Electronic transmission of prescriptions in primary care: transformation, timing and teamwork

KEYwords: General practice; community pharmacies; primary health care; telemedicine; electronic prescribing, workflow.

Electronic prescribing generally describes the process in which the traditional paper prescription is replaced by a system that enables a prescription to be created and transferred to a pharmacy electronically. There is variation in technical architecture and implementation of electronic prescribing approaches internationally.^1–3

In New Zealand (NZ), paper prescriptions generated by computer and physically signed by prescribers has been business-as-usual in primary care. The New Zealand Electronic Prescribing Service (NZePS) added a layer whereby the prescription data generated by prescribers using the NZePS were sent electronically to a central transaction broker. Paper prescriptions with unique barcodes were generated at the same time, signed by the prescriber, and given to patients to present to the pharmacy of their choice. Pharmacists could process requests manually using the information provided on paper prescriptions, or they could scan barcodes to retrieve electronic prescriptions from the central server. This process is depicted in Figure 1.

Figure 1.  Process with the New Zealand Electronic Prescribing Service (NZePS) when a patient takes their prescription to the pharmacy.

The vision described for the NZePS (a component of the eMedicines programme)⁴ is that patients will benefit from improvements in patient safety and quality of care, such as reduced risk of transcribing errors during dispensing, better communication between prescriber and pharmacist, improved ability to evaluate and address patient medicines adherence issues, and improved quality of patient medication history information.⁵

Limited national roll-out of the NZePS began in 2012, but uptake was slow. By the beginning of 2020, ~30% of general practices were set up to use the NZePS. As part of the NZ response to the COVID-19 pandemic, there was a substantial shift to virtual consultations in primary care. This created an urgent need to facilitate sending prescriptions electronically directly to pharmacies.

Although not originally part of the NZePS process, tests had been underway of the transmission of electronic prescriptions without a physical signature. This was enabled by a Director General of Health waiver to the Medicines Act requirement for a physical (handwritten ink) signature of the prescriber on a prescription, provided certain criteria were met.⁶ The waiver was expanded nationally, and adaptions made to general practice patient management systems (electronic patient record than prescribing software) to enable prescriptions to be emailed directly to pharmacies (Figure 2). By June 2020, 80% of general practices were signed up to the NZePS.⁵

Figure 2.  Process with the New Zealand Electronic Prescribing Service (NZePS) with direct electronic transmission of signature-exempt prescription to a pharmacy (not for controlled drugs which still require a physically handwritten prescriber signature).

International experience suggests some improvements achieved by the electronic transmission of prescriptions can be offset by unintended consequences and the introduction of new issues.^7–9 It is therefore important to evaluate local implementation to understand the effect of the change on practice, so that adjustments can be made if needed to avoid compromising patient care.

The aim of this study was to explore the experiences of NZ general practitioners (GPs) and community pharmacists when prescriptions are transmitted electronically directly from prescriber to pharmacy rather than being printed, signed by the GP and taken to the pharmacy by the patient or faxed. Although the NZePS underpins and enables the electronic process, this study was not focused on NZePS per se.

A purposive sample of GPs and community pharmacists was recruited by researcher invitation to cover a range of health-care practitioner and practice characteristics.

Qualitative data were collected by face-to-face semi-structured interviews. Interview objectives were to gain an understanding of the effects of direct conveyance of the prescription electronically on professional workflow, interprofessional interactions and communication between prescribers and pharmacists, and interactions between health practitioners and patients. Interview questions therefore focused on these three areas (see interview guide – Appendix 1). Sufficient demographic data about participants and their practice settings were collected to provide an indication of their characteristics.

The interviews were conducted by C.C. and digitally recorded with participant consent. An inductive thematic analysis of the qualitative data collected was undertaken.¹⁰ The final thematic framework was discussed and agreed by all three authors.

Māori consultation was undertaken according to the University of Otago policy. Ethical approval was obtained from the University of Otago Human Ethics Committee (Reference number D20/330).

Four GPs (all male) and four community pharmacists (three female, one male) were interviewed between October and December 2020. They were all located in the Wellington region, apart from one pharmacist who was located in a small town in the upper North Island (interview conducted using Zoom video conferencing software).

Interview duration ranged from 34 to 78 min (average 49 min).

Key participant and practice demographics are presented in Table 1. Inductive thematic analysis of the interview data identified four themes, which are described below with illustrative quotes.

Table 1.  Participant and practice demographics

The change to electronic prescription transmission direct from prescriber to pharmacy had a transformative effect on the workflow of the participants. For GPs, the transformation has been largely positive, with key benefits being time saved and increased work flexibility:

‘Huge [impact on workflow]. Prior to this I could not do prescriptions from home … I’d have to wait till I was physically in the practice to be able to print out the script, sign, and then dish it out to the admin office for them to either fax it off or call the patient to pick it up whereas now I just [click] and it’s away.’ [GP 4]

Although there has also been substantial change in the workflow experience for community pharmacists, the positives tend to have been offset by new challenges created.

A key positive for pharmacist workflow was the opportunity to get ahead on the dispensing process. When everything went smoothly, there was potential for the medicines to be ready for collection when patients arrived at the pharmacy.

‘I find it really easy to process it all cos we get like 15 odd scripts when we first come in in the morning, so I just print them all out and then we get on top of it...’ [Pharmacist 1]

However, positives were offset by some negatives such as non-collection of dispensed items.

Pharmacist clinical review of prescriptions in relation to the patient’s history does not appear to be well supported by the software when a prescription barcode is scanned:

‘Normally when I’m doing a prescription, I would bring up a patient [on the pharmacy computer], get an overview of their history and then I would go ahead with the script but with NZePS you scan it, and you can’t see the history until you’re finished. You specifically have to go back...’ [Pharmacist 2]

Although saving time is a benefit for GPs, one participant also noticed that the increased speed meant they had to build in steps to ensure they were still checking what they had prescribed.

‘Whereas before when I was printing something off and putting my signature on it and taking it to the fax machine … my checking process would be looking at the piece of paper, so I’ve had to make a conscious effort to read it very carefully before hitting ‘send’.’ [GP 3]

GP participants observed no meaningful effect on their interactions and felt it was more convenient for patients. They did not use paper prescriptions as a communication tool in their consultations; prescriptions were considered more as an administrative detail.

‘I’d rather the piece of paper they’re holding, and reading, is the information about their disease unless the prescription is fairly complicated like a reducing dose or an escalating dose of something. But almost always where I work the pharmacist does that mahi [work].’ [GP 3]

Although both GPs and pharmacists agreed it was more convenient for patients when the system worked and the medicine was ready, pharmacists expressed mixed views on the effect of the change on their interactions. Two perceived little effect, but the other two commented on lost opportunities to build rapport and receive information from patients before dispensing.

‘It’s amazing how much information we glean from the patient of changes, brand, all of that. So we lost that source of information for us.’ [Pharmacist 3]

‘I think we still interact with patients the same way, you just miss that initial [interaction], but you make up for it [later] with your counselling and … [the patients] seem satisfied.’ [Pharmacist 1]

A key challenge of the new process related to getting the timing right, understanding the timing and managing patient expectations.

‘I’ve noticed recently the patients would see the doctor and then come straight away but the prescription just hasn’t turned up on our end and they would expect it. They would say but the doctor sent it while I was there, why isn’t it here?’ [Pharmacist 1]

‘If I had a better idea of what the processing time was … Some will just go shopping and then come back and collect it. But if it’s going to take 2 hours… what I’ve generally done is said take the hard copy through next door because that will take priority, that’s what I’m assuming.’ [GP 1]

Figuring out these delays was a new type of issue to deal with:

‘Particularly initially if [the prescription] wasn’t there it was unclear which part of the chain had failed. Was it that we’d sent it to the wrong pharmacy? Was it that the e-mail system was hooked up and it hadn’t sent off the e-mails?’ [GP 2]

Participants generally agreed that interactions between pharmacists and GPs had not been adversely affected; however, one participant suggested that relationships between the wider pharmacy and medical centre staff may have been tested because they may be more involved in troubleshooting missing or delayed prescriptions.

There were examples of use of the new channels for practitioner-to-practitioner communication, including letting pharmacists know that a dose change was intentional, to request pharmacists’ help to explain a complicated dosing regimen or explain about withholding medication in acute illness:

‘We’ve got some patients with reduced renal function who are on metformin, for example, and if they were to be dehydrated or get gastro you want them to stop their metformin; those sorts of things that you just cut and paste into Doctor Info [facility to send message to pharmacist].’ [GP 3]

In some cases, the tools embedded in the system were used by prescribers to request that pharmacists communicate to patients certain information (eg the need for a blood test or blood pressure check). However, it also seemed that some tools were often not used due to unknowns and even ‘dead-ends’, where only a certain number of communication exchanges were possible.

‘They can send us a message as well but I cannot reply to that particular message. It’s not a two-way communication. … they don’t know that we’ve read it or not, and they don’t know our response until a few days later a new prescription turns up in their pharmacy. So, a way for us to [say] … oh yep, I’ll change this.’ [GP 4]

Unknowns included where responses to messages end up:

‘We don’t know what happens to it, whether they only see that note if they go back into that patient, does it only come up for that prescription?’ [Pharmacist 4]

Similarly, when asked about the possibility of replying to the email that had been used to send the prescription, one pharmacist commented they were unsure whether the reply would get to the individual doctor.

Despite GP participants commenting on their wish for pharmacists to be able to contact them when needed for clarifying prescriptions, pharmacists still mentioned experiencing difficulty with this. Participants were generally hopeful for the potential for new electronic communication solutions:

‘It’s quite hard to reach a doctor so it would be quite nice to have some sort of communication method to interact with them without having to bother them … It would have to be collaborative. You’d have to talk about it to make sure everyone is on board with it.’ [Pharmacist 1]

‘It would be good if there was a good system for those sorts of communications. Nothing complicated but, you know, actually you’ve got the wrong quantity here, can you please amend? It ought to be able to be done electronically...’ [GP 2]

A challenge is understanding the implications on each other and limitations of the tools that affect each other’s practise:

‘It’s actually quite good talking to the GPs saying so this is how we’re struggling. OK that makes sense why it’s happening at your end because you don’t know it pushed send so you keep pushing send, which is cancelling the one we’ve got... It’s almost like you need to get a pharmacy computer and a GP computer next to each other just to see what happens.’ [Pharmacist 4]

The findings of this study suggest that enabling electronic transmission of prescriptions direct from prescriber to pharmacy has had a transformative effect on the workflow of NZ GPs and community pharmacists. However, certain areas need attention if the positives are to be embedded and expanded, and negatives mitigated. Local evaluation is important because of the influence of the technical systems used by health-care practitioners and the potential for unintended consequences and new issues.^9,11 The substantial uptake of NZePS during the pandemic response to enable electronic transmission of prescriptions accentuates the need for evaluation and refinement now more than ever.

There were both positives and negatives for pharmacists’ workflow. One key area requiring resolution is ensuring that the systems underpinning the change to electronic transmission are not only designed to increase dispensing efficiency, but also to support pharmacists’ clinical checking processes. We found that it was not easy for pharmacists to review the patient’s history before dispensing, which was consistent with findings internationally reported in as early as 2012,¹² highlighting the need to learn from others’ experiences. Systems that facilitate clinical review before dispensing will also be needed to make use of the extended roles of pharmacy technicians in final accuracy checking of dispensed products.¹³

Similarly, although saving time was a major benefit for GPs, the effect of speeding up the prescribing process may need consideration from a professional practice perspective. One participant described the need to build in an intentional slow moment to review the final prescription before clicking ‘send’. Training and ongoing support have been identified as important to ensure systems can best support safe prescribing.^14,15 GPs appreciated the increased work flexibility of being able to send prescriptions electronically. This may help explain a recent Australian survey finding of a strong association between physician use of digital health technology and high job satisfaction and work–life balance.¹⁶

For GP participants, there was little perceived change in interactions with patients. International research suggests that patients appreciate the improved convenience of electronic prescription transmission.¹⁷ Early reports of the impact of virtual consultations in NZ indicate the likelihood of a similar finding here.^18,19 However, the mixed views of pharmacists about the impact of the change on patients, together with the inherent potential for variable patient experiences implied by the ‘juggling timing and expectations’ theme, indicate further investigation is warranted. Understanding and resolving the issues of timing and expectations, such as patients arriving in the pharmacy before the prescription, is important to preserve relationships and successfully consolidate this new process. Delays in pharmacies receiving prescriptions have been reported internationally and there may be simple technological fixes such as ensuring prescriptions are sent in real time rather than batches.⁷

Some pharmacists were mindful of the reduced number of patient interactions potentially limiting opportunities for relationship building and information exchange. This concern has also been identified by patients in a US study of their perceptions of electronic transmission of prescriptions.²⁰ However, other participants perceived minimal impact. It is possible that there may be benefits from a single but longer block of time with the patient. Given the potential role of pharmacist-patient relationships in optimising outcomes from medicines, how time with patients is used is an important consideration for professional practice.^21,22

Participants in this study described encouraging examples of the communication tools embedded in the systems being used for interprofessional collaboration. The need for a team approach to communicating about medicines was highlighted by recent studies undertaken in Hawkes Bay.^23,24 The inclusion of the indication on prescriptions is another communication opportunity, enabled by technology, that has been previously identified as helping pharmacists reinforce physicians’ patient education.^9,25

Pharmacists and GPs both felt the opportunity for the systems to deliver transformation in prescription-related communication practices between prescribers and pharmacists was yet to be fully realised. Although some tools were built in, participants described pitfalls such as not knowing where messages ended up or when they had been read, and a limited number of interchanges. Clarification of prescription issues is one of the most common communications between pharmacists and GPs, and multiple factors contribute to making this currently suboptimal and more time-consuming than necessary,^26–28 so the benefits of improving the communication technology are potentially substantial for interprofessional interactions and relationships. Providing a channel for efficient, effective communication about prescription issues could create time and opportunity for more collaboration on medicines optimisation. In the future, there may be opportunity to include patients as well with tools such as the shared electronic medication plans described in a recent Swiss study.²⁹

A key strength of this study was combining the perspectives of both GPs and pharmacists to provide a holistic understanding in contrast to the professional silos common in health care. We acknowledge that including perspectives of patients would provide an invaluable focus for future investigations. Drawing data from a small purposive sample is a limitation.

At policy level, an integrated approach to evaluation and governance that brings together key stakeholders such as prescribers, dispensers, software developers and patients will help to ensure the current system continues to evolve to meet user needs and support patient safety.

The change to electronic transmission of prescriptions direct from prescriber to pharmacy is transforming workflow in NZ primary health care. Further work is needed to fully realise the potential for electronic transformation of prescription-related team communication. Likewise, there appears to be room for further streamlining to smooth timing issues, which may have an effect on patient experience.

The authors of this paper have no competing interests to declare.

This research did not receive any specific funding.

The data that support this study will be shared upon reasonable request to the corresponding author.