with the printout of ePrescription (bar code included)

Viewing which healthcare units and pharmacies have viewed or processed personal

ePrescriptions

Viewing medical records (e.g. admissions, laboratory test results, discharge summaries)

Medical records remain in the service for the statutory period of time.

This feature is currently being introduced Viewing which healthcare units have accessed

the individual’s medical records

Checking that data entered into My Kanta pages is correct

The health service is responsible for entering patient records and correcting them

Giving consent to healthcare units to access personal data

Entering a living will and/or organ donation testament

Marking information about the service as ‘read'

2.2 Study setting

A questionnaire survey was conducted in Finland in autumn 2015. The survey was targeted at individuals with experience of using ePrescriptions. Adult pharmacy customers aged ≥18 purchasing medicines for themselves with an ePrescription were included. The questionnaires were handed out in 18 community pharmacies in six regions. One University Pharmacy branch, one big city pharmacy and one small rural pharmacy were recruited from each area. The number of questionnaires delivered to each pharmacy varied between 30 and 200, and was adjusted according to the number of prescriptions dispensed daily at the pharmacy. We provided instructions on the distribution of questionnaires to pharmaceutical staff. Pharmacists informed customers about the study after their medication was dispensed and offered them the questionnaire. Customers filled in the questionnaire at home and mailed it to the researchers. The questionnaires were handed out as long as there were forms left, but for a maximum of two weeks. After the study period, pharmacies reported the number of questionnaires left in order to compute the response rate. Pharmaceutical staff were not required to keep a list of customers who refused to participate. Altogether, 2915 questionnaires were distributed. Since no customer’s personal data was available, reminders could not be sent.

The study setting and research process complied with local and national ethical instructions for research [31].

This study required no ethical approval.

2.3 Questionnaire

The four-page form contained 26 multiple-choice, Likert-type and open-ended questions concerning the respondent’s experiences with ePrescriptions and My Kanta, their opinions on the benefits and problems with ePrescriptions, as well as information sources and information needs related to ePrescriptions. The questionnaire was developed on the basis of the mandated objectives of ePrescriptions [27], the anticipated impacts of ePrescriptions [32] and some previous studies [18,33]. The questionnaire was pilot-tested in a local pharmacy in spring 2015. Pilot customers were interviewed in the pharmacy after filling in the questionnaires to check that they had understood the questions. Minor modifications were made based on the pilot. However, modifying the questions analyzed in this paper was not necessary.

This paper reports the results from four questions related to the My Kanta pages. Pharmacy customers’

familiarity with, and experiences of, using My Kanta were investigated using three structured questions: “Are you familiar with the My Kanta service?”, “Have you used My Kanta to view your ePrescription information?”, and “Have you printed out a summary of your ePrescriptions from My Kanta?”. Each question had response options: “Yes” and “No”. If respondents answered “No” to either of the first two questions, they were directed to skip all the following questions concerning the My Kanta service. Their opinions of the usability of the My Kanta service were measured using an eight-item list of statements concerning features of the My Kanta pages.

The respondents were instructed to answer using a five-item Likert-scale to indicate their degree of agreement:

1 = I fully agree, 2 = I agree to some extent, 3 = I disagree to some extent, 4 = I fully disagree, and 5 = I don’t know.

The structured questions yielded background information on gender, region, education, and use of prescription medicines. The respondent’s year of birth was obtained by means of an open-ended-question. We also used the structured question, “Do you feel you have received sufficient information about ePrescriptions?”

(response: yes or no) as a background variable.

2.4 Statistical methods

Correlations between respondents’ answers and their background information were tested for significance using the chi-square test. Statistical significance was determined as p<0.05. Results from Likert-type questions were analyzed using descriptive statistics.

In order to further analyze which factors were related to familiarity with the My Kanta pages (versus not familiar with) a logistic regression analysis was conducted with gender, age group, education, use of prescription medicines, and whether or not the respondent had received sufficient information about ePrescriptions. A logistic regression analysis was also conducted for the respondents’ use of My Kanta pages to view their own ePrescriptions (versus not used). The results are presented as odds ratios (ORs) together with their 95% confidence intervals (CIs).

In the analyses the respondent’s age was placed into one of four groups (18–34, 35–59, 60–74 and 75 years or older). In addition, the Likert scale items were combined to form the classes: “I agree to some extent/I fully agree” and “I disagree to some extent/I fully disagree”. Statistical software (SPSS Statistics for Windows, Version 21.0 SPSS Inc., Chicago, IL, USA) was used in the data analysis.

3 RESULTS 3.1 Respondents

The study flow is presented in Figure 1. In total, 1290 questionnaires were returned. However, two questionnaires were excluded since the respondents were only 17 years old. Consequently, the final study sample was 2913, of whom 1288 (44%) returned the completed questionnaire.

Figure 1. Study flow.

2915 questionnaires distributed to pharmacy customers in 18 pharmacies across Finland

1290 responses returned

Two questionnaires excluded (underage respondents)

Final study sample 2913

1288 questionnaires included, response rate 44%

Background information on the respondents is presented in Table 2. Most of the respondents were female. The respondents’ ages ranged from 18 to 93, mean 59 and median 62. There were respondents from all six geographical areas of Finland. The majority of the respondents felt they had received sufficient information about ePrescriptions. However, a sixth of the respondents were dissatisfied with the information.

Table 2. Background information on the study population (N=1288).

n %

Gender (n=1287¹)

Female 965 75.0

Male 322 25.0

Age, years (n=1167¹)

18–34 137 11.7

35–59 379 32.5

60–74 476 40.8

≥75 175 15.0

Education (n=1263¹)

Basic education (comprehensive school) 274 21.7

Vocational degree 459 36.3

Secondary school graduate 152 12.0

Lower-level university degree 203 16.1

Higher-level university degree 175 13.9

Current use of prescription medicines (n=1272¹)

Temporarily 117 9.2

Regularly 715 56.2

Both regularly and temporarily 440 34.6

Region (n=1276¹)

Southern Finland 301 23.6

Southwestern Finland 208 16.3

Western and Central Finland 205 16.1

Eastern Finland 183 14.3

Northern Finland 256 20.1

Lapland 123 9.6

Received sufficient information about ePrescription (n=1237¹)

No 207 16.7

Yes 1030 83.3

1Some of the respondents did not report their gender, age, education, usage of prescription medicines, region or whether they have they received information about ePrescriptions

3.2 Familiarity with My Kanta

Most of the respondents (62.1%) were familiar with My Kanta pages (Table 3). However, over a third (37.9%) did not know the service at all. Younger pharmacy customers were more likely to be familiar with the service than the oldest (p<0.001). Respondents with only a basic education were less likely to know the My Kanta service than those with more education (p<0.001).

In the multivariate analysis when adjusted for other variables, age, education, current use of prescription medicines, and information received about ePrescriptions were all significantly associated with familiarity with the My Kanta service (Table 4). The likelihood of being familiar with My Kanta was significantly lower among respondents aged 75 or older compared to those aged 18 to 34. Respondents with more than just a basic education were more inclined to know My Kanta than those with only a basic education. Table 3 also illustrates that familiarity with My Kanta was predicted statistically significantly by the regular use of prescription medicines. Respondents who had obtained sufficient information about ePrescriptions were more likely to be familiar with My Kanta than those who were dissatisfied with the information.

3.3 Viewing ePrescriptions with My Kanta

Of those familiar with the My Kanta service 77.5% (45.7% of all respondents) had used the service to view their own ePrescription details (Table 3). According to the results of a univariate analysis, respondents aged 18 to 74 were more likely to have viewed their own ePrescriptions with My Kanta than the oldest respondents (p=0.004). In the logistic regression analyses gender and age remained significant after adjusting for other variables (Table 4). Men were more likely to use My Kanta to view their ePrescriptions than women. Age 75 years or older reduced the likelihood of having viewed ePrescriptions with My Kanta.

Table 3. Respondents’ experiences with the My Kanta pages (N=1288).

1Some of the respondents did not answer this question

2If the respondent was not familiar with My Kanta, he/she did not answer this question

3If the respondent had not used My Kanta to view ePrescriptions, he/she did not answer this question

*Pearson chi-square test; p-value ≤0.05 considered statistically significant Familiar with My Kanta

(n=1267¹)

Have used My Kanta to view ePrescriptions (n=759^1,2)

Have printed out a summary of own ePrescriptions from My Kanta

(n=587^1,3)

n % p-value* n % p-value* n % p-value*

All 787 62.1 588 77.5 221 37.6

Gender 0.729 0.079 0.018

Female 595 62.4 436 76.0 152 34.9

Male 192 61.3 152 82.2 69 45.7

Age <0.001 0.004 0.004

18–34 years 97 70.8 72 76.6 15 20.8

35–59 years 258 68.6 209 82.3 74 35.6

60–74 years 296 63.0 229 80.9 96 42.5

≥

Education <0.001 0.586 0.318

Basic education 120 45.3 86 76.8 38 44.7

Vocational degree 292 64.5 229 80.6 89 38.7

Secondary school graduate 99 66.0 72 75.0 21 29.2

Lower-level university degree 149 73.8 107 74.3 37 34.3

Higher-level university degree 114 65.5 84 77.1 32 39.0

Current use of prescription medicines 0.006 0.216 0.011

Temporarily 64 54.7 43 70.5 9 20.9

Regularly 421 60.3 308 76.4 110 35.7

Both regularly and temporarily 297 68.1 233 80.1 101 43.5

Received sufficient information about ePrescriptions

<0.001 0.674 0.239

No 88 43.6 70 79.5 31 44.3

Yes 680 67.0 508 77.6 188 37.0

Table 4. Logistic regression model of respondents’ familiarity with My Kanta and use of My Kanta to view ePrescriptions (N=1288).

1A total of 1267 respondents answered the question, of whom 195 were excluded from the logistic regression and calculation of unadjusted ORs because of the missing covariate values

2A total of 759 respondents answered the question, of whom 98 were excluded from the logistic regression and calculation of unadjusted ORs because of the missing covariate values

Familiar with My Kanta (n=1072¹) Have used My Kanta to view ePrescriptions (n=661²) Unadjusted OR (CI 95%) Adjusted OR (CI 95%) Unadjusted OR (CI 95%) Adjusted OR (CI 95%) Gender

Female 1.00 1.00 1.00 1.00

Male 0.96 (0.73–1.24) 0.95 (0.69–1.29) 1.46 (0.96–2.22) 1.70 (1.02–2.82)

Age

18–34 years 1.00 1.00 1.00 1.00

35–59 years 0.90 (0.59–1.38) 0.84 (0.52–1.35) 1.42 (0.80–2.52) 1.38 (0.75–2.53)

60–74 years 0.70 (0.45–1.06) 0.67 (0.42–1.09) 1.30 (0.74–2.27) 1.17 (0.63–2.16)

≥75 years 0.26 (0.16–0.42) 0.24 (0.14–0.42) 0.49 (0.24–1.00) 0.40 (0.18–0.86)

Education

Basic education 1.00 1.00 1.00 1.00

Vocational degree 2.19 (1.61–2.99) 2.05 (1.43–2.95) 1.23 (0.74–2.14) 1.08 (0.59–1.98)

Secondary school graduate 2.35 (1.55–3.55) 1.74 (1.07–2.83) 0.91 (0.48–1.72) 0.95 (0.45–2.01)

Lower-level university degree 3.40 (2.29–5.05) 2.78 (1.74–4.43) 0.87 (0.49–1.56) 0.85 (0.43–1.69)

Higher-level university degree 2.30 (1.55–3.41) 2.76 (1.69–4.49) 1.02 (0.54–1.90) 0.88 (0.43–1.78)

Current use of prescription medicines

Temporarily 1.00 1.00 1.00 1.00

Regularly 1.26 (0.85–1.87) 1.70 (1.06–2.73) 1.36 (0.75–2.46) 1.60 (0.82–3.13)

Both regularly and temporarily 1.77 (1.17–2.68) 2.29 (1.40–3.75) 1.68 (0.90–3.13) 1.75 (0.88–3.50) Received sufficient information about

ePrescriptions

No 1.00 1.00 1.00 1.00

Yes 2.63 (1.93–3.58) 3.67 (2.57–5.23) 0.89 (0.51–1.54) 0.80 (0.42–1.53)

Of the respondents who had viewed their own ePrescriptions through My Kanta 37.6% (17.2% of all respondents) had printed out a summary of their ePrescriptions from the service (Table 3). Women (p=0.018), respondents older than 18–34 years (p=0.004) and respondents using prescription medicines regularly (p=0.011) had printed out a summary more often than men, than respondents aged 18–34 years or respondents using prescription medicines only temporarily.

3.4 Experiences of using My Kanta

The vast majority of respondents who had used My Kanta considered the service clear, understandable and easy to log on to (Figure 2). A majority of the respondents also felt that My Kanta provides a good overall picture of their medications and makes it easy to check the status of their ePrescriptions. Most of the respondents agreed that My Kanta works without any problems and that it is easy to check if their ePrescription has been renewed. However, half of the respondents (49.4%) were unsure whether it is easy to see which pharmacies and healthcare units have viewed or processed their ePrescription details.

Figure 2. Respondents’ opinions on statements concerning the My Kanta service (respondents who were not familiar with My Kanta or who had not used the service to view

their own ePrescriptions did not give their opinions on the statements).

31

81,4 89,7 90,5 93,1 93,6 95,2

96,8

19,5

3,7 5 4,6

3,7 3,7 4,6

3

49,4

14,8 5,2

4,9 3,2

2,7 0,2 0,2

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

With My Kanta it is easy to see at which pharmacies and/or healthcare units my ePrescriptions have been viewed (N=593)

It is easy to check if my prescription was renewed with My Kanta (N=587)

My Kanta works without any problems (N=595) It is easy to check expiration of a prescription with My

Kanta(N=592)

It is easy to check the amount of medication remaining on a prescription with My Kanta (N=594)

My Kanta provides a good overall picture of the medications prescribed for me (N=596)

The My Kanta Pages are clear and understandable (N=586) It is easy and efforless to log on to My Kanta (N=599)

I fully agree/I agree to some extent I fully disagree/I disagree to some extent I don't know

4 DISCUSSION

Over half of the Finnish pharmacy customers surveyed were familiar with My Kanta pages, an online service for viewing ePrescriptions. Most of them had also used the service. The users were satisfied with the usability and functions of the service. However, a considerable number of pharmacy customers were unaware of the service or did not use it to view their ePrescriptions. The oldest pharmacy customers, customers who use prescription medicines only temporarily, customers with just a basic education, and those who had received insufficient information about ePrescriptions were less likely to be familiar with the My Kanta pages.

In the main, the respondents using My Kanta had a positive attitude towards the service. They felt that the service is clear and easy to operate. They felt that the portal is helpful in giving an overall picture of their medications and in keeping them up to date with their prescriptions. Only two-fifths of My Kanta users had printed out a summary of their ePrescriptions, which indicates that papers are not needed to manage prescription details. In Sweden, users of the “My dispensed medications” web service reported that access to their dispensed prescription data is useful, gives a good overview, and helps them to manage their medications [34]. According to the findings of a Finnish population survey conducted in 2014, persons who had used some online patient portal were mainly satisfied with the service [35]. The respondents hoped that they could view their patient records, prescriptions, and laboratory test results as well as request their prescriptions to be renewed online. These findings indicate that ePrescription-related online services are important to pharmacy customers.

A substantial number of the pharmacy customers were unacquainted with My Kanta, however. Customers who had received insufficient information about ePrescriptions were less likely to be familiar with the service. Lack of information has been reported as the main reason for non-use of online patient portals [6,21,36]. According to Finnish legislation on ePrescriptions, patients are entitled to obtain information about ePrescribing and My Kanta pages before receiving their first ePrescriptions [27]. Healthcare facilities are obliged to provide the information either verbally or in writing. However, our study indicates that the patient information mandate has not been met completely. In the US, aggressive marketing of the online patient portal using various strategies, such as oral and written information, postcard and letter mailings, advertisements in practices’

telephone systems, and posters, tripled the adoption of the portal [11]. Public promotion and informing patients should be considered carefully before implementing eHealth services.

Unfamiliarity with My Kanta was also predicted by some of the pharmacy customers’ characteristics. In agreement with earlier studies, advanced age and low education have been associated with the improbability of obtaining health information or personal health records via the internet [4-6,9,37,38]. In addition, low socioeconomic status and limited health literacy have been inversely correlated with the use of online patient portals in previous studies. However, a few studies have illustrated that lack of internet access is a major barrier to portal use [4,10].

The digital divide – the gap between individuals of different socioeconomic status with regard to opportunities to access electronic technologies – can cause difficulties in introducing eHealth among citizens. According to the Official Statistics of Finland, 87% of people aged 16 to 89 use the internet and 80% have bank log-in IDs [39]. Poorly educated people and those over 65 use the internet less often than well-educated and younger people. Thus, My Kanta is probably inaccessible to approximately a fifth of the population, especially older residents. Lack of a computer or internet access are barriers to the use of My Kanta. Nevertheless, customers who could use these technologies but are reluctant to use My Kanta may feel that logging into the service with bank log-in IDs is burdensome or complicated [40]. Patients below the digital divide need other services to keep up to date with their ePrescriptions. Printed ePrescription summaries along with written and oral information offered by healthcare providers and pharmacy staff are necessary for patients without online access to their records. Some patients might benefit from a reminder service sending a text message when an ePrescription’s expiry date approaches. A mobile application with an easy log-in tool would be useful for patients with smartphones.

Our study has several strengths. A fully operational ePrescription system was widely adopted during the study period, since approximately 90% of all dispensed prescriptions were electronic [28,29]. The method was suitable for reaching the target group, i.e. patients who have experience of ePrescriptions. In addition, the study sample was large and involved pharmacy customers across the country. The response rate for our survey was

44%, which is typical of this kind of survey for which reminders cannot be sent [41,42]. Comparable statistics on Finnish pharmacy customers’ characteristics are not available. However, current use of prescription medicines, age and sex distributions of our study respondents were similar to those of an earlier study surveying Finnish pharmacies’ prescription customers’ experiences with generic substitution [41]. Hence, we suggest that our study population well represents those customers who purchase their prescription medicines at Finnish community pharmacies.

The study also has some limitations. First, due to the random sampling adopted by the pharmacies involved, we lacked information about the characteristics of customers to whom the questionnaire was offered, who refused to participate, or who did not return the questionnaire. Second, the questions analyzed in this study were generally formulated. Even so, our results met the objectives set for the study. Third, in order to assess respondents’ opportunities to use the My Kanta pages, it would have been valuable to know whether the respondents use computers, or have internet access or bank log-in IDs. We identified medicine users who do not know about or do not use the My Kanta pages. However, in order to improve the My Kanta service, more qualitative information is needed. Future studies should focus on the reasons why some patients refuse to, or cannot, use the service, and how it should be improved in order to maximize the user rate.

Although the Finnish ePrescription system is in wide use, it has only fairly recently been implemented and is still under development. The perceptions of pharmacy customers should be further investigated in the future.

Since the Finnish system is in nationwide use and as conventional prescriptions will soon only be allowed in exceptional situations, future studies concerning familiarity with and use of ePrescriptions and My Kanta should be targeted at the general population. Nevertheless, the early findings of this study can be utilized internationally in developing national ePrescription systems and patient portals. Looking to the future, a nationwide eHealth system with patient access engaging all healthcare providers and pharmacies is achievable.

Patients feel that access to ePrescription records is useful in managing their medication. However, in order to widen acceptance of the portal, the responsibilities and practices of providing patients with information should be agreed and carefully implemented. Despite the advances made in eHealth, there will still be patients disinclined or unable to use the new technologies. These groups need to be identified and the reasons for their

disinclination established. In order to prevent inequalities in healthcare, alternative ways for online services must be created to allow patients unable to use new technologies to keep up to date with their medical data.

5 CONCLUSIONS

Most Finnish pharmacy customers are familiar with the national online service for viewing ePrescriptions.

Service users perceive it as easy to use and beneficial in managing their overall medication. Customers under 75, those with an education beyond basic school, those using prescription medicines regularly, and those who have received sufficient information about ePrescriptions are most likely to be familiar with My Kanta. Men and customers under 75 are the typical users of the service. Some customers, however, are unaware of the service or are unable or reluctant to use it.

AUTHORS’ CONTRIBUTIONS

EL, JT and RA participated in designing the study and collecting the data. All authors discussed the findings of the study. EL conducted the data analysis and drafted the manuscript. All authors contributed to the critical revision of the manuscript, and read and approved the final manuscript.

CONFLICTS OF INTEREST

The Authors declare that there is no conflict of interest.

ACKNOWLEDGEMENTS

The Authors wish to thank the pharmacies for their help in distributing the questionnaire. This study was funded by The Social Insurance Institution of Finland (Kela). The opinions expressed in this document are those of the authors and do not reflect the official position of Kela.

SUMMARY POINTS

What was already known about the topic

- As part of eHealth, ePrescriptions have been implemented in several countries worldwide.

- ePrescribing may hinder patients from keeping up to date with their prescriptions.

- National online portals offering patients access to their ePrescriptions are rare.

- Previous research into patients’ experiences with ePrescription portals is lacking.

What this study added to our knowledge

- Users are satisfied with the online service for viewing ePrescriptions to manage their overall medication.

- Some pharmacy customers are still unable or disinclined to use the online service.

- People should be informed about ePrescriptions and related services carefully in advance.

- Alternative ways need to be created for the online service to keep up to date with ePrescriptions.

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