The group of Swedish physicians studied was generally satisfied with their specific EHR-system and with ePrescribing as such. However, we identified some problems that may affect the ePrescribing process, e.g. one quarter of the physicians seldom or never performed a final check of the ePrescription before transmission, the drug choice was perceived to be complicated, and there were different routines among physicians when cancelling ePrescriptions or in case of disrupted ePrescription transmission. Also, more than half of the respondents reported a lack of receipt from the pharmacy after successful transmission of the ePrescription. These weaknesses in the ePrescribing process warrant improvements of the provided EHR-systems per se, as well as of their implementation in the individual health care organisation, and the associated training for users.
The present study was not designed to quantify differences or to rank the six different EHR-systems. Rather, it was useful to identify general attitudes among users, and also to reveal strengths and weaknesses in the ePrescribing processes. We regard our study to reflect the situation for the Swedish physicians in 2007 in the selected health care regions but not to be representative for all physicians, since the population included was selected and thus not a random sample. However, physicians from 7 out of 21 health care regions and 4 different disciplines were included. Furthermore, the six EHR-systems included in the study dominate the Swedish market. We cannot exclude that attitudes and behaviour differ from other health care regions depending on the EHR-system used, the organisation, and how the prescribers are trained and supported.
The results should be regarded as hypothesis generating, depending on the non-random method of recruitment. Our selections of regions and clinical heads as well as the clinical heads' ways to provide us with e-mail addresses represent potential risks for selection biases. A random sample of physicians and a higher response rate would have improved the validity of the study. In contrast to many other countries, Sweden has a single-payer health care system which might result in a less complex ePrescribing process. Consequently, the generalisability of the results to other nations might be limited.
We did not collect data about how long respondents had used handwritten prescriptions, and we cannot exclude that some respondents had never used handwritten prescriptions. However, given that the ePrescribing systems have been implemented at one clinic at a time, mainly during the last five years, and physicians work at a number of different clinics during their education and further training, we estimate the probability that a substantial proportion of the respondents had never used handwritten prescriptions as small.
A majority of the respondents stated that ePrescriptions are time saving, in agreement with previous studies [1, 11, 12]. A study using time-motion techniques to compare prescribing times for paper-based prescribing and ePrescribing reported no differences in prescribing times [13]. In our study, more than 90% of the physicians felt they were able to offer their patients better service by ePrescribing. An example of the improved service according to the respondents is that patients are able to fill the prescription at any Swedish pharmacy.
The varying answers to the questions about cancelling prescriptions and disrupted ePrescription transmission might be explained by the lack of distinct routines and training. When cancelling prescriptions, prescribers should always inform the pharmacy and cancel the prescription in the EHR. How to proceed when the ePrescribing transmission is disrupted depends on which EHR-system the prescriber is using. In some EHR-systems, the prescription is automatically sent when the transfer is restored, in others this function is missing. The prescriber needs to be aware of how disrupted ePrescribing transmission is managed in his/her specific EHR-system; otherwise the result could be duplicate prescriptions or no prescription at all. The finding that 13% of the physicians perceived it possible to handle more than one patient at a time was hard to interpret, as all EHR-vendors state that this is impossible.
For some of the survey items, rare users of ePrescriptions were found to have more negative attitudes and extensive users more positive attitudes towards ePrescribing. Physicians transmitting more than five ePrescriptions per day were more positive towards ePrescribing than those prescribing less with respect to ease of use, time savings, and how clearly the patient's personal security number and name together with the price of the drug were displayed. A similar pattern was seen when analysing differences between prescribers who had used their EHR-system for less than a year and prescribers who had used it for more than a year; the more inexperienced users being more negative about ease of use and how the personal security number and name were displayed. One explanation to the differences in attitudes between these groups might be that physicians have to use the ePrescribing function regularly and extensively in order to fully appreciate it [14, 15]. The ePrescribing function of the EHR-systems might not be intuitive enough for being fully appreciated also by rare users.
ePrescriptions were considered as safer compared to handwritten prescriptions by the majority of the respondents; an opinion supported by others [11, 16–19]. However, prescribers and pharmacists need to be aware that EHR-systems may introduce new types of errors [16, 18, 20]. We revealed important weaknesses, which could be attributed to the user interface, special features in the EHR-systems or lack of distinct routines. None of the EHR-systems investigated was "perfect" overall. Some of these shortcomings might imply an increased risk for medication errors. Based on our findings, we suggest that:
-
The prescriber should get a receipt when the transmission is complete, and know how it is displayed.
-
It should be mandatory to check the ePrescription a last time before transmitting it to the pharmacy.
-
There have to be distinct routines how to handle situations when the ePrescription transfer is disrupted.
-
The EHR-system must clearly and unambiguously display the patient's name and personal security number.
To improve the ePrescribing process, there is a need for extensive guidelines and distinct requirements from the authorities. There is also a need for good cooperation between EHR-system software providers and health care providers to enable compliance to these guidelines. We believe that it is necessary to have a more formal certification procedure of EHR-systems and ePrescribing.
Since ePrescription during the last few years has developed to be the regular way to prescribe drugs in Sweden, repeated user studies are warranted aiming at further improvement of quality and security of the ePrescription process. We also recommend research studies for investigation of new types of prescribing errors, including risk assessment for patients.