A review of the literature and proposed classification ...

Research in Social and Administrative Pharmacy j (2015) j–j

Review Article

A review of the literature and proposed classification on e-prescribing: Functions, assimilation stages, benefits, concerns, and risks Pouyan Esmaeil Zadeh, Ph.D.a,*, Monica Chiarini Tremblay, Ph.D.b a

Decision Sciences and Information Systems, College of Business Administration, Florida International University, 11200 SW 8th Street, RB 261B, Miami, FL, USA b Decision Sciences and Information Systems, College of Business Administration, Florida International University, 11200 SW 8th Street, RB 250, Miami, FL, USA

Abstract Background: Evidence from the literature indicates that besides its benefits, e-prescribing also generates new types of unintended medication errors that have the potential to harm patient safety. Analyzing both the benefits and risks of e-prescribing can give health care organizations a better understanding of the improvements gained and errors generated by this technology. Objectives: To review the primary functions of e-prescribing and its assimilation stages in the health care context. This review also aims to classify the potential benefits, risks and concerns associated with eprescribing along with factors contributing to e-prescribing errors. Methods: A literature review was conducted primarily in Web of Sciences electronic databases. The online databases were searched for both peer-reviewed quantitative and qualitative research papers written in English and published between January 2008 and December 2014 (i.e., the last seven years). Several additional studies were also accessed through Google Scholar and the citations of the selected articles. A total of 73 publications met the study’s inclusion criteria. Results: The key benefits of e-prescribing were identified as improving the quality of health care services, increasing the efficiency and effectiveness of prescribing and dispensing medications, reducing medication errors, and health care cost savings. Failure to properly implement e-prescribing systems can also result in new types of errors that reduce workflow efficiency, increase medication cost, and threaten patient safety. In this study, factors contributing to potential errors were categorized into four primary groups (human, technical, interaction and organizational errors). Conclusions: This review identified the primary benefits and risks of e-prescribing services. The study contributes to the body of knowledge related to the design, adoption and use of e-prescribing by providing a clear reflection on its potential gains and risks. Based on the findings of this review, conducting research in several areas is quite promising as future work. This review also

* Corresponding author. Tel.: þ1 305 348 2830. E-mail address: pesmaeil@fiu.edu (P. Esmaeil Zadeh). 1551-7411/$ - see front matter Ó 2015 Published by Elsevier Inc. http://dx.doi.org/10.1016/j.sapharm.2015.03.001

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Esmaeil Zadeh & Tremblay / Research in Social and Administrative Pharmacy j (2015) 1–19

has practical implications for health care providers, e-prescribing software vendors and policy makers. Ó 2015 Published by Elsevier Inc. Keywords: E-Prescribing; E-Prescription; Prescribers; Pharmacies; Benefits; Risks; Assimilation stages; Medication errors

Introduction E-prescribing is a system that facilitates the interaction between physicians and pharmacies by enabling physicians to create and pass on prescriptions electronically to pharmacies.1,2 The growth of the e-prescribing adoption rate demonstrates that almost 34% of all US office-based prescribers used computers to generate and transmit prescriptions to pharmacies electronically by 2010.3 Due to the allocation of funds aimed at encouraging the adoption and implementation of e-prescribing systems, the number of e-prescription receipts in US pharmacies grew by 72% between 2009 and 2010.4 According to the US national progress report on e-prescribing, the total number of transmitted e-prescriptions to community pharmacies increased by 27% from 2007 to 2012 in the United States.4 Medical errors are capable of creating severe harm that injures one million patients and result in 44,000 deaths yearly just in the US.5 Medical errors have a number of subcategories; one of these is medication errors, which are considered to be the main reason for approximately 7000 deaths yearly.5 These types of errors can affect care planning as well as the length of treatment, which in turn leads to higher priced health care services.6 Medication errors have several dimensions, one of which is classified as prescription errors.7,8 E-prescribing enables direct communication between physicians’ offices and pharmacies via computers to increase efficiency and reduce errors.9 Although a well-implemented e-prescribing system can reduce errors related to illegible handwriting, the technology itself can introduce new types of e-prescribing errors such as the incorrect entry of dosing directions, drug quantity or patient’s information.10 E-prescribing services are mainly used to improve patient safety and prevent medication errors, but they can also generate some additional errors and unintended consequences for pharmacies and patients. The occurrence of some unintended e-prescribing errors is inevitable; however, evidence shows that 9% of e-prescriptions contain medication errors.4 Therefore, despite the potential benefits of e-prescribing in improving the

quality of health care and large investments in the development of this project, e-prescribing systems have not been adopted as expected.11 More research is required to provide insights into health care providers’ decisions to adopt and use e-prescribing in their practices.12 The literature reflects that little is known about the unintended consequences of e-prescribing technology in community pharmacies and further research is required to understand the true benefits and risks of e-prescribing in the context of community pharmacies and hospitals.13 Furthermore, e-prescribing errors and potential benefits are not classified in prior reviews on e-prescribing. For instance, a systematic review by Ammenwerth et al14 describes the general effect of e-prescribing on medication errors and concludes that e-prescribing can reduce the risk of medication errors. A review by Clyne et al15 examines the current evidence related to the use and gains of e-prescribing to reduce inappropriate prescribing for older people. Kannry16 shows that although e-prescribing can reduce medication errors, it also can be a source of new type of errors. Johnson et al17 discuss some of the limitations and potential benefits of e-prescribing systems in pediatrics and Papshev and Peterson18 examine advantages and obstacles to e-prescribing in the ambulatory care setting. Caldwell and Power19 explain the benefits and concerns related to the use of e-prescribing in the pediatric setting. They indicate that more study is required to identify and optimize the benefits and minimize the unintended consequences of e-prescribing. Odukoya et al20 explain e-prescribing errors and their potential consequences in community pharmacies. Consistent with their study, there is a significant need to apply a national reporting and learning system to better understand e-prescribing functions, errors, concerns, benefits and safety. Therefore, additional research is needed to address the main functionality, benefits and risks of e-prescribing services to better utilize the system and prevent e-prescribing errors from reaching patients. It is the aim of this review study to examine the current literature relating to the function and assimilation steps of e-prescribing


systems, discuss e-prescribing benefits, risks, and concerns, and classify factors contributing to e-prescribing errors in the health care setting. Methods Eligibility criteria To meet the research objective, the authors reviewed existing qualitative and quantitative studies focused on e-prescribing implementation, benefits and risks. In the literature review process, editorials and articles without an abstract were excluded, as were studies that were not primarily related to e-prescribing (such as issues related to prescription setting) or were written in languages other than English. Therefore, the publications were mainly extracted based on their relevance to e-prescribing functionalities, its risks, concerns and benefits, as well as the year of publication from 2008 to 2014, during which time HIT efforts, especially e-prescribing, were significantly planned and developed. Owing to the rapid pace of change in HIT, we limited our search to the last seven years, although some key earlier studies were also cited based on their significant results and if no new research had been conducted. Therefore, the search selection criteria were fourfold, as follows: English language, abstract inclusion, year of publication, and direct relevance to e-prescribing systems (addressing e-prescribing adoption, usage, risks or benefits). Search strategy Under consideration were the existing studies, beginning with a Web of Sciences search for the keywords of electronic prescription, e-prescription, electronic prescribing, and e-prescribing. Google Scholar also was searched with the same search keywords to expand our research beyond the journals indexed by Web of Sciences. The search was repeated until no new studies were found based on the selection criteria. Screening and classification Initially, beginning, article abstracts were reviewed to exclude manuscripts that did not meet the eligibility requirements. Then, articles consistent with the aim of the review, i.e., those that addressed the main functions, assimilation stages, benefits and risks associated with e-prescribing systems, were read in their entirety to be included in conducting this review. We also examined the relevant references in the selected articles. The definition of e-prescribing used to screen articles was that of a system of

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communicating the medicine choices of patients that transmits e-prescriptions electronically via a secure network between physicians and pharmacists.13 To better screen the publications, the included articles were categorized into six main categories according to their abstracts. The six groups were: e-prescribing functionalities, e-prescribing benefits, e-prescribing risks and concerns, e-prescribing assimilation stages (such as factors affecting e-prescribing adoption and implementation), e-prescribing error producing factors and mixed results. In the last category (e-prescribing mixed results), the studies not only addressed e-prescribing benefits but also explained risks and concerns. Therefore, we divided the research into five sections to review the e-prescribing functions, assimilation stages, benefits, and risks and concerns, as well as factors contributing to e-prescribing errors accordingly. The core benefits risks and concerns extracted from the articles were transferred into a Microsoft Office Excel spreadsheet. This method allowed the authors to better analyze and categorize the core benefits and risks that were retrieved from the publications. Selection of studies During the search period, 154 records were retrieved through database searching. To expand the search, 41 additional studies were added from articles indexed by Google Scholar. After excluding 64 duplicates and non-English articles, we screened the titles and abstracts of a total of 131 studies and excluded 57 papers based on the initial exclusion criteria (not relevant abstracts, years of publication, and not relevant/applicable setting). The selected papers (74 studies) were reviewed in full and assessed for eligibility. To obtain the final included studies, 16 articles were further excluded mainly because of their focus on prescription-related issues rather than e-prescribing, and having too-general discussions or offering no clear theoretical and practical contributions. An additional 15 articles were also added for full-text review that were accessed from the bibliographies of included studies. Finally, 73 studies were included in qualitative synthesis. The following figure (Fig. 1) shows the study selection flow diagram. Results Characteristics of studies Seventy-three papers published between 2008 and 2014 met the inclusion criteria. Overall, 12 of the 73 articles (16%) mainly focused on e-prescribing gains and benefits. A total of 14 articles (19%)


IdenƟficaƟon

4

ArƟcles idenƟfied through Web of Sciences database searching (n = 154)

AddiƟonal arƟcles idenƟfied through Google Scholar (n = 41) Records excluded

Screening

Duplicates and non-English removed (n = 64)

Title and abstract screened (n = 131)

Eligibility

Full-text arƟcles assessed for eligibility (n =74)

because of iniƟal exclusion criteria (not relevant abstracts, years of publicaƟon, unrelated to any health fields) (n = 57 )

Full-text arƟcles excluded with reasons (n = 16 )

Included

CitaƟon lists of included arƟcles =15 Studies indicated in qualitaƟve synthesis (n = 73)

Fig. 1. Selection strategy for the review.

directly referred to various types of e-prescribing errors, cost and risks. Five articles (almost 7%) described e-prescribing error producing conditions and factors. Eleven articles (almost 15%) were related to barriers and contributing variables affecting e-prescribing adoption and implementation. A total of 31 studies (almost 43%) addressed both the benefits and risks of using e-prescribing compared to traditional prescribing methods. The majority of the included studies were conducted in North America (almost 64% in the United States and 4% in Canada), 16% addressed e-prescribing systems in European centuries, 9% in the Asian context, and the remaining 7% discussed e-prescribing issues in Australia. Tables 1–3 represent the study designs, practice setting, and professional groups. Thirty-nine studies used a qualitative study design over a methodological range from various types of literature reviews, conceptual and reflective papers to studies using interview observations. Sixteen papers described their findings based on a quantitative study design that consisted of a paper-based questionnaire (twelve) or an Internet survey (five). Eighteen studies used a mixed methods

design that consisted of focus groups and surveys or direct observation and surveys (Table 1). The included studies were conducted in a variety of settings and based on various sample sizes. The four most common practice settings identified were community pharmacies (n ¼ 21), followed by hospital-based settings (n ¼ 14), primary care clinics (n ¼ 12), and private practices (n ¼ 9). The remaining three settings in the Table 1 Study designs of included studies Study design Qualitative

Method

Interview Direct observation and follow-up interview Conceptual or reflective paper Literature review Quantitative Survey Mixed (qualitative Focus group and and quantitative) survey Direct observation and survey

Number of studies 16 12 4 7 16 10 8

Esmaeil Zadeh & Tremblay / Research in Social and Administrative Pharmacy j (2015) 1–19 Table 2 Practice settings of included studies Practice settings

Number of studies

Community pharmacies Hospital-based Primary care clinic Private practice Ambulatory care clinic Hospital owned-office based University health center

21 14 12 9 8 6 3

included studies were ambulatory care clinics (n ¼ 8), hospital owned-office based (n ¼ 6) and university health centers (n ¼ 3) (Table 2). Pharmacists were the professional group most frequently targeted in the included studies (19), alone, or along with pharmacy staff (7). The pharmacy staff was another identified group in fourteen studies. Twelve papers presented the results of studies conducted with physicians and nine papers considered physicians along with nurses. The remaining studies used clinicians and medical office staff (n ¼ 8) or a multidisciplinary advisory team (clinicians, pharmacists, and researchers) (n ¼ 4) as professional groups (Table 3). Key findings The benefits, concerns and risks of using e-prescribing were classified according to the information extracted from the included studies and organized in a Microsoft Office Excel spreadsheet. The key results present the main benefits, risks and concerns associated with e-prescribing in two tables (Tables 4 and 5) as follows: Discussion Consistent with the research objective, the core components of this study are discussed in a Table 3 Participants/professional groups of included studies Participants/professional groups

Number of studies

Pharmacists Pharmacists and pharmacy staff Pharmacy staff Physicians Nurses and physicians Clinicians and medical office staff Multidisciplinary team (clinicians, pharmacists, and researchers)

19 7 14 12 9 8 4

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narrative review format based on five categories, as follows: a) review of how e-prescribing systems work, b) e-prescribing assimilation stages, c) benefits gained from e-prescribing services, d) risks and concerns associated with e-prescribing systems and e) classification of factors contributing to e-prescribing errors. Review on the function of E-prescribing systems On the basis of a rich body of current literature related to e-prescribing functionalities, a model was developed called 3Ps to better explain how e-prescribing works. The model shows the main function of e-prescribing and how the three Ps (prescriber, pharmacy and patient) are connected via e-prescribing systems. The model is explained using a triangle: the three main sides show the relationship among the three Ps and three additional sides that depict the interface between the Ps and the e-prescribing system. The first side (1) explains the interaction between physicians and patients. During the appointment time, physicians examine a patient for symptoms and signs. If it is the patient’s first visit and there is no medication history, the physician seeks more information including demographic information, allergy list, medical history and so forth. The physician (or the medical technicians or nurses) then enters the information into the electronic health record (EHR) system with e-prescribing. Side (a) shows the interface between the prescriber and e-prescribing system (integrated or stand-alone prescribing system). If is it not the first consultation visit with the patient, the prescriber is able to retrieve the patient’s information from the certified EHR with e-prescribing capabilities. Thus, the patient eligibility, formulary, and medication history/fill status will be provided to the prescriber. The main difference between traditional paper prescribing and e-prescribing is the availability of mandatory fields, the drug selection process and the presence of basic clinical decision support (CDS).21 Allergy details, patient weight, dose, and route are the required inputs for e-prescribing. Medications are selected from a menu that includes names of approved medications, strength, and formulation. A drug monograph (including information on use directions, interactions, dosage and side effects) is available for prescribers through e-prescribing systems. The CDS for e-prescribing can provide drug allergies, dose calculation functions, and drug–drug

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Table 4 Classification of e-prescribing benefits Benefits

Percentage of studies

Medication error rate reduction Saving health care costs Improving the quality of healthcare services and patient safety Facilitating the coordination of care and communication with other providers Cutting pharmacy costs through reduced redundancy Improving the efficiency in the workflow of prescribers Speeding up prescription refill requests Facilitating the management of medication stocks Informing prescribers about patients’ insurance coverage Improving patient convenience Checking patient adherence to medication to complete treatments Facilitating clinical decision making by providing decision support features (such as checking for drug–drug, drug-allergy and drug–dose interaction) Providing updated information about medication formularies Reducing wait times and increasing patient satisfaction with pharmacies Reducing the possibility that prescriptions are erased or lost

83% 81% 76% 68% 63% 57% 48% 41% 36% 32% 30% 26%

interactions as well as exact and therapeutic drug duplication alerts.21 Once the e-prescription is ready it should be checked to ensure the right patient, right drug, right dose, right route, right frequency, and right date have been entered. Side (b) shows the interface between pharmacy and eprescribing system when the prescription is electronically transmitted to a pharmacy selected by the patient. The reimbursement agency will be

21% 18% 11%

notified automatically through a notification sent by the e-prescribing system when an e-prescription is issued.11 The medical prescription is issued directly to the patient if he or she does not specify a pharmacy.22 In the case of patients who need to refill their prescriptions, they no longer need to visit their physicians to collect their prescription. They can pick up the medications from the pharmacy of their choice, resulting in time and cost

Table 5 Classification of e-prescribing risks and concerns Risks and concerns

Percentage of studies

Failure to properly implement e-prescribing Cost of e-prescribing implementation and maintenance Emergence of e-prescribing errors (such as wrong strength, wrong quantity, dose and drug selection, direction, duplicate e-prescriptions) Lack of standardized e-prescribing software Threats to patient safety due to inappropriate drug therapy Increasing medication cost Increasing work responsibilities and imposing an excessive burden for pharmacy personnel (such as performing additional checks involved in error recovery) Reducing pharmacy workflow efficiency due to additional transaction cost Time required to integrate e-prescribing into workflow Lack of computer support services Distracting e-prescribing system design features (such as poor drop-down menus, screen design and inaccurate patient medication) Heterogenous e-prescribing database management systems Unclaimed e-prescriptions Complicated EHR systems with robust CDS for e-prescribing The cost of training for medical staff The restrictions placed on prescribing controlled substances electronically

76% 69% 65% 57% 53% 50% 44% 38% 31% 28% 25% 23% 21% 18% 16% 12%


saving. Side (3) of the triangle shows the relationship between pharmacy and patient. Side (2) indicates the relationship between prescriber and pharmacy. Pharmacists and technicians need to learn the new types of errors that can occur through the use of e-prescribing systems to better detect errors.23 Pharmacists and pharmacy staff are the last check layer to detect medication errors before reaching out to patients. They can use different methods to confirm the prescription with the prescriber, or can ask for clarification or that the prescription be re-entered. E-prescriptions can be confirmed via fax, phone, and online or network checking if the phone is busy. Side (c) shows the interface between the system and patents. When the prescribed medications are ready at the pharmacy, the system can send an alert to the patient to collect the medicine. The e-prescribing system will then send a notification to show dispensing status by automatically alerting prescribers if the patient has collected a prescription (part of side a). If they have not picked up a prescription, physicians would call the patient to explain the serious medical implications of not taking the drug, or address the consequences at the next visit (part of side 1). The following figure (Fig. 2) depicts the main function of e-prescribing systems: E-prescribing assimilation stages The adoption of e-prescribing system among pharmacists is rising but has yet to meet the requirement recommended by the Institute of Medicine to generate and transmit all prescriptions electronically by 2010.3 To achieve the incentive designed in the meaningful use of HIT, physicians are supposed to transmit at least 40% of prescriptions

to pharmacies through a certified e-prescribing system.24 In 2012, an e-prescribing incentive program began to use penalties as Medicare payment adjustments for health care professionals who did not use e-prescribing systems in their practice. Some studies report that even with the presence of incentives and penalties, several pharmacists have yet to adopt e-prescribing services.11,12 Several pharmacists seemed to have accepted the e-prescribing system but continued to manage prescriptions using the conventional paper-based method. The main reasons were reported as perceived risk of safety issues and technology mismatches between prescribers and pharmacists.25 This reflects that if pharmacists perceive no safety gains from e-prescribing systems or if they experience any technology incompatibilities with prescribers, they may switch to conventional prescriptions in the presence of an e-prescribing system. To explain the status of e-prescribing adoption, the authors borrowed the assimilation conceptualization from a study conducted by Bala and Venkatesh.26 Consistent with the framework developed in their study, the assimilation of a technology can be conceptualized according to four stages: awareness, adoption (rejection), limited deployment, and general deployment. We applied this framework in this context to better discuss the assimilation of e-prescribing based on the four distinct stages as follows: 1. Awareness: the level of awareness is associated with key decision makers’ initial understanding of and familiarity with the existence of e-prescribing services. For instance, if hospitals or community pharmacies become aware of this technology, they may perform a formal evaluation or

Prescriber

Asking for clarificaon or re-entering prescripons

(a)

(1)

Consultaon with paents

Integrated or stand-alone eprescribing system

(2)

(c)

(b)

7

Pharmacy

Pa ent (3)

Dispensing medicaons

Fig. 2. The 3Ps model.

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join a trial step that is usually initiated by policy makers and promoted by vendor organizations. 2. Adoption (rejection): the initial cost-benefit analysis is performed by the health care institutions considering the potential challenges and opportunities of e-prescribing. According to the results, institutional decision makers may adopt e-prescribing technology to make changes in their organizational processes, or they may reject it. If the perceived costs exceed the potential benefits, they may decide not to adopt, meaning that compared to manual forms of prescribing, e-prescribing services are not always advantageous to health care organizations. The costs can range from the initial investment to challenge of unintended prescribing errors that put patient safety at risk. The perceived benefits can also range from a reduction in medication errors to improvement in efficiency and performance. 3. Limited deployment: in this stage, hospitals or community pharmacies that have already adopted the e-prescribing technology may implement it in certain portions of their workload. They may try to handle prescriptions partially using e-prescribing systems while still using other traditional methods to transmit prescriptions such as faxes or paper-based methods. Especially when physicians encounter problems with e-prescribing systems and must complete the task immediately, they sometimes try to use paper prescriptions to reduce work interruptions.27 The organizations in this stage are not fully implementing e-prescribing systems for all exchanges, and they often switch to other methods. Currently, many medical offices and pharmacies in medical practice are utilizing parallel systems namely e-prescribing technology along with handwritten prescriptions, paperbased patient charts, faxing hard copies, and phone calls. Using mixed systems to proceed with prescriptions may lead to some logistical issues.28 In a study conducted by Lapane et al,29 the order of efficient prescribing methods used by clinicians was e-prescribing, computer fax, computer, handwritten, phone, and fax. The most inefficient prescribing method turned out to be prescribing over the phone. 4. General deployment: in the general deployment stage, health care organizations are fully

utilizing e-prescribing services in all prescription-related transactions with other organizations and all patients. In this stage, e-prescribing users perceive that the efficiencies gained clearly outweigh the concerns and costs, and they are therefore unwilling to use other traditional methods of prescribing. They mainly focus on e-prescribing to completely integrate this technology across their processes and practices including prescribing, administration, and dispensing medications to patients. In general, according to Jariwala et al,12 e-prescribers are the health care providers who have integrated the e-prescribing system into their workflows and have used the system in their practices. Non-e-prescribers are categorized into three groups. The first group is the health care providers who are currently in the process of planning or implementing e-prescribing. The second group includes providers who consider using this technology in the future but have no precise adoption intention. The final group consists of providers who do not want to use this system in their practice and in turn, have no adoption intention at all. In another possible scenario, health care professionals may begin using e-prescribing but stop after a certain point due to problems encountered such as hardware or software issues or the inability to connect with pharmacists. One of the keys to MIPPA (Medicare Improvements for Patients and Providers Act) is to provide incentives for the adoption of e-prescribing by physicians.12 Federal incentives motivate providers to adopt and meaningfully use interoperable, certified EHRs that also enable e-prescribing. Compared to older systems, the new commercial EHRs include more robust CDS for e-prescribing to improve the quality and safety of health care delivery.30 Many providers have transitioned from paper-based transactions, locally developed EHRs or older versions (PCbased EHR with minimal CDS) to the new commercial EHRs, which are certified by the Certification Committee for Health Information Technology (CGHIT). The certified EHRs offer more robust CDS for e-prescribing (such as drug–drug interactions, alerts for allergies, default dosages and instructions) to meet the eligibility criteria and basic standards that entitle them to receive federal incentive payments.31 User satisfaction with e-prescribing systems can lead directly to continuous usage.32 According to


Abramson et al,27 in general, physicians perceive that the new EHRs are too complex and consist of some clumsy elements and features for e-prescribing that slow their efficiency instead of improving medication safety. The providers’ dissatisfaction with the new EHRs (with more robust CDS for e-prescribing) shows the importance of a technological design that enables better integration into workflow and medical practices. Physicians perceive that locally developed EHRs are easier to use for e-prescribing services compared to the new EHRs, which are complex and over-engineered due to the availability of too many steps and too many ways to complete tasks.27 Benefits related to e-prescribing services New HIT systems (such as e-prescribing) have primarily been introduced to eliminate medication errors.33 E-prescribing systems enable the electronic transmission of prescriptions via a secure network between prescribers (i.e., physicians’ offices) and pharmacies (i.e., community pharmacies).34 E-prescribing is primarily intended to increase the quality of care while reducing costs.35 The primary reason for using e-prescribing systems is to reduce medical errors and cut pharmacy costs.36 The main benefit of e-prescribing is related to reducing the rate of medication errors. Medication errors can lead to mortality and morbidity,5 and are defined as errors that can occur during any medication process such as prescribing, dispensing, and the administration of medication.33 Because prescription errors fall under the general term of medication errors, as a technology, e-prescribing is mainly used to eliminate medication errors.20 The most reasonable method is to reduce medication errors caused by unreadable physician handwriting. Illegible, incomplete and omitted prescription information are the main factors that increase medication errors and jeopardize patient care.37 E-prescribing can reduce transcription errors and improve the legibility and completeness of prescriptions.38 Overprescribing, misprescribing and underprescribing are the three main types of prescribing errors that the use of e-prescribing systems is intended to decrease. Overprescribing is defined as prescribing more medication than what is clinically necessary. Misprescribing consists of wrongly prescribing a necessary medicine, and underprescribing is referred to as the omission of a necessary medication.39 There is some evidence

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to show that e-prescribing systems can help to reduce medication errors by 50% and improve the quality of patient safety40,41 and save health care costs42 as well as order-processing time.43 According to Kuperman et al,44 some advanced eprescribing systems can provide decision support features such as checking for drug–drug, drugallergy and drug–dose interaction. The system can promote evidence-based practice and facilitate clinical decision making.45 E-prescribing is the generation of electronic solutions for the medical industry to improve workflows and reduce medication errors such as drug conflicts.46,47 The software can also detect preventable errors by checking for drug–drug interactions and other possible medication errors.12 The function of adverse drug alerts can assist doctors in checking contradictions when prescribing new medications.11 Some studies show that e-prescribing systems cause less prescription errors compared to handwritten prescriptions.48,49 An e-prescribing system is the computer–computer transmission of prescription information from physicians’ offices to pharmacies, and it can play an important role in patient management.28 Health care providers use e-prescribing systems not only to decrease errors but also to reduce the cost associated with dispensing errors.50,51 Unnecessary patient hospitalizations that lead to cost reductions for hospitals can be an outcome of using e-prescribing in developing a rapid medication dispensing system for outpatients.11 E-prescribing can enable physicians to better track if patients are taking their medications on time by checking the refill dates. The system enables physicians to refill prescriptions wherever they are and whenever they want to eliminate delays. E-prescribing systems are very efficient from the view of clinicians because they can generate, send and approve prescriptions directly to the pharmacy even from remote locations.29 Goldman et al28 conducted a study in 64 physicians’ office practices to evaluate the refill functionality of e-prescribing software. The results showed approximately 50% savings in time spent on refills per day. The main gains were reported as time reduction, tracking patient refill histories and patient convenience. The results also emphasized the usefulness of the “alerting the physician” capability that was enabled by the e-prescribing software. Almost 77% of participants reported they would call patients if the software alerted them when patients failed to pick up a prescription that would lead to serious medical

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consequences if not taken on time. Physicians can also see the extent to which patients have used narcotic prescriptions and check on the overuse of medications with abuse potential. Because it is more difficult to falsify electronic records than traditional handwritten prescriptions, e-prescriptions are easier to monitor and can prevent and detect fraud faster.11 With e-prescribing systems, clinicians are better aware of patients’ insurance coverage and can also better manage medications based on patients’ financial considerations.29 In the case of chronic illness, e-prescriptions can facilitate patient adherence to medication, resulting in cost savings and improved patient health outcomes.52 E-prescribing systems can also be incorporated into hospitals’ patient management system.21 Therefore, they are able to prevent errors by updating the databases that contain patient records and clinical and medication information.38 Using EHRs for e-prescribing targets is advantageous due to the accessibility of EHR systems across locations whenever physicians wish to prescribe. EHRs with e-prescribing can eliminate communication gaps between care providers, facilitate the coordination of care, and improve communication among network providers due to sharing accurate and updated medication lists and patients’ health information.27 Using e-prescribing can improve the workflow efficiency of both prescriber and pharmacy, facilitate communication between physicians’ offices and pharmacies,53 reduce the number of phone calls between physicians’ offices and pharmacies, and speed up prescription refill requests.36 It can also result in efficiency gains through reduced redundancy in the practices of both prescribers and pharmacies. Pharmacists can check the incoming e-prescriptions to better manage their medication stocks and dispense medicine in a timely fashion.54 Efficiency gains from e-prescribing systems originate largely from decreased time spent on phone calls for clarification, streamlined refill processing, organized record keeping, and having updated information about both medication formularies and prior authorizations.29 Implementing e-prescribing can remove the necessity of using paper in the processing of prescriptions in pharmacies. Patients also benefit from e-prescribing because e-prescriptions are rarely lost or erased. E-prescribing services are aimed at improving the patient’s access to medication and increasing the efficiency and effectiveness of health care services.55,56 E-prescribing is intended to benefit

patients through reducing wait times and increasing their level of satisfaction with pharmacies.57 The literature shows that patients who have their prescriptions linked directly to a pharmacy experienced greater convenience in obtaining repeat prescriptions compared to those who submit an initial request before collecting their medications per prescription.58 One of the most cited benefits of e-prescribing systems for patients in the UK is the Prescription Prepayment Certificate (PPC) electronic service.11 This e-service provides patients with a certificate that enables them to acquire medication at a reduced cost by letting them pay the medication cost annually or quarterly. This service enables patients to collect prescribed medications without any other charges during the validity period, which is either three months or one year. During this time period, the patients are allowed to fix the medication cost.59 Risks and concerns associated with e-prescribing Based on World Health Organization (WHO) reports, there are five main categories of traditional prescribing errors: wrong patient, wrong drug, wrong dose, strength or frequency, wrong dosage formulation, and wrong quantity.60 The risk associated with legibility, misinterpretation, and falsification of handwritten prescriptions encouraged the adoption of e-prescribing systems.61 As Pizzi et al62 report, the most important concerns related to use of e-prescribing are the cost of implementation and maintenance, as well as the time needed to integrate new systems into the workflow. The hidden cost of e-prescribing is considered as the cost of training staff to manage possible computer issues around e-prescribing services.62 More training programs for prescribers are required to improve their prescribing skills and reduce the risk of medication errors that may occur on the prescribers’ side.63 The personnel should also be connected directly to computer support services and facilitating conditions in case they face problems. According to Hor et al,64 the main obstacles affecting the implementation of e-prescribing include the cost of implementation, the inability to provide financial incentives, and the lack of standardized software. Because numerous e-prescribing software vendors offer a variety of EMR packages with an e-prescribing option, operability may be violated as a result of heterogenous software standards and database management systems.65 Patients’ demographic data in the computer systems of


pharmacies and prescribers may not match, with the result that prescribers fill prescriptions for the wrong patient. The lack of a standard e-prescribing format is reported as one of the most frequent problems faced by pharmacies. Many prescriptions are transmitted electronically with no prescribers’ license information, phone number or allergy information, and additional time is needed for the pharmacy staff to gather such data.66 Updating the database according to emerging data, protecting data, confidentiality maintenance and routine trouble shooting can be a key concern in the implementation of e-prescribing systems.67 If any application of HIT (such as an e-prescribing system) is poorly designed or implemented, it can become very risky to patient safety by introducing a new source of medication errors.13 One of the most important risks of using eprescribing is e-prescribing errors. A number of studies have reported that the e-prescribing error rate is no lower than other methods of traditional transmission such as paper-based, faxed, or phoned prescriptions.68 Some unintended consequences that may affect both prescribers and pharmacies are new types of medication errors, disruptions in workflow, demands for system upgrades, and overreliance on the e-prescribing systems.69 The concerns over the rising number of e-prescriptions generated and transmitted in community pharmacies have increased the likelihood of medication error occurrence. Some studies indicate that the e-prescribing errors reported by pharmacy personnel are very similar to the handwritten ones.13 The rate of this type of error, especially in the context of community pharmacies, may be as high as 11% yearly.70,71 However, the accuracy of information is mainly dependent on the input information coming from prescribers. Consistent with Rupp and Warholak,72 the problem related to e-prescribing systems most frequently indicated by community pharmacists is the receipt of incorrect drugs or directions from prescribers’ offices. According to Redwood et al,73 most medication errors occur at the point of prescribing the medication. Nanji et al74 show that at least 1 out of 10 eprescriptions transmitted via computer-generated medication errors, 33% of which negatively impact patient safety. E-prescribing errors can also lead to increased costs in auditing and additional transaction costs due to the need to reenter the incorrect information and send a new e-prescription. E-prescribing errors are mainly defined as omitted, inaccurate and unclear e-prescription

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information that may result in inappropriate medication use by patients, which in turn, causes harmful consequences.70 The possible consequences of e-prescribing errors for patients are the increased possibility of inappropriate drug use (too much or too little of the prescribed drug), which may lead to worse patient conditions. It is also stated that increased medication costs due to inappropriate dosage quantity and more expensive forms is another consequence of e-prescribing errors for patients.20 The wrong strength is referred to as abnormal dosing, whether too low or high. Wrong dosing directions usually occur due to incorrect auto-populated information, and wrong quantity errors are created due to the incorrect calculation of medication quantities by prescribers or when prescribers are unaware of the available package size.70 According to Hincapie et al,66 the most frequent type of e-prescribing errors is e-prescriptions with conflicting information, wrong quantity, dose and drug selection issues, and direction issues. Directions issues are mostly referred to as the discrepancy between directions and drug route, mismatch between strengths and the directions, and disagreement between the package size and the directions. Directions issues occur mainly when default directions are available but prescribers do not verify them before sending the eprescription. In some e-prescribing systems, if directions are changed during prescription, the quantity will also be removed without the prescriber being notified. Thus, in case of refills, many e-prescriptions are received with no quantities, forcing pharmacists to prescribers for further clarification. To reduce e-prescriptions with missing information, prescription direction and medication names should be more consistent. Drug (both duplication and omission), prescribing route, frequency, and dosing (both underdosing and overdosing) errors are the most common errors detected in a study conducted in the pediatrics setting after the implementation of e-prescribing.21 Duplicate e-prescriptions, which is a common problem for pharmacists, usually occur when prescribers send the same prescription via different transmission methods (e-prescription, fax, and phone) to confirm delivery.66 The main concerns of community pharmacists are reported as patient safety issues owing to unintended adverse consequences and omissions of information caused by the use of e-prescribing systems.10 Many pharmacists and pharmacy staff believe that e-prescribing decreases pharmacies’

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workloads while simultaneously doubling their work responsibilities and imposing an excessive burden. Pharmacists are supposed to perform additional checks when dealing with certain drugs that come in multiple dosage forms and usually have incorrect dosing directions.75 Pharmacies are also observed as being responsible for documenting and intercepting errors that originate in e-prescribing systems before they harm patients.23 They need to intervene in the e-prescribing process quite frequently compared to their intervention in traditional paper prescriptions.34 Odukoya et al75 stated that pharmacies and technicians are more likely to double check the prescriptions and medications that are mostly observed as e-prescribing problems. This verification step mainly occurs through a review of the patient’s profile during the drug entry and dispensing phase. According to Gilligan et al,34 approximately 11% of e-prescriptions transmitted to community pharmacies contain errors that must be detected and removed by pharmacists’ intervention. Error recovery consists of three steps: detecting, explaining, and correcting an error. Through error recovery, pharmacists can minimize confusion for patients on taking medications and ensure they are billed correctly. Most e-prescribing errors can be detected by pharmacists and technicians using several methods, including double checking e-prescription information, printing the e-prescription out on paper to confirm the information, and highlighting important and sensitive information on the printed versions of e-prescriptions. According to Odukoya et al,75 the majority of errors detected by technicians are related to incorrect quantities or incorrect duration of therapy, and most of the errors detected by pharmacists are wrong dosing directions and incorrect dosage formulation. Pharmacists can also use strategies for explaining errors such as reviewing patients’ medication histories, consulting with patients and other team members in the pharmacy, and checking online drug information tools, as well as using manufacturer databases. Error recovery steps can put too much pressure on pharmacy personnel. Additionally, pharmacists are only able to correct e-prescribing errors if they have access to patients’ medical records and have sufficient time. Otherwise, the system can produce unfavorable workflow issues.23 Unlike hospital settings, pharmacists working in community pharmacies cannot access real-time patient medical records to detect and correct possible incorrect or incomplete information on

e-prescriptions.13 Instead, they typically use stand-alone e-prescribing software. Therefore, some studies indicate that the most visible consequence of e-prescribing errors for pharmacy personnel is additional work, time and effort to eliminate identified errors. These errors can interrupt the routine activities and workflow of pharmacies and render personnel constantly concerned about addressing possible errors. The frequent interruptions can result in greater confusion and dissatisfaction among pharmacy personnel and technicians.20 Warholak and Rupp10 indicate that unanticipated errors can decrease pharmacy efficiency. The occurrence of any unpredicted errors (such as incorrect day supply or patient name) can lead to lengthy delays for both pharmacies and patients because they must wait to receive clarification from the prescriber. Pharmacists usually require approximately 6 min to resolve incorrect e-prescribing orders, leading to an additional cost of $ 4.74. According to Astrand et al,61 pharmacists are more involved in asking for clarification from prescribers compared with the traditional dispensing system. An important consequence of missing or inaccurate information on e-prescriptions is the time taken to resolve the issues, which is reflected as workload implications for both pharmacists and prescribers.21 The high rate of clarification is required due to the receipt of wrong, missing or unclear information that is considered as potentially harmful errors that can affect patient safety. Due to frequent calls for clarification between prescribers and pharmacists, e-prescribing technology cannot always deliver the expected cost effectiveness. One of the main reasons clinicians use eprescribing systems is to speed up ordering prescriptions.76 There is evidence to reflect that physicians are unlikely to prescribe electronically using EHR systems equipped with robust CDS for e-prescribing because too many keystrokes results in a slow prescription process.27 Health care providers may become dissatisfied with an e-prescribing system that is integrated into the EHR if the system is observed as very complicated, even if offers many functionalities. Having robust CDS functionalities for e-prescribing may lead to alert fatigue felt by physicians, especially when the majority of the alerts are irrelevant, overridden and considered not useful.27 Many physicians are not aware of the available features (such as system shortcuts) that are intended to increase


efficiency while using EHR with robust CDS for eprescribing. As far as ease of use is concerned, complicated user interface design and complex functionalities of e-prescribing systems should be modified to better match physician practices. Some physicians still prefer to use traditional, handwritten prescriptions and simply hand them to patients because the steps they must complete in e-prescribing systems are more time consuming.29 The system appears to be even more time consuming when prescribers must enter patient records into the system for the first time; this can be frustrating when the patient turnover rate is very high and the patient may not return. Although e-prescribing is intended to save physician time, some studies show that no improvement has resulted.50 Devine et al77 demonstrate that generating and sending e-prescriptions takes approximately 25 s longer than traditional handwritten prescriptions. Sometimes patients are also frustrated and become dissatisfied because their prescriptions are still in transmission and thus not ready at the pharmacy when they go to pick up the medications. Unclaimed e-prescriptions are another problem frequently reported by pharmacies. Sometimes patients are not willing to claim their e-prescriptions from pharmacies. At times, physicians perceive that the generated prescription is unnecessary; sometimes, patients cannot afford the medication. Other reasons for unclaimed prescriptions are lack of time to pick up the medication or being unaware that a prescription is waiting at the pharmacy.78 Research has shown that one of the best ways to reduce the rate of unclaimed e-prescriptions is using fill status notifications by e-prescribing systems.79 One type of error caused by e-prescribing systems is sending the e-prescription to the wrong pharmacy instead of that used by the patient.75 Better communication among physicians, pharmacists and patients (the 3Ps) can resolve this problem to some extent. The design of e-prescribing systems still facilitates the incidence of errors.66 System design features such as poor drop-down menus, screen design and inaccurate patient medication lists can cause patient safety issues.80 One of the main concerns of using e-prescribing software is handling day-to-day glitches and cumbersome elements of the software that may lead to user frustration. Sometimes, the technical representatives from software vendors are not available, and other times representatives are slow or

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unresponsive in addressing problems.28 According to Jariwala et al,12 more than half of the primary care physicians they surveyed reported having encountered problems with e-prescribing software, including slow processing, frequent system freezes, lack of updates, excessive safety alerts, incorrect information in the medication list, and productivity reduction. Data entry errors can stem from both e-prescribing software (i.e., drop-down menus) and prescribers’ errors (i.e.: lack of concentration).62 Therefore, software vendors should seek to design an appropriate interface to help prevent these errors. Another e-prescribing problem is related to the restrictions placed on prescribing controlled substances electronically.12 Due to confusion about the regulations concerning e-prescribing controlled substances, some physicians utilize multiple prescribing methods (such as faxing and handwritten) to cover all prescribing needs.81 Some e-prescribing systems still do not facilitate the application of e-prescribing laws for controlled substances and prescribers are still transmitting e-prescriptions that fail to meet regulations. In some states, an e-prescription for brand-name medications must be accompanied by a handwritten prescription to meet state requirements.66 The Drug Enforcement Agency (DEA) facilitated physicians’ ability to e-prescribe controlled substances in 2010, but the inability to generate and transmit controlled substances electronically is still considered problematic for prescribers.12 Categorization of factors contributing to e-prescribing errors Prescribing medicines is an important part of the medical care process and consists of choosing medications in the form of prescriptions and sending them to pharmacies for dispensing and administration of medicines.67 The incidence of errors at any stage of the prescription process is categorized as prescribing errors and can threaten patient safety. Prescribing errors occur due to inappropriate prescribing decisions or inaccurate prescription ordering processes, which lead to untimely and ineffective treatments or an increased risk of harm to patient safety.82 Finding factors that contribute to e-prescribing errors can help us better understand what elements may facilitate the occurrence of errors and how. The factors contributing to e-prescribing errors are multidimensional and can range from lack of knowledge

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and experience to errors in electronic transmission and system features.83 In this study, we categorize the producing conditions and factors of e-prescribing into four main types, as follows: - Computer (technical) factors: Computer factors generate errors that originally stem from the e-prescribing software regardless of human interactions; errors mainly originate from software design or malfunctions. The main technical factors are slow system functionality during busy days, system downtime, repeated warnings or notifications by the software, plus software glitches, technical bugs or network delays that may slow down the practice or cause the process to malfunction. In general, technical factors are outside the control of e-prescribing users. As supported by Odukoya et al,20 pharmacists and technicians perceive that a considerable portion of e-prescribing errors can stem from the technology that is used in prescriber offices and pharmacies. - Human factors: These factors are defined as incorrect or inappropriate human participation in e-prescribing-related activities, regardless of the software function. Purely human factors and technical factors are extricable given an e-prescribing system that generally works well without glitches, wrong alerts or network delays. One of the most cited factors that increase the probability of e-prescribing errors is unintentionally entering incorrect information (concerning the patient or medication, for example) from the prescriber side.20 This typically occurs due to human factors such as fatigue or lack of concentration or experience. Moreover, improperly trained medical staff may also lead to e-prescribing errors. The selection of an incorrect option or dosage by prescribers who are unfamiliar with the functionalities of a given e-prescribing system can endanger patient safety. Human factors are isolated from the system when it is presumed that nothing about the technology affects the selection error and the features of the system are not distracting. Human factors can generate errors directly due to conflicting or incomplete information entered by prescribers, sending a wrong note unrelated to a patient, or transmitting the information for the wrong patient. Furthermore, when e-prescriptions are delayed or not received by pharmacies at all, it may lead to more follow-up

phone calls between prescribers and pharmacies. In conclusion, sending e-prescriptions to the wrong pharmacy or selecting an incorrect option can be due to wrong data entry, fatigue, lack of knowledge, or delayed or inappropriate practice of prescribers.29 In this case, it is assumed that e-prescribing systems do not contribute to the error incidence and that the error is caused by purely human factors. - Interaction factors: In some cases, errors can be the result of both technical and human factors (human–system interaction factors), which can be referred to as interaction factors. Interaction factors are the intersection of both human and technical contributing factors to e-prescribing errors. These factors can lead to e-prescribing errors when errors are a combination of both users’ careless or incorrect practices and distracting features of e-prescribing systems. Distracting features of e-prescribing systems (such as the auto-populate feature) can increase the probability of error occurrence when they are accompanied poor practices on the part of medical staff. Distracting features of e-prescribing software can be misleading but can also be dealt carefully when medical staff knowledge, experience, scrutiny and concentration suppress the possible errors. Therefore, distracting features are not the only contributing factors by themselves as long as they are not reinforced by human factors. Auto-populate features and dropdown menus can generate conflicting outputs, especially in case of refilling old prescriptions. For instance, the drop-down menu, default directions, or auto-population capacity of e-prescribing software may lead to an error that is compounded by the lack of prescribers’ concentration in selecting the right medication and strength. Long lists of medications on the order entry can also be distracting and may lead to medication errors if they are dealt with carelessly or subject to inadequate scrutiny by medical staff. In case of the refill function, errors may occur due to less than careful review and critical scrutiny of the refill request. The incidence of medication errors has roots in the too-perfect appearance and presentation of the refill requests and ease of refill processing, which can lead to the careless approval of refills without any scrutiny.28 Default dosing for e-prescribing may be problematic and contribute to e-prescribing errors, particularly when used by medical residents. Residents frequently accept computer-


generated doses without critical investigation and further checking for accuracy. Therefore, some physicians believe that this function should be removed from e-prescribing systems to increase patient safety.27 - Organizational factors: E-prescribing inefficiencies are also caused by organizational factors such as the limited adoption of certified e-prescribing systems, lack of standard e-prescribing formats, and inconsistent medication names among health care providers. Organizational factors are different from the other categories because they are addressed at the corporate level and encompass organizational foundations and conditions that contribute to e-prescribing errors. Organizational contributing factors include the failure to match patients’ medical information, history and demographic data across health care institutions, the lack of collaboration between prescribers and pharmacies, lack of information technology support training, inadequate organizational readiness, and poor strategic planning for e-prescribing implementation.84 E-prescribing errors can also be the result of the mismatched interface between the technological and organizational foundations (such as EHR systems) of the prescriber versus the pharmacy.66 Organizational technology incompatibility between the e-prescribing systems used in pharmacies and prescribers, especially in case of drug and patient names, can result in errors and misinterpretation. Therefore, insurance formularies, patients’ medical histories, lists of medications, and pharmacies’ address that are not kept up-to-date and consistently among all the involved health care organizations may lead to e-prescribing errors. The following table (Table 6) depicts the proportion assigned to each category of contributing factors identified in the literature. The results show that human factors are reported as the most important contributing factor to e-prescribing errors.

Table 6 Proportion of the contributing factors to e-prescribing errors Type

Percentage

Computer (technical) factors Human factors Interaction factors Organizational factors

12% 40% 31% 17%

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Limitations Like any study of this kind, the findings of this research should be interpreted with caution due to several limitations. The first limitation is related to the methods used to select eligible studies. To begin with, potentially relevant studies were limited to the keywords used by authors. Inclusion criteria were also set by authors and relatively few papers were found to be eligible. The included studies were selected through a search of two databases: the Web of Sciences electronic databases and Google Scholar. Searching other databases and using other inclusion criteria and search terms may have identified additional studies. Therefore, it is possible that some eligible relevant studies were not identified by the selection strategy and not included in this review. Gray literature, including reports, policy documents, and dissertations, were also not included in this review. This type of information may be relevant but is not peer-reviewed and may also bias the review. The second limitation is related to the search execution. Only one author screened the retrieved articles based on their titles, abstracts and citations. Then, both authors were involved in reviewing the selected articles in full for eligibility assessment. The third limitation was the heterogeneity among study designs, settings and purposes that makes the synthesis and classification of this literature difficult. Having studies conducted in different settings limits our ability to generalize the results. Lastly, this study was intended to reflect a summary of the available literature related to e-prescribing systems. It was not intended as a systematic or comprehensive review to include critical appraisals of the evidence. Thus, it is acknowledged that a broader reflection of the current literature may have been conducted if a more extensive and additional search had been used. The search was conducted on a similar pattern to previous reviews in the area of e-prescribing systems, however, suggesting that the included articles may be a reasonable representation of the current literature.14,15

Lessons learned and future research This study is a review and classification of the current literature related to e-prescribing functions, assimilation stages, benefits, risks, concerns, and factors contributing to e-prescribing errors. To cover the first section, we developed the 3Ps model to better explain the main function of the

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e-prescribing system and how it connects the three main building blocks, namely prescribers, pharmacies, and patients. In the second section, the four main stages are described to show the assimilation process of e-prescribing services. Evidence shows that economic barriers directly impact the success of e-prescribing implementation. The cost of implementation for health care institutions includes financial, personnel and time costs. A lack of financial incentives can also affect the adoption of e-prescribing. According to a study conducted by Lapane,29 most e-prescribing users reported that the efficiencies gained outweigh the costs. Over the seven year review period, we noticed that the adoption and use of e-prescribing is rising annually. The rapid change of pace in adopting e-prescribing systems among health care providers can be a result of health care reform, national policy or incentive programs that promote the adoption of EHRs. One of the main requirements for the meaningful use of certified EHRs is e-prescribing adoption, which seeks to improve the quality, safety and efficiency of health care delivery. Our review shows that certified EHRs and standardized e-prescribing systems can potentially result in better interoperability and lead to a reduction in medical errors and improved workflow efficiency. The lack of standardized prescribing software is not only considered as one of the main obstacles to the successful implementation of e-prescribing but also increases the risk of unintended errors that harm patient safety. Unintegrated software and isolated systems may cause inconsistency in the delivery of health care services. Federal incentives encourage health care providers to use of interoperable EHRs that also enable e-prescribing. As a result, more health care institutions have transitioned from locally developed EHRs or older diversified versions to the new standardized and certified EHRs to receive federal incentive payments.31 The findings indicate that the adoption of integrated e-prescribing systems with standardized functions is on the rise among health care providers to increase potential gains and reduce errors. Concerns regarding successful implementation, training, and technical support, however, as well as the complexity of standardized systems, still make the transition difficult. The review also suggests some practical and theoretical implications, both for e-prescribing policy-makers and e-prescribing research. The review analyzed and classified the key e-prescribing benefits, concerns, risks and contributing factors

to e-prescribing errors that are reflected in the existing literature. According to the findings, e-prescribing system design greatly impacts users’ satisfaction and the achievement of potential gains. Prescribing software vendors need to improve alerting and minimize technical errors that lead to unintended consequences. They are also required to advance functionality as well as the decision support features of e-prescribing systems to improve potential benefits and minimize safety threats. Moreover, the stakeholders involved in e-prescribing decision-making and policy-makers in hospitals, community pharmacies and other health care settings can use the results to better understand the opportunities, gains, concerns and risks of using e-prescribing. Accordingly, they can also remove e-prescribing errors and adoption barriers to increase the success of e-prescribing services. For instance, all health care providers should be trained to be aware of new types of errors originating from technology. Furthermore, better collaboration and commination is required between prescribers, pharmacies, and patients (P3 model). Providers must use reporting platforms to report common concerns and errors to software vendors so that they can better identify problems and improve e-prescribing systems. The perceived error-free transmission of prescriptions through e-prescribing systems can help this technology reach its full potential. Future studies can use the identified benefits and risks to support the findings using empirical data. Areas for future work include recognizing contributing factors and conditions to e-prescribing errors supported by quantitative data, finding applicable solutions to remove e-prescribing errors, identifying the effects of e-prescribing risks and benefits on the quality of health care services supported by empirical data, and performing a cost-benefit analysis related to the adoption of e-prescribing using empirical data. Conclusion Investing in e-prescribing technology has been associated with workflow efficiency for pharmacists and prescribers and improved health care services. This study showed however that adoption of e-prescribing systems can also result in new types of problems leading to medication errors, patient safety issues, increased medication costs, and increased auditing and transaction costs. Unpredicted errors associated with using e-prescribing systems can arise due to technical factors, purely


human factors, interaction factors, and organizational factors. The work structure redesign of pharmacies and prescribers’ offices, appropriate interactions between users (prescribers and pharmacists), collaborative interaction between users and e-prescribing technology, and better technology design can facilitate efficiency and effectiveness gains for e-prescribing services. References 1. Lapane KL, Waring ME, Schneider KL, Dube´ C, Quilliam BJ. A mixed method study of the merits of e-prescribing drug alerts in primary care. J Gen Intern Med 2008;23:442–446. 2. Moniz TT, Seger AC, Keohane CA, Seger DL, Bates DW, Rothschild JM. Addition of electronic prescription transmission to computerized prescriber order entry: effect on dispensing errors in community pharmacies. Am J Health Syst Pharm 2011;68:158–163. 3. Bootman JL, Wolcott J, Aspden P, Cronenwett LR. Preventing Medication Errors: Quality Chasm Series. Washington, D.C: National Academies Press; 2006. 4. Surescripts. The National Progress Report on Eprescribing and Interoperable Healthcare; 2012. Available at: http://www.surescripts.com/aboute-prescribing/progress-reports/national-progressreports.aspx; Accessed 25.09.14. 5. Kohn LT, Corrigan JM, Donaldson MS. To Err Is Human: Building a Safer Health System. Washington, D.C: National Academies Press; 2000. 6. Roughead EE, Semple SJ. Medication safety in acute care in Australia: where are we now? Part 1: a review of the extent and causes of medication problems 2002–2008. Aust New Zealand Health Policy 2009;6(18). 7. Ashcroft DM, Quinlan P, Blenkinsopp A. Prospective study of the incidence, nature and causes of dispensing errors in community pharmacies. Pharmacoepidemiol Drug Saf 2005;14:327–332. 8. Knudsen P, Herborg H, Mortensen AR, Knudsen M, Hellebek A. Preventing medication errors in community pharmacy: root-cause analysis of transcription errors. Qual Saf Health Care 2007;16:285–290. 9. Lawrence D. Steps forward on e-prescribing. As eprescribing becomes more widespread, even hospital organizations without full EMR implementation are seeing gains in clinician workflow and patient safety. Healthc Inform 2010;27:24–26. 10. Warholak TL, Rupp MT. Analysis of community chain pharmacists’ interventions on electronic prescriptions. J Am Pharm Assoc 2008;49:59–64. 11. Irani Z, Weerakkody V, Molnar A, Lee H, Hindi N, Osman I. A user satisfaction study of the NHS Online Prescription Prepayment Certificate. Health Policy Technol 2014;3:176–184.

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