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Electronic prescription system requirements: a scoping review

Abstract

Background

An electronic prescription system is a mechanism that has long been implemented in many countries around the world. In the present study, we reviewed the requirements, standards, and features of an electronic prescription system for its correct and accurate execution.

Methods

This scoping review was conducted according to the PRISMA-SCR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews). A comprehensive literature search was performed with the related keywords in Web of Science, PubMed, Scopus, and ProQuest with no time limit. The selection of papers was based on inclusion criteria. After removing duplicates, reviewing titles, abstracts, and full-text, 13 articles were included in the analysis.

Results

Electronic prescription system requirements extracted from the studies: Patient data, Patient selection or identification and data access, Drug Selection, Security, Privacy and administration, Transparency and accountability, Interoperability and communication, Monitoring, report, reminder, and renewals, Feedback at the prescriber level, Infrastructure: Computer equipment, Awareness of physicians and System support, Patient education and information, Usability, Standards, History of Medications / Current Medications, Data transfer and storage, Alerts and other messages to prescribers, and filtering of user-selectable alerts for possible prescription problems and Decision support.

Conclusions

The results of this study showed that the electronic prescription systems have several functional and technical capabilities that can provide significant benefits to all system’s stakeholders, including service providers, drug distributors, patients, and insurance organizations if used correctly.

Peer Review reports

Background

Electronic Prescribing is a broad term used to define either computer-based systems to write drug prescriptions, or comprehensive systems supporting the prescribing process [1]. The following are some of the benefits of e-prescription: improving the quality of health care services, increasing the efficiency and effectiveness of prescribing and dispensing medications, reducing medication errors, lowering health care costs, increasing patient safety, improving prescription, saving time for doctors, pharmacists, and patients, preventing adverse drug reactions, more precise dosage, monitoring how prescription drugs are prescribed, prescription abuse, and overprescribing [2,3,4,5]. The main steps to create and manage the electronic prescriptions are (1) a user (admin or doctor) sign-on, (2) the physician identifies the patient in the electronic prescription system. At this stage, the physician reviews the available data, (3) warnings and recommendations should be considered in the three activities of the electronic prescribing process, such as drug selection, parameter entry, and prescription signing, (4) the approved prescription was sent directly or indirectly to the pharmacy for distribution [6]. Systems must be able to interact with each other to share important information between health care centers. Multiple systems' inability to communicate information in standard forms and vocabularies has become a barrier to efficient electronic transcription deployment, highlighting the need for standards in the area of electronic transcription [7]. E-prescribing standards, like any structural component of health care, should be based on the extent to which they enable improvements in health care processes and outcomes [8]. All systems that are capable of electronically transmitting prescriptions share certain characteristics such as a need for connectivity. Most systems will require dedicated telephone lines or broadband Internet connectivity, a potential problem in more remote areas. All of them will require a computer, modem to connect to the telephone (usually dedicated digital subscription line) or Internet (via digital subscription line or cable), and likely a router. The need for connection may establish a single point of failure, rendering the whole system useless in the event of a malfunction, especially for applications that operate as application service provider systems [9]. Studies showed that pharmacopeia and insurance information standards to achieve the desired results in electronic prescribing are necessary but not sufficient, so more work needs to be done on medication or pharmacopeia and insurance information standards to increase patient safety. Additionally, incentives should be given to enable good communication between organizations engaged in prescription and payment for drugs, so that the full advantages of the electronic prescribing system may be realized via timely, patient-centered communication across these systems [8]. Wang's research demonstrates that currently existing electronic prescription systems lack a number of functional characteristics that might have a substantial impact on patients' health and expenditures. More importantly, these deficiencies varied a great deal among the systems studied. They suggest that standards for electronic prescribing should include a set of minimal functional capabilities; because would guarantee a minimal level of support for patient safety and protect against biases of third-party [10].

Regarding we did not find an analysis of the requirements for the optimal operation of electronic prescribing systems so this study was conducted to identify the requirements of the electronic prescribing system.

Methods

This scoping review was conducted by the PRISMA-SCR (Preferred Reporting Items for Systematic Reviews and Meta-Analyses Extension for Scoping Reviews) [11] and Arksey and O’Malley’s framework [12]. The framework includes 1. identifying the research questions, 2. identifying relevant studies, 3. study selection, 4. data charting, 5. collating, summarizing, and reporting the results. According to this framework, comprehensive coverage of a subject should be provided, and its purpose is to identify all relevant literature without considering the design of the study. This study includes the following steps:

  • Step 1: Identifying the research questions

Consultation and exchange with the research team were used to identify the main research question. The research questions were designed in such a way that include requirements, standards, and key features of the electronic prescribing system. In other words, the questions were selected in accordance with the objectives of the research.

Research questions include:

  • What are the features of the electronic prescribing system?

  • What are the requirements and standards of an electronic prescribing system?

  • What are the recommendations for the electronic prescribing system?

The inclusion criteria for studies were:

(1) Quantitative, qualitative, mixed-method, and review published studies, original and gray texts including thesis, proceedings, and reports, (2) studies published in English, and (3) studies whose full text was available for data extraction.

The exclusion criteria were as follows: (1) studies in languages other than English, (2) studies whose full text was not available.

  • Step 2: identifying the relevant studies

The main researcher and an expert person with a background in review studies (an experienced health economist) helped develop a keyword search protocol. The two researchers independently conducted extensive and comprehensive searches in the electronic databases of Web of Science, PubMed, Scopus, and Proquest, regardless of the period up to date 2021-06-19 to identify relevant studies. The following keyword combination was used for the search. Moreover, search terms were customized for each database individually.

"Prescribing Electronic", "Electronic Transmission of Prescriptions," "Electronic Prescription", "Electronic medical prescription", "Electronic prescription system", "Electronic Prescription Service", "On-line prescribing", "Characteristics", "Requirements", "Concept", "Features", "Standards", "Recommendation", "guidelines", and "criteria"

We entered the results into referral management software (EndNote X8.2) and removed duplicates. Two team members reviewed and verified the search results. All search procedures and results were documented.

  • Step 3: Study selection

After implementing the search strategy, the first stage of the selection process was performed; two researchers independently reviewed the titles and abstracts of all studies and screened them based on inclusion and exclusion criteria. A third party resolved the disagreement regarding the Competency of the documents. To assess how the screening process is progressing, a regular discussion among research team members was conducted. Unrelated studies were discarded and the full text of the remaining studies was reviewed. Two individuals independently reviewed the full text of these studies to confirm their relevance (Fig. 1).

  • Step 4: data charting

Fig. 1
figure 1

Flowchart of study retrieval and selection process (adapted from PRISMA)

The data extracted from each study include the following: title, author (s), date of publication (year), place of study, type of study, type of document, and key findings.

  • Step 5: collating, summarizing, and reporting the results

This step includes gathering, summarizing, and reporting the results. To create and develop a framework for summarizing and combining data and summarizing results, researchers should prioritize specific aspects of the literature [12]. This study used a thematic analysis approach to collating and summarizing the findings. First, one researcher (Ma.V.) read all the records, annotated them, and identified topic categories. the same researcher re-read and finaled all of the records listed under each topic category. To establish trustworthiness, a second researcher (E.H.) verified the analysis for the records listed.

Results

The data collected from the databases were as follows: 4546 records from Web of Science, 2412 records from PubMed, 6100 records from Scopus, and 365 records from Proquest. A total of 13,435 original articles and gray texts were found. 6998 records were duplicates and had been removed. By examining the titles of the texts, it was determined that 6333 entries did not meet the inclusion requirements and were thus eliminated. The remaining 104 items were evaluated for their titles and abstracts. 19 full-text papers were retrieved and evaluated, and six records were excluded due to conflicts with the research's goal. Also the full texts of 4 of them were not found. Finally, 13 papers were chosen for the analysis of the complete review. The oldest study was published in 2000, and the most recent study was published in 2015. Among the studies reviewed, 8 studies were original articles [10, 13,14,15,16,17,18,19], 3 studies were reported [20,21,22], 1 study was editorial [23] and 1 study was a review article [24]. 6 studies (%78) were conducted in the US [10, 13, 14, 20,21,22] and the rest of the studies were carried out in various other countries, as listed in Table 1.

Table 1 General characteristics of the studies included in this research

After conducting the research steps, electronic prescription system Features, requirements, standard, recommendations or capabilities were extracted from the studies: Patient data, Patient selection or identification and data access [10, 13, 14, 16], Drug Selection [13,14,15,16, 18, 24], Security, Privacy and administration [10, 14,15,16, 18], Transparency and accountability [10, 14, 16], Interoperability and communication [18], Monitoring, report, reminder, and renewals, Feedback at the prescriber level [10, 13, 14, 16], Infrastructure: Computer equipment, Awareness of physicians and System support, Patient education and information, Usability [10, 13, 14, 16,17,18, 20, 21, 23], Standards [20, 22, 24], History of Medications / Current Medications [10, 14], Data transfer and storage [10, 14], Alerts and other messages to prescribers, and filtering of user-selectable alerts for possible prescription problems and Decision support [13,14,15,16, 18] (Table 2).

Table 2 Features, requirements, standards, recommendations, and capabilities for the electronic prescribing system

Recommendations for improving the electronic prescription system see in Fig. 2 (Fig. 2).

Fig. 2
figure 2

Recommendations for improving the electronic prescription system

Discussion

The purpose of this research was to use the scoping review approach to ascertain the needs for an electronic prescription system. The findings of this research indicate that the following needs should be addressed while developing an electronic prescription system: Patient data, Patient selection or identification and data access, Drug Selection, Security, Privacy and administration, Transparency and accountability, Interoperability and communication, Monitoring, report, reminder, and renewals, Feedback at the prescriber level, Infrastructure: Computer equipment, Awareness of physicians and System support, Patient education and information, Usability, Standards, History of Medications / Current Medications, Data transfer and storage, Alerts and other messages to prescribers, and filtering of user-selectable alerts for possible prescription problems and Decision support. One of the requirements in this study is patient identification, which is usually the first step of electronic prescribing [13]. Prescribers often make mistakes when choosing from menus, and as a result, inadvertently choose the wrong patient. Errors are reduced when there is a detection and correction system [25]. Since the reduction of errors in the electronic prescription system is one of the main advantages of this system, so the correct identification of the patient is one of the main requirements.

One of the requirements of electronic prescription system identified in this study is safety alerts and filtering of user-selectable alerts for possible prescribing problems. Safety alarms in the system dramatically reduce allergy errors and drug selection [26]. Adequacy of system alerts should be considered as one of the main requirements. Repeated and excessive error messages are likely to reduce users' sensitivity to them. Moreover, when there is a reasonable reason for the warning displayed, prescribers will no doubt accept a higher percentage of drug interaction alerts.

Another requirement that we achieved in the present study was computer-assisted dose calculations, increasing prescribing accuracy [27, 28]. However, appropriate calculations require electronic prescription systems to access medical records data such as age, weight, BMI, and laboratory results that reflect renal and hepatic function [29].

Data transfer and storage were identified as one of the recommendations to improve the electronic prescribing systems. Transmitting data electronically from prescribing systems to pharmacies led to eliminating human transcription errors, and improving safety and efficiency. However, errors or physician work might increase if transmissions are unreliable or if prescribing data is entered manually at the pharmacy [13]. Proper transfer of data to the pharmacy or in other words entering the electronic prescription by the physician (instead of the prescription being written by the physician and the pharmacy entering the pharmaceutical items in the system) is necessary, especially in the countries that have recently worked with this system.

Providing infrastructures, such as computer equipment, system support, patient education, information, and user education were identified as features of the electronic prescription system. Well-designed training materials can reduce outpatient errors. The systems which facilitate physician-nurse-pharmacist collaboration in patient education can increase compliance [30]. Unfortunately, in developing countries, because of users' resistance to change, their educability is affected. On the other hand, the low speed of the national Internet in such communities is one of the underlying causes for the failure of projects. Therefore, much attention to the main infrastructure of this system is a key factor.

The research cited prescriber input as a guideline for enhancing electronic prescription systems. Prescription systems that have access to pharmacy data may alert doctors when patients fail to complete prescriptions on time, allowing physicians to probe patient non-compliance. However, physicians presently lack this capability [31, 32]. Numerous computerized tools, like as reminders, feedback, and treatment suggestions, as well as patient care based on established protocols, may help physicians improve their prescription [33].

Data security and confidentiality were identified as the key requirements in the implementation of electronic prescription systems. Security and privacy are two key challenges that electronic health systems face [34]. Security of medical data can be controlled easily by healthcare organizations; however, if medical data is to be transmitted to some other healthcare institution then some third party may compromise with the security and privacy of medical data [35]. There is no doubt that patient privacy is necessary, but with the emergence of various applications that help users to better implement electronic prescribing should be accompanied by caution and compliance with legal issues.

Another requirement identified in the present study was the drug selection and the history of current drugs/drugs in the electronic prescription system. Drug lists included in e-prescriptions should be precise and clear, and the system should include patient follow-up about medications that were previously prescribed [36]. Electronic prescription is suggested to improve proper medication adherence and access to medication history [24]. The physician's knowledge of the patient's medical history, especially in the case of chronic or special patients, is particularly important.

Another essential requirement of the electronic prescription system that we achieved in this study was decision support. Clinical decision support in electronic prescribing systems that provide physicians or patients with clinical knowledge and are presented at appropriate times can improve the safety, quality, efficiency, and cost-effectiveness of care. However, these potential benefits have not been fully realized [20]. Of course, decision support seems to act as a double-edged sword. Because on the one hand, it guides and helps the doctor in making decisions, and on the other hand, it confronts the doctor with limitations. In other words, the physician's decision is influenced by the support system and he cannot diagnose and treat independently. While, the system may not be able to cover a wide range of medical science.

Transparency and accountability were identified as other important requirements for the implementation of an electronic prescription system. Wang et al. panel’s recommendations included several related to transparency and accountability in the electronic prescription system, which prevent third parties from introducing prescribing biases that would not benefit patients, because vendors can substantially influence prescribing decisions [10]. Transparency in system alerts and messages is an essential part of electronic prescription and should be such that there is no conflict of interest.

The standards for the implementation of an electronic prescription system were identified. Formulary and Benefit (F&B) standard provides data for drug insurance benefits plans as opposed to data about individual patients which is necessary to enable the display of coverage information for each medication in the pick-lists that prescribers use to make initial medication choices. SCRIPT standard provides prescribers with information about patients’ current and past medications by listing the pharmacy claims that the patient's health plan has paid for. SureScripts now enforce this standard to list drug purchases beyond what is paid for by insurance. The prescription fill status notification standard is rarely used among electronic prescription systems. This transaction, initiated by the pharmacy, is designed to inform the prescriber of pharmacy events, including distribution, partial distribution, or non-distribution for the original prescription and refill. Prior authorization (PA) standard in electronic prescription systems refers to the process of requesting approval for a prescription’s coverage from the health plan or PBM [22]. RxNorm standard is a drug nomenclature that was created by the National Library of Medicine to standardize the representation of clinical drugs, distinguishing drugs based on their therapeutic or diagnostic intent [8, 22]. The Structured and Codified Sig standard is intended to provide an interpretable representation for the patient instructions portion of a prescription, thereby enabling more automated safety checking, improved communication between prescribers and pharmacists, and better efficiency of prescribing, renewal, and dispensing activities [22]. Wang et al. findings indicate that federal standards for electronic prescribing could best advance patient safety, health outcomes, and health care efficiency by including a minimal set of functional capabilities along with the more technical standards for system interoperability [10].

Limitations

This study had its limitations. We could not access the full text of some of the studies. Although we contacted the authors by email and telephone, we did not have access to the full text of their articles. Another limitation of this study was the lack of university access to the Embase database, so this database was not searched in terms of the lack of subscription at the university.

Conclusion

This paper discusses the prerequisites for implementing electronic prescription systems correctly, accurately, and completely. The findings of this study indicated that existing electronic prescription systems possess a variety of functional and technical capabilities that, when properly identified and utilized, can result in significant benefits for all system stakeholders, including service providers, drug distributors, patients, and insurance organizations. It is advised that each of these needs be carefully considered when designing electronic prescription systems to ensure their quality and safety. Additionally, legislators, decision-makers, and insurance companies may utilize the set of needs established in this research to build assessment criteria for the electronic prescription system.

Availability of data and materials

All data generated or analysed during this study are included in this published article.

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Acknowledgements

We would like to thank the Mashhad University of Medical Sciences Library for providing the resources to help us in setting up and conducting this review study.

Funding

This work is a part of a Ph.D. dissertation supported by Mashhad University of Medical Sciences (Grant Number: IR.MUMS.FHMPM.REC.1400.054).

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Authors

Contributions

MaV screening of titles, abstracts, and full text of articles for inclusion in the study, the thematic analysis and drafted and reviewed and approved the submitted manuscript. MeV conducted the database search, the thematic analysis and drafted and reviewed, and approved the submitted manuscript. MM, JJ and EH participated in the thematic analysis; critically revised the manuscript, drafted and reviewed, and approved the submitted manuscript. AV participated in the screening of titles, abstracts, and full text of articles for inclusion in the study, conducted the thematic analysis; the project administration, supervision the project, drafted the manuscript, and reviewed and approved the submitted manuscript. All authors read and approved the final manuscript.

Corresponding authors

Correspondence to Elaheh Hooshmand or Ali Vafaee-Najar.

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The authors declared that they have no competing interests.

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Vejdani, M., Varmaghani, M., Meraji, M. et al. Electronic prescription system requirements: a scoping review. BMC Med Inform Decis Mak 22, 231 (2022). https://doi.org/10.1186/s12911-022-01948-w

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Keywords

  • Electronic prescription
  • Requirements
  • Standards