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Rinnakkaistallenteet Terveystieteiden tiedekunta
2017
Medication safety and the usability of electronic prescribing as perceived by physicians: a semistructured interview among primary health care physicians in Finland
Kauppinen H
Wiley-Blackwell
info:eu-repo/semantics/article
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© John Wiley & Sons All rights reserved
https://doi.org/10.1111/jep.12759
https://erepo.uef.fi/handle/123456789/3482
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Medication safety and the usability of electronic prescribing as perceived by physicians – a semi- structured interview among primary health care physicians in Finland
Hanna Kauppinen (MSc, Pharm)a,*, Riitta Ahonen (Professor)a, Pekka Mäntyselkä (Professor)b, Johanna Timonen (PhD, Pharm)a
aSchool of Pharmacy/Social Pharmacy, Faculty of Health Sciences, University of Eastern Finland, P.O.B. 1627, FI-70211 Kuopio, Finland
bPrimary Health Care Unit, Hospital District of Northern Savo, Kuopio University Hospital, University of Eastern Finland, P.O.B. 1627, FI-70211 Kuopio, Finland
E-mail: Hanna Kauppinen – hanna.kauppinen@uef.fi – Riitta Ahonen – riitta.ahonen@uef.fi – Pekka Mäntyselkä – pekka.mantyselka@uef.fi – Johanna Timonen – johanna.timonen@uef.fi
*Corresponding author:
Hanna Kauppinen
School of Pharmacy / Social Pharmacy, Faculty of Health Sciences Kuopio Campus, University of Eastern Finland
P.O.B. 1627, FI-70211 Kuopio, Finland Phone: +358 40 355 3669
Email: hanna.kauppinen@uef.fi
Running title: ePrescribing as perceived by Finnish physicians
Keywords: electronic prescription, physician, prescribing, medication safety, interview, Finland
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Summary
Rationale, aims and objectives
In Finland, a fully operational and nationwide electronic prescription (ePrescription) system was implemented by law in 2012–2015. From 2017, all prescriptions have to be electronic.
ePrescriptions are intended to facilitate prescribing and to improve medication safety in Finnish health care. In this study, the aim was to explore physicians’ experiences with the impacts of ePrescriptions on prescribing and medication safety in Finland.
Method
Data was collected by conducting 42 interviews among primary health care physicians in spring 2015. The data obtained was analyzed by means of qualitative content analysis.
Results
Most of the physicians considered ePrescriptions to be convenient to issue because of the paperless procedure. Additionally, physicians stated that information concerning patients’ prescriptions was better available through the Prescription Centre since physicians were able to check patients’
prescriptions, including those issued elsewhere. In particular, ePrescriptions have improved the control of narcotics and medicines classified as primarily affecting the central nervous system.
However, establishing a patient’s overall medication through the Prescription Centre was regarded as difficult because prescription information was sometimes incoherent and had not been updated.
The ePrescribing system was also described as inflexible, especially the correcting, cancelling, or renewing of ePrescriptions. For example, the system required too many “mouse clicks” and PIN entries to justify the actions taken in prescriptions. The system’s slowness and the poor connection between physicians’ electronic patient records and the Prescription Centre were also underlined.
3 Conclusions
According to the Finnish physicians interviewed, ePrescriptions have facilitated prescribing in some respects. However, the ePrescribing system still has problems and the Prescription Centre cannot be fully utilized for the management of a patient’s overall medication.
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Introduction
Prescriptions have traditionally been the principal means by which physicians can influence their patients’ treatment. Physicians have to be familiar with not just the increasingly complex range of medications resulting from the aging population but also with today’s information-intensive health technology. To ensure high-quality and safe patient care, medication information has to be easily accessible and usable; it should also be accurate, valid, and coherent. To this end, electronic health information technology, such as electronic patient records (EPRs) and electronic prescribing (ePrescribing) have been adopted as standard tools for physicians to provide effective and safe patient medication treatment [1-3].
The European Union (EU) has put forward health policy initiatives aimed at encouraging the introduction of ePrescription systems in order to enhance prescribing and improve medication safety [1]. In the EU, ePrescribing is defined as the electronic issuing, transferring, storing, and dispensing of prescriptions. However, only a few European countries, among them Denmark, Sweden, Estonia, Norway, Iceland, and Finland have succeeded in implementing a fully operational and nationwide ePrescribing service [1,4-7]. ePrescribing is also widely used in the US [3] and Canada [8], while several pilots employing ePrescribing have been planned or initiated in many countries across Europe [1].
The implementation of ePrescription systems has led to notable changes, especially for prescribers and pharmacists. From the physicians’ point of view, combining EPRs with ePrescribing allows not merely the electronic issuing and transferring of prescriptions but also provides better electronic access to patients’ medication information [2,5,9]. In addition, ePrescribing has been shown to facilitate and enhance the physician’s workflow and the safety and quality of patient care in primary health care [10-17]. Studies show that improvements in workflow result from the paperless procedure, quicker prescription renewals, and the better availability of patient information [11-13].
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It has been suggested that patient safety benefits from the better quality of prescriptions (e.g. fewer prescription errors) and better management of patients’ medication information [10,15-17].
Although the benefits of ePrescribing have been widely recognized, the technology itself can create new kinds of problems for prescribing processes, such as technical disruptions or slow data processing [11,12,18,19] or problems with the system or software usability [15,19-24].
Studies, especially qualitative ones, which exclusively focus on primary health care physicians’
experiences with ePrescribing, are rather limited [10,16,21]. In addition, ePrescribing systems and their stage of implementation vary between countries, which complicates comparison of these systems [1,2,25]. Thus, we need more knowledge about the end users’ experiences with the system- related effects on ePrescribing and patient care.
The objective of this study was to explore primary health care physicians’ experiences with the impacts of ePrescription on prescribing and medication safety in Finland.
Methods
Study context
Health care in Finland
The Finnish health care system is mainly based on public municipal health care services divided between primary health care and specialized health care [26,27]. Occupational and private health care sectors complement these services. Finland is divided into five university hospital regions and further into twenty hospital districts [26,27]. Each municipality belongs to one of the hospital districts. Municipalities are responsible for organizing primary health care services. In general, primary health care is organized at municipal health centers. In 2015, there were 163 such health centers [28].
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There were 20,403 working-age physicians in Finland in 2015 [29]. Of these, 21% worked at health centers and 44% at public hospitals. In 2014, there were some 24 million visits to public health care centers, of which over 6.8 million (29%) were visits to primary health care physicians [30].
Electronic prescribing and electronic patient records in the Finnish health care system
In Finland, the public health care sector was required by law to join the fully operational and nationwide electronic prescription system between 2012 and 2013 [31]. Private health care was required to join the system at the beginning of 2015. From the beginning of 2017, all health care providers were obliged to introduce the system, and conventional prescriptions (paper, fax, telephone) are now allowed only in special cases such as technical system failures. At the end of 2014, over 90% of all prescriptions from the public sector were ePrescriptions [32]. In 2015, Finnish pharmacies dispensed over 49 million ePrescriptions, which was over 90% of all prescriptions dispensed [33,34].
ePrescriptions are part of the national electronic data system service for health care, pharmacies, and citizens called the National Archive of Health Information (Kanta services) (www.kanta.fi/en/).
ePrescriptions are issued and transferred with the prescribing physician’s electronic signature to the EPR system (Figure 1). EPR systems are widely used in both primary health care and specialized health care in Finland, and all EPRs are compatible with ePrescribing [27,35]. Once issued, ePrescriptions are stored in a nationwide centralized database called the Prescription Centre, which contains all electronic prescriptions and the dispensing records entered on them by pharmacies.
ePrescriptions can be retrieved and dispensed in any Finnish pharmacy. A physician can view patients’ ePrescription information held in the Prescription Centre, although the patient’s consent and a current treatment relationship are required. However, when prescribing narcotics or medicines classified as primarily affecting the central nervous system (CNS medicines) with abuse
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potential, physicians may view prescriptions without the patient’s consent. Physicians can also view all the ePrescriptions they have issued themselves.
[Take Figure 1]
The aims of ePrescriptions set by law were to facilitate the prescribing and dispensing processes and to improve medication safety in Finnish health care [31,36]. These aims were expected to be achieved, for example, through the enhanced management of patients’ overall medication through the Prescription Centre, and thus better detection of drug-related problems (e.g. drug-drug interactions, duplicate therapy, and adverse reactions). In addition, ePrescriptions were expected to improve the quality of prescriptions, and also to reduce prescription forgeries.
Data collection
The data were collected by conducting 42 semi-structured telephone interviews among primary health care physicians in spring 2015. An interview method was chosen for this study in order to discover and understand more deeply physicians’ own experiences with ePrescriptions [37].
Besides, in recent years questionnaire surveys conducted among Finnish physicians have yielded only low response rates [15,38,39].
A convenience sample was collected from primary health care centers across five university hospital regions in Finland (Figure 2). Senior physicians at local health centers were asked to forward the invitation letter and a study announcement to their physician colleagues. Willingness to participate in the study, as well as permission to record the interview, was obtained by e-mail. After receiving the physician’s permission, one researcher (HK) arranged and conducted the interview. The main themes set out in the interview guide were sent to interviewees one week before the interviews.
[Take Figure 2]
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The themes and questions in the interview guide (see online Appendix 1) were designed on the basis of the objectives set by law [31], the anticipated impacts of ePrescribing [36] and in light of some previous studies [12,40,41]. The interview guide was developed to enable participants to tell their own experiences with ePrescribing. The guide outlined the major themes such as the physician’s experiences with ePrescribing, the impacts of ePrescriptions on medication safety, and the main benefits and problems with ePrescribing. At first, physicians were asked about the main theme with an open-ended question (e.g. What experiences do you have of the usability of ePrescriptions when prescribing medicines?). Additional questions were asked as required to allow interviewees to elaborate on their answers and in cases where they found it difficult to answer the open-ended question. Thus, not all additional questions were necessarily asked. In addition, physicians were asked to rank their overall satisfaction with ePrescriptions using a six-point scale ranging from 1 (very dissatisfied) to 6 (very satisfied). The interview guide was pilot tested on three physicians.
These interviews were also included in the study because only minor subsequent modifications were made to the interview guide. The interviews were tape-recorded and the recordings transcribed verbatim to a MS Word document. Interviews lasted an average of 28 minutes (range 15–53 minutes).
Data analysis
The data were analyzed by one researcher (HK). However, to confirm the emerging themes a continuous discussion was held during the analysis process with the study group. Both inductive and deductive content analysis were used to describe and quantify the data systematically and objectively [37,42]. The analysis unit could be a single word, a sentence, or a group of sentences describing an idea relating to the study question.
Deductive analysis was used when collecting the themes put to physicians, using questions such as:
“What kind of experience do you have of the usability of ePrescriptions when prescribing
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medicines?”, “In your opinion, what are the impacts of ePrescriptions on medication safety?”, and
“In your opinion, what are the main benefits/problems with ePrescriptions?” Inductive analysis was then used to find categories and to create new themes within the interviews. This analysis method is an ongoing process as a means to develop categories emerging from the data. The inductive analysis was stopped after 23 transcribed interviews, meaning that no new themes or categories related to the research questions emerged in the transcribed interviews (a thematic saturation was reached). The analysis process was continued by thematic categorization in order to classify all the ideas or views in the transcribed interviews into the categories created. Counting and tabulation were also used to quantify regularities in the interviews. In the quantification, we included both physicians’ spontaneous expressions and their elaborations on separately asked questions. Atlas.ti qualitative analysis software was used to analyze the content of the transcriptions. The final categorization took the form of a Word document. The analysis process on ePrescribing and medication safety appears in online Appendix 2.
Ethical statement
The study setting and research process complied with the local and national ethical instructions for research (Finnish Advisory Board on Research Integrity: http://www.tenk.fi/en/ethical-review- human-sciences). According to the instructions, this study did not require ethical approval. In addition, to ensure the confidentiality and total anonymity of the physicians, the health care centers in which physicians were working were anonymized. No incentives were given.
Results
The total number of interviewees was 42. Of these, 26 were women and 16 were men. Almost all (n
= 40) processed ePrescriptions daily. The characteristics of the participating physicians are shown in Table 1.
[Take Table 1]
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The physicians were in general satisfied with ePrescribing (Figure 3) and did not want to return to the paper-based system. They considered ePrescriptions to be a useful tool for prescribing and to have many benefits. Despite this, all physicians mentioned some problems with the ePrescribing system and highlighted areas needing development.
[Take Figure 3]
Five main categories with a total of 13 sub-categories were found (Table 2). Two of the main categories related to prescribing and renewing ePrescriptions, one category to prescribing systems, and two categories to medication safety. The sample comments citing the opinions of ePrescribing and medication safety appear in online Appendix 2.
[Take Table 2]
Category 1: ePrescriptions are convenient
Most of the physicians (n = 38) considered that ePrescriptions were convenient to issue (Table 2, see also citations #1–6 in Appendix 2). The principal benefits of ePrescribing were related to the electronic accessibility of patients’ medication information and the paperless procedure. The prescribing process was easy and convenient since everything was done electronically.
Furthermore, 21 physicians mentioned that it was easier for patients to get their prescriptions at any pharmacy across country.
Category 2: Prescribing and controlling narcotics and CNS medicines has become easier
According to the physicians, ePrescriptions have improved the prescribing and control of narcotics and medicines classified as primarily affecting the central nervous system (CNS medicines) (Table 2, see also citations #7–8 in Appendix 2). Thirty-four physicians drew particular attention to the fact that controlling the use of narcotics and CNS medicines has become easier since they were able to check their patients’ medication held in the Prescription Centre. This meant they could check such prescriptions issued by other physicians. In addition, ePrescribing of narcotics has become
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technically simpler because there is no longer a need for a separate verified prescription form for narcotics and no longer a duty to keep a separate record for narcotics.
Category 3: Technical problems in the ePrescribing system hinder prescribing
The inflexibility and rigidity of the ePrescribing system was criticized most by the physicians. During the interviews, the physicians repeatedly emphasized the inflexibility and rigidity of the ePrescribing system throughout the prescribing process (Table 2, see also citations #9–17 in Appendix 2). They described the system as “rigid”, “inflexible”, “awkward”, and “clumsy”. In particular, the correcting and cancelling of ePrescriptions were regarded as problematic or even impossible by 38 physicians.
They complained that the system required too many “mouse clicks” and PIN entries to justify the actions taken in prescriptions. The system also checked a number of confirmations (e.g. patient’s consent) during the correcting or cancelling of a prescription. The physicians mentioned that, in some cases when an ePrescription was being corrected (e.g. change of pack size or strength of the medicine), the system required the entire new prescription to be entered instead of allowing the existing prescription to be modified. This was considered problematic, especially when dealing with ePrescription renewals. In addition, many physicians (n = 32) highlighted several problems concerning the renewal of ePrescriptions.
The interoperability of EPRs and the Prescription Centre was seen as poor because corrections or cancellations made in ePrescriptions were not automatically transferred to the Prescription Centre (Table 2). Physicians therefore had to make these changes separately in the Prescription Centre.
This was considered laborious and time-consuming, and physicians simply avoided it by issuing a new prescription. Moreover, the link between EPRs and the Prescription Centre was experienced as slow by 27 physicians, partly because of the long information processing times. Occasional technical system failures were also considered troublesome by 13 physicians.
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As regards system rigidity and system slowness, it was difficult for physicians to say whether ePrescriptions have made prescribing more efficient or whether they have saved them time.
Twenty-three physicians thought that ePrescriptions have not made prescribing more efficient.
Twenty-nine physicians also thought that no time had been saved. They complained that any efficiencies or time savings gained with ePrescriptions would be lost due to the system’s rigidity or slowness.
Category 4: Information about patients’ prescriptions is more readily available through the Prescription Centre
Most of the physicians (n = 34) valued the fact that the Prescription Centre enabled them to collect information about patients’ prescriptions (Table 2, see also citations #18–20 in Appendix 2). For example, physicians were able to check what medicines their patient is using or what prescriptions are being issued elsewhere. Use of the Prescription Centre was usually restricted to cases where a patient could not remember his/her medication or when the patient was unfamiliar to the physician.
When necessary, the Prescription Centre also helped physicians to detect and prevent possible drug-related problems in patient medication, for example, duplicate prescriptions.
Category 5: Patients’ prescription information is incoherent in the Prescription Centre
Although the Prescription Centre was considered to be beneficial in certain situations, several physicians (n = 28) pointed out that prescription information held in the Prescription Centre was incoherent, incomplete, needed updating, and was thus unreliable (Table 2, see also citations #21–
24 in Appendix 2). The Prescription Centre was regarded merely as a place where ePrescriptions are stored without any logical order, which made the layout of the Prescription Centre confusing. The physicians also complained that prescription information was not congruent between the EPRs and the Prescription Centre because unnecessary ePrescriptions were not removed or cancelled in the Prescription Centre. In addition to the issues presented above, the physicians found it difficult to
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establish a patient’s overall medication through the Prescription Centre. Moreover, the poor interoperability and the slow link between the physician’s EPR and the Prescription Centre was another obstacle to checking the patient’s prescription information through the Prescription Centre.
Consequently, the physicians did not use the Prescription Centre in their daily practice.
Discussion
The Finnish physicians interviewed were in general satisfied with the ePrescribing system. They had accepted the system and thought it had the potential to facilitate the prescribing processes in their practice. The physicians valued the electronic access to patients’ information and the paperless procedure. Our study findings are comparable to those of some earlier studies conducted among physicians [12,19,43].
However, the physicians in our study raised several problems and areas needing development in the Finnish ePrescribing system. The study findings revealed that some key functions of the ePrescribing process did not work properly. In particular, the correcting and cancelling of ePrescriptions were perceived to be difficult. The findings corroborate the experiences of Finnish pharmacists [44].
Furthermore, our findings indicate that the poor integration and link between the EPR system and the Prescription Centre – the nationwide database – have complicated physicians’ work. Similar problems in the integration or link between health information systems have been demonstrated elsewhere in Europe, the US, and Canada [11,12,17,19,21,45]. For example, the study by Gagnon and colleagues (2015) showed that challenges with the links between local electronic medical records and the ePrescribing network caused potential loss of time in the physician’s practice and increased the risk of prescribing errors [45].
In Finland, there are several different EPRs used in public and private health care [24]. As long as this is the case, the integration of these systems with the nationwide ePrescribing linkage will pose
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a challenge. In future, therefore, the integration and standardization of health information systems should be prioritized, especially as regards better communication and information transfer between the systems.
The usability of, and interoperability between, new technologies have considerable effects on medication safety. In Finland, one of the main anticipated impacts of the ePrescription system was to improve medication safety through better management of patients’ overall medication via the Prescription Centre [36]. Our study showed that this kind of centralized and nationwide prescription database might be useful in that it affords physicians an opportunity to check their patients’
prescription information. However, the physicians in our study could not take full advantage of the Prescription Centre because, among other things, patients’ medication information was sometimes incoherent and had not been updated in the database. In general, when developing this kind of nationwide prescription database, which is integrated with an ePrescribing system, the database should include an updated and coherent list of patients’ current medication. This would allow medication information to be used to manage patients’ overall medication and thus support safe patient care.
Studies of nationwide ePrescribing systems and, more specifically, the integration between nationwide ePrescribing systems and health information systems are scarce [45]. Future research should therefore study how such health information systems are exploited together and examine what issues should be taken into account when planning or developing the link between different health information systems.
Strengths and limitations
Our study has several strengths. The findings are based on a fully operational ePrescription system widely adopted in Finnish public primary health care [33,34]. The convenience sample was drawn from five university hospital regions in Finland involving different health centers. Physicians were
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represented in each university hospital region and their experiences were based on their daily use of ePrescribing. We used the qualitative approach to understand in depth primary care physicians’
own experiences with the impacts of ePrescriptions on the prescribing process and medication safety. Most of the physicians spontaneously related their experiences and thoughts when answering the open-ended questions. However, more closed questions were also needed in some cases, especially when discussing the impacts of ePrescriptions on patient safety. Thus, the more closed questions we presented may have steered physicians’ answers in a particular direction. The number of physicians interviewed was quite high in comparison with other qualitative studies concerning ePrescribing among physicians and/or their staff [16,21]. In addition, the number of interviews was adequate, as shown by the fact that saturation was reached [37]. Increasing the sample size was therefore unlikely to have brought new information on the study questions. The interviews were recorded and transcribed verbatim for content analysis. Counting and tabulation were also used to make the results more reliable.
Conclusions
The physicians in our study were in general satisfied with ePrescribing. However, the ePrescribing system still has problems and areas needing development, such as the system’s rigidity and slowness. In addition, the Prescription Centre cannot be fully utilized for the management of patients’ overall medication because the list of patients’ current medication could not be found in the database. Integration between ePrescribing systems and physicians’ electronic health information systems should be developed so that the current list of patients’ overall medication can be found and utilized by all health care providers involved in their patients’ treatment.
Acknowledgements
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. The authors
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would like to thank all physicians involved in collecting the study sample, and all physicians interviewed for their valuable opinions regarding the study questions.
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38. Ilmanen A, Myllykangas M, Tuomainen TP, et al. Lääkärien suhtautuminen vaihtoehtohoitoihin vuonna 2012. (The Attitudes of Finnish Physicians towards Alternative Treatments in the Year 2012). Suomen Lääkäril 2013;68:1014–1018. (in Finnish, summary in English).
39. Silvoniemi M, Vasankari T, Vahlberg T, Clemens K, Salminen E. Physicians' attitudes towards euthanasia in Finland: Would training in palliative care make a difference? Palliat Med.
2010;24(7):744–746.
40. Hyppönen H, Hännikäinen K, Pajukoski M, et al. Sähköisen reseptin pilotin arviointi II (2005- 2006) (Evaluation of the National Electronic Prescribing Pilot II (2005-2006)) 2006.
41. Kivekäs E, Kuusisto H, Enlund H, et al. Ensikokemuksia e-reseptin käytöstä
perusterveydenhuollossa (Experience with ePrescribing in primary health care) Suomen Lääkäril 2014;69:1567–1571. (in Finnish, summary in English).
42. Elo S, Kyngäs H. The qualitative content analysis process. J Adv Nurs. 2008;62(1):107–115.
43. Devine EB, Williams EC, Martin DP, et al. Prescriber and staff perceptions of an electronic prescribing system in primary care: A qualitative assessment. BMC Med Inform Decis Mak.
2010;10:72. doi: 10.1186/1472-6947-10-72.
44. Timonen J, Kauppinen H, Ahonen R. Sähköisen reseptin ongelmat ja kehittämiskohteet - kyselytutkimus apteekkien farmaseuttiselle henkilöstölle (Problems and areas needing
22
development in electronic prescriptions -A survey of community pharmacy staffs). Suomen Lääkäril 2016;3:51–59. (in Finnish, abstract in English).
45. Gagnon MP, Payne-Gagnon J, Sicotte C, Langue-Dube JA, Motulsky A. Connecting primary care clinics and community pharmacies through a nationwide electronic prescribing network: A
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23 Table 1 Characteristics of the physicians interviewed (n = 42).
Characteristic Gender (n)
Female 26
Male 16
Age/years, median, (range) 42,5 (28–65)
Working years, median (range) 15 (2–40)
University hospital region (n)
HYKS (Southern Finland) 12
OYS (Northern Finland) 11
KYS (Eastern Finland) 9
TAYS (Western Finland) 7
TYKS (Southwestern Finland) 3
Electronic patient record (EPR) system (n)
Effica 22
Pegasos 12
Mediatri 6
GFS 2
Use of ePrescriptions (n)
Daily 40
Weekly 2
ePrescriptions as a proportion (%) of all prescriptions issued daily (n)
95–100 38
75–95 4
24
Table 2 The main categories and sub-categories found in the study interviews.
Main categories Sub-categories
Examples for defining sub-categories
Physicians (n) 1. ePrescribing is easy and
convenient.
Technically easy to prescribe 38
Electronic access to patients’ (prescription) information
Paperless procedure (e.g. less “office work”, less stamping)
No need to call pharmacy for phone prescriptions
Availability of ePrescriptions across the country and from any pharmacy 21
Prescription renewal is easy 18
for single prescriptions
for unambiguous prescriptions 2. Prescribing and
controlling narcotics and CNS medicines have become easier.
Controlling medicine use is easier. 34
Availability of patient’s prescription information through the Prescription Centre
Prevention of misuse of narcotics or CNS medicines
Technically simpler to prescribe 25
Separate prescription form or recordkeeping is no longer needed.*
3. The ePrescribing system is inflexible and rigid.
Making changes (corrections/cancellations) to prescriptions is difficult. 38
The pack size or the strength of medicine cannot be changed.
Changes made in the EPR system are not automatically transferred to the Prescription Centre.
Too many “mouse clicks”, which slows down the prescribing process.
System checks various security and confirmation issues (e.g. the system requires reasons for the actions taken in ePrescriptions).
Renewing an ePrescription is difficult. 32
Prescription renewal is slow.
Outdated prescriptions (over 16 months) cannot be renewed.**
Fully or partially non-dispensed prescriptions cannot be renewed. [Correction added on 17 May 2017, after first online publication: In Main Category 3, the 3rd point under subcategory “Renewing an ePrescription is difficult”wrongly referred to‘dispensed
prescription’and this is now corrected in this version.]
Checking dispensing intervals is difficult during the renewal.
4. System slowness and disruptions
The link between EPRs and the Prescription Centre is slow. 27
Technical system failures make working difficult. 13
5. Information about patients’ prescriptions is more readily available through the Prescription Centre.
The Prescription Centre helps to collect information about patients’ prescriptions. 34
Physicians are able to check which medicines the patient is using.
Physicians are able to check prescriptions issued elsewhere.
Possibility to detect drug-related problems (e.g. monitoring duplicate prescriptions).
Physicians’ local EPRs support the evaluation of patient medication information held in the Prescription Centre.
24
Drug-drug interaction alerts, duplicate therapy alerts, allergy alerts.
6. Incoherence of patients’
prescription information
Medication information not updated in the Prescription Centre. 28
Prescription information is not congruent between EPRs and the Prescription Centre.
Physicians do not cancel unneeded ePrescriptions in the Prescription Centre (too time-consuming).
The layout of the Prescription Centre is unclear. 18
Prescription information is disorganized (e.g. cancelled, expired, and stopped prescriptions are all displayed as “cancelled” prescriptions, the Prescription Centre is just “a pile” of prescriptions).
The Prescription Centre is used by several health care units (e.g. hospitals, private health care)
EPR, electronic patient record.
ePrescription, electronic prescription.
*Before the introduction of ePrescriptions, narcotics had to be prescribed using a separate verified prescription form and records had to be kept of narcotics prescribed.
**Prescriptions can be dispensed up to one year from the issuing date. However, ePrescriptions can be renewed up to 16 months from the issuing date.
25
Figure 1 The issuing, transmission, dispensing, and renewal of electronic prescriptions
(ePrescriptions) in the Finnish ePrescription system. Arrows demonstrate the directions of actions between those involved.
Patient
Pharmacy Physicians
My Kanta service
Prescription Centre
Own medical information views
and requests for renewals Dispensing of medicine Patient instruction
sheet regarding ePrescription
ePrescription records and renewal requests
Prescribing and prescription renewal
Dispensing entries Renewal requests ePrescription information on the web
Renewal request by
patient
ePrescriptions stored for 2.5 years
Medical need, patient’s consent
ePrescription request
26
Figure 2 The recruitment and participation of public primary health care physicians from local health centers from five university hospital regions in Finland (Southern Finland, Northern Finland, Eastern Finland, Western Finland, and Southwestern Finland).
27
Figure 3 Physicians’ overall satisfaction with electronic prescribing (ePrescribing).
28
28 Appendix S1.
The impacts of electronic prescriptions (ePrescriptions) on prescribing and medication safety from the viewpoint of primary health care physicians
Interviewee No._____ / University hospital region_______
General information about ePrescribing
What electronic patient record system are you using in your practice?
1. Pegasos 2. Effica 3. Mediatri
How often do you personally process ePrescriptions?
1. Daily 2. Weekly
3. Less than weekly
Please estimate what proportion of the prescriptions you issue daily are ePrescriptions 1. Less than 25%
2. 25–50%
3. 50–75%
4. 75–95%
5. 95–100%
Themes and additional questions for physicians during the interview 1. The usability of ePrescriptions
What experiences do you have of the usability of ePrescriptions when prescribing medicines?
- Was it easy to learn to use the ePrescription system? If not, why?
- Is the ePrescription system clear and understandable? If not, why?
- Has prescribing become easier and more efficient with ePrescriptions? If not, why?
- Has ePrescribing saved time in your practice? If not, why?
- What experiences do you have with the ePrescription system when correcting prescriptions?
- What experiences do you have with the ePrescription system when cancelling prescriptions?
- What experiences do you have with the ePrescription system when prescribing narcotics and CNS medicines (medicines classified as primarily affecting the central nervous system)?
What experiences do you have with the usability of ePrescriptions when renewing them?
29
29 2. The impacts of ePrescribing on patient safety
In your opinion, what are the impacts of ePrescribing on patient safety?
- Has ePrescribing facilitated the management of patient’s overall medication? If not, why?
- Has ePrescribing made it easier to detect adverse reactions to patients’ medication? If not, why?
- Has ePrescribing made it easier to detect drug-drug interactions in patients’
medication? If not, why?
- Has ePrescribing made it easier to detect duplicate therapy in patients’ medication? If not, why?
3. The principal benefits of ePrescriptions
In your opinion, what are the main benefits of ePrescriptions?
4. The principal problems of ePrescriptions
In your opinion, what are the main problems with ePrescriptions?
In your opinion, what aspects of ePrescriptions need developing?
5. Overall satisfaction with ePrescriptions
How satisfied are you with ePrescriptions as a whole?
(1=very dissatisfied, 6=very satisfied)?
1 2 3 4 5 6
- Would you prefer to go back to using old paper prescriptions?
Background information on physicians Year of birth _______
Working years______
30
30 Appendix 2 The inductive analysis process and sample comments by physicians.
Original comments Condensed version Sub-categories Main categories
#1 “…somewhat easier [prescribing] of course if you compare paper prescriptions because it [the information needed for prescribing] is available from the EPR...” (female)
Prescribing is easier because information is more readily available electronically
Electronic
procedure helps to issue prescriptions
ePrescriptions are convenient.
#2 “…paperwork logistics, i.e. office work, is significantly reduced…”
(female)
Less paperwork
#3 “…no longer any need to sign and stamp by hand…” (female) Less writing/stamping
#4 “It [ePrescribing] is very easy and smooth…you can easily collect from there [from the EPR] those prescriptions you’re going to renew or…
prescribe… and… for both physician and patient this is a very simple system if you compare, for example, to earlier practice when you had to renew prescriptions by phone and you called different pharmacies…”
(male)
Fewer phone call to pharmacies for prescriptions/renewals
#5 “…medicines can be retrieved at any pharmacy without a paper prescription…” (male)
Medicines available at any pharmacy without a paper prescription
Availability of ePrescriptions across the country and from any pharmacy
#6 “…it [renewal] is certainly easier because it [patient information] is there anyway in the EPR when prescribing, so in that way yes, in my opinion, it’s better than the paper system…” (female)
Renewal is easy because patient
information is readily available from the EPR
Prescription renewal is easy
31
31
#7 “…it’s very good that you can control the use of medicines [narcotics or CNS medicines] through the Prescription Centre and see when the patient has received the medicines… very significant improvement.”
(male)
Through the Prescription Centre you can check how the patient has used/retrieved (narcotics/CNS) medication
Controlling medicine use is
easier Prescribing and
controlling narcotics and CNS medicines has become easier
#8 “…prescribing [narcotics] is simple… prescribing is actually faster than writing a paper prescription…” (female)
Prescribing narcotics with ePrescriptions is easier (because there is no longer a need for a separate verified prescription form for narcotics and no longer a duty to keep a separate record for narcotics)
Technically simpler to prescribe
#9 “…I started typing just to be able to add one tablet [to dosing instructions]… I counted that had to press twenty keys before I was able to do it…without actually prescribing anything… but typing passwords, it slows things down a lot, it is not a matter of just typing things in - you always have to wait in between…” (female)
Making corrections is laborious (slow and requires many “clicks”)
Making changes (corrections/cancel lations) in
prescriptions is difficult
Technical problems in the ePrescribing system hinder prescribing.
#10 “…when you go through the ePrescription Centre, then it is slow…you have to wait and with every click a bit more waiting, so it [prescription correction] is pretty laborious…” (female)
Correcting ePrescriptions is laborious because it’s slow and you have to keep
“clicking”
#11 “…annoying… it [the software] wants the reason for the correction…
it really irritates me because you have to carefully justify everything, why are you doing this or that…” (female)
Annoying because the system/software requires reasons why prescriptions are being corrected
32
32
#12 “…you have to go to the ePrescription to correct it… but it [the correction] is not necessarily…, however, sent to the ePrescription Centre…” (male)
Changes are not sent automatically from the EPR to the Prescription Centre (corrections have to be made in both the EPR and the Prescription Centre)
#13 “…it [renewal] involves far too many clicks and confirmations…
jumping back and forth takes a long time…” (male)
Prescription renewal is slow because it involves many “clicks” and long waits
Renewing an ePrescription is difficult
#14 “…renewing a prescription… it takes too much time to send a prescription from the electronic patient record to the Prescription Centre… at least if there is more than one prescription… it’s very slow, it [the machine] just runs and ticks over…” (female)
Sending prescription renewals to the Prescription Centre takes too much time
#15 “…a prescription can’t be renewed if it’s sixteen months old, so you’re forced to write a new prescription.” (male)
ePrescriptions older than 16 months can’t be renewed so a whole new prescription has to be issued
#16 “Well, the biggest problem is that ePrescribing is very slow. It takes ages, like an hourglass emptying… the system’s just sending and sending [prescriptions to the Prescription Centre] (female)
ePrescribing is slow when sending prescriptions to the Prescription Centre
The link between EPRs and the Prescription Centre is slow
#17 “…[ the main problems] are related to information technology; if there are technical disruptions in connections, you can’t do anything [relating to ePrescribing]…” (male)
ePrescribing is impossible during technical disruptions
Technical system failures make working difficult
#18 “…for example… a forgetful patient… who may not be able to tell about all his/her medicines, so they are easy to check from there [Prescription Centre] (female)
Information about prescriptions is easy to check from the Prescription Centre (e.g.
patients with poor memories)
The Prescription Centre helps to collect information about patients’
prescriptions
Information about patients’
prescriptions is more readily
#19 “…finding out a patient’s medication and thus avoiding possible duplicate therapy is easier [thanks to the Prescription Centre]…” (female)
It is easier to avoid duplicate therapies through the Prescription Centre
33
33
#20 “…EPR checks drug-drug interactions and flags them if you’re prescribing a new medicine and there are some interactions…” (female)
EPR flags interactions when a new medicine is being prescribed
Physicians’ local EPRs support the evaluation of patient medication information held in the Prescription Centre
available through the Prescription Centre
#21 “…when I think about a patient’s overall medication… there’s just this problem that there are many players [health care units]… it’s quite messy this view of the Prescription Centre…” (female)
The view of the Prescription Centre (how a medication list is displayed) is messy because there can be ePrescriptions from
many health care units The layout of the Prescription Centre
is unclear Patient’s prescription information is incoherent in the Prescription Centre.
#22 “…there are [in the Prescription Centre] lots of prescriptions that are outdated and cancelled which are shown as a pile of prescriptions…”
(female)
The view of the Prescription Centre (how a medication list is displayed) is messy
#23 “…to maintain the Prescription Centre so that it shows up-to-date medication… it’s so difficult that it’s awkward trying to find medication.
The information probably isn’t valid at all.” (female)
Medication information in the
Prescription Centre is not updated Medication information not updated in the Prescription Centre
#24 “…probably not all changes are sent to the Prescription Centre…”
(female)
Not all changes [in ePrescriptions] are passed on to the Prescription Centre
