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].
