E-prescription: views and acceptance of general practitioners and pharmacists in Greater Sydney

Introduction

Telehealth was introduced in Australia in 2011 to reduce barriers of distance, time, and cost, and improve access to care particularly for rural and remote populations (Australian Government Department of the Prime Minister and Cabinet 2011). During the COVID-19 pandemic lockdowns, telehealth’s benefits of providing protection to healthcare providers (HCPs) and the community from exposure to infectious diseases, and the introduction of government subsidies, substantially increased its use under Medicare (Taylor et al. 2021; Australian Government Department of Health and Aged Care 2022a, 2022b). In May 2020, the implementation of electronic prescription (e-prescription) was expedited to complement telehealth as part of the Australian government’s response to the pandemic. The overarching aim was to provide convenience and choice to patients and improve the efficiency of prescribing and dispensing medications, reduce errors, and minimise the use of paper prescriptions (Australian Government Department of Health and Aged Care 2022c).

Prescriptions for medications have historically been hand-written, or printed and hand-signed on paper by medical practitioners, and provided to patients who present them to pharmacists for dispensing (Tsirtsakis 2020; Australian Digital Health Agency 2021–2022; Australian Government Department of Health and Aged Care 2022d). There are, however, many inherent issues with paper prescriptions including errors due to prescribers’ poor handwriting and security issues with lost, stolen, or forged prescriptions (Velo and Minuz 2009; NSW Government 2023). As our world advances with technology, e-prescriptions are increasingly used (Samadbeik et al. 2017; Wrzosek et al. 2020). Patients in Australia can receive a paper prescription or, alternatively, choose an e-prescription where they receive a ‘token’ (QR code or barcode) either on paper, via SMS, email, or a mobile app, that can be scanned and dispensed by pharmacists (Australian Digital Health Agency 2022a, 2022b). Patients can also use a token management system, ‘Active Script List’ (ASL), with their chosen doctors and pharmacists, to organise multiple medications (Australian Government Department of Health 2021; Australian Digital Health Agency 2022a).

A systematic review of the perceptions of users (including physicians, nurses, pharmacists, patients, IT staff, and managers) of barriers and facilitators to the implementation of e-prescription in primary care highlights the importance of technical and organisational support (e.g. information technology, and material and human resources) and attitudes of users (e.g. users who do not believe in the value of e-prescription) on the adoption of e-prescription (Gagnon et al. 2014). A survey that explored the factors impacting doctors’ acceptance of e-prescribing found considerable barriers, criticisms, and resistance from doctors to the implementation and utilisation of the new technology in Poland whose approach is similar to that in Australia (Wrzosek et al. 2020). In a comparative analysis of e-prescription systems in eight countries, the lack of technological infrastructure was identified as a barrier to the adoption of e-prescription in Australian telehealth (Aldughayfiq and Sampalli 2021; Fisher et al. 2022).

E-prescription is a relatively new technology and understanding users’ experience is critical to its continuing design. This study aimed to explore Australian general practitioners (GPs) and community pharmacists’ experience with e-prescription, and the facilitators and barriers to its use.

Research question

What are the experiences, benefits (or facilitators) and challenges (or barriers) of e-prescription for Australian GPs and pharmacists?

Methods

Results

Eleven GPs – four of whom were GP registrars – and nine pharmacists were interviewed May–June 2022; they consisted of seven males and 13 females; they were aged (years) in their 20–50s; and had professional experience ranging between 2 and 32 years (Table 1). All participants had experience with e-prescription. Eight interviews were conducted via zoom, four by phone, and eight in-person, the durations of which lasted 7–30 min.

Thirteen themes were elicited, seven of which were categorised as benefits (facilitators) and six were challenges (barriers). Four facilitator themes were mapped to the TAM construct of ‘perceived usefulness’; and one facilitator and two barrier themes were mapped to the TAM construct of ‘perceived ease of use’. Themes that fell outside these constructs were separately categorised: four barrier themes were identified under the category ‘other issues with e-prescription’, and two facilitator themes were identified under the category ‘suggestions to improve’. Table 2 gives an overview of the themes and categories.

Data saturation both in the themes elicited and the meaning of the themes was determined by the team to have been reached.

The 13 themes are discussed below against the TAM constructs and the two additional categories to illustrate how they acted as barriers and facilitators to the acceptance of e-prescriptions by HCPs.

Discussion

This qualitative study explored Australian GPs and community pharmacists’ experiences of e-prescription, and the facilitators and barriers to its use. Findings reveal many facilitators from the perspectives of HCPs. Using the two TAM constructs (perceived usefulness and perceived ease of use) to map the facilitators and barriers enabled a better understanding of the impact of different factors on the acceptance and use of e-prescription by our participants. They perceived e-prescription to be useful, as described in TAM, because it provides convenience, addresses paper prescription issues, reduced barriers to access during the COVID-19 pandemic, helps patients to manage multiple prescriptions, and its process is easy. Education and training for HCPs and consumers and a more streamlined e-prescription system are also potential facilitators. However, HCPs had mixed perceptions about e-prescription’s ease of use described in TAM. Whilst they perceived that the e-prescription process was easier than the paper prescribing and dispensing processes, they were challenged by the lack of information for HCPs and consumers, and technological issues. There were other challenges to the acceptance and use of e-prescription that were outside the TAM constructs of perceived usefulness and perceived ease of use, like patients’ reluctance to change, patient expectations and lost opportunities to physically review patients, perceived inadequate governmental governance, and ongoing costs associated with e-prescription. Our results did not indicate any difference between the experiences of GP registrars and vocationally registered GPs, or between GPs and pharmacists. They mostly faced similar issues albeit from different perspectives, for instance, both GPs and pharmacists perceived e-prescriptions to be convenient, but poor handwriting and missing information with hand-written paper prescriptions were the issues for pharmacists, whereas the handwriting load of paper prescriptions was the issue for GPs.

The benefits of contactless e-prescription became particularly evident when its implementation was fast tracked as part of the Australian government’s response to supporting telehealth during the COVID-19 pandemic (Australian Government Department of Health and Aged Care 2022c). E-prescription not only facilitated healthcare access, it also decreased the risk of infections. Experience with e-prescription around the world has consistently reported a significant reduction in unnecessary visits to GP clinics for prescriptions, patients’ wait time at the pharmacy, and handling of paper prescriptions, which directly minimised COVID-19 infection transmission risks (Aldughayfiq and Sampalli 2021).

Compared to paper prescriptions, e-prescription processes of dispensing medications, tracking patients’ medication history, managing patients’ prescriptions, and making prescriptions more accessible were more convenient for the HCP participants in our study. Bulut et al. (2019) conducted a survey of 1564 family physicians in Turkey, and reported similar satisfaction with e-prescription in the management of patients’ medications, facilitation and simplification of prescription writing, and optimisation of time.

E-prescription seemed to reduce GPs’ handwriting and administrative load, and their burden of re-issuing prescriptions to replace lost prescriptions or repeats. Although existing medical software stores patients’ information and automatically completes relevant details into a prescription for printing, the e-prescription system is additionally able to send the prescription directly to the pharmacy, eliminating third-party involvement. The prescription QR code is electronically stored in the system and can be easily retrieved, verified, and re-issued. Bulut et al.’s (2019) survey also identified e-prescription’s ability to store patients’ details, provide information regarding past medication history, and efficiently facilitate the process of writing prescriptions.

Elimination of the handwriting component of prescribing means that printed prescriptions and e-prescriptions also eliminated the burden for pharmacists to verify illegible doctor handwriting. A 2014 systematic review similarly reported that e-prescriptions increase prescription legibility, decrease prescribing time, and decrease medication errors (Porterfield et al. 2014).

Safety issues, such as prescription fraudulences, are minimised since it is harder to forge an e-prescription, and the QR code automatically becomes invalid once dispensed. Enhanced legitimacy and trackability of e-prescription for DDs also reduced the legal burden placed on pharmacists. Reviews of the e-prescriptions of controlled substances (EPCS) in the United States similarly described an increase in patient’s safety as fraud, forgery, medication pad theft, and illegitimate dose alteration were reduced, and an electronic record significantly assisted in addressing opioid misuse and diversion (Gabriel et al. 2016; Achar et al. 2021).

A key barrier to effective use of e-prescription is the lack of information provided to HCPs and patients during implementation, particularly at the start of the COVID-19 outbreaks in 2020. This challenge was also described in the e-prescription pre-implementation phase in Indonesia (Oktarlina 2020). Adequate information for HCPs and patients is necessary to ensure the continuation of e-prescription post-COVID-19.

Technical issues, such as internet and cellular reception requirements, unfamiliar e-prescription systems, and low digital literacy in some patients, are major challenges. Interviews with community pharmacy professionals that adopted the Electronic Prescription Service in England reported similar technical issues such as glitches, missing prescriptions, and download problems (Harvey et al. 2014).

Many participants perceived e-prescriptions to be especially demanding for older patients. They said that e-prescription SMS links without adequate information regarding the status of the prescriptions are particularly confusing for patients with multiple prescriptions and repeats for chronic illnesses because they had to scroll through many similar looking links. However, a survey of 75 participants of average age 66.9 ± 9.3 years in Pittsburgh, Pennsylvania, found that 84% preferred e-prescriptions over paper prescriptions for reasons of convenience, time optimisation, and prevention of lost prescriptions (Schleiden et al. 2015). More than half took four or more prescription medications daily, and about 20% took six or more. This shows that patients’ age and technological ability are not reasons for the challenge of managing multiple e-prescriptions in the system. Improving the software, for instance optimising the display of tokens and the amount information provided, would significantly improve the utility for patients, especially patients with chronic diseases and on multiple medications.

E-prescription has inadvertently altered the communication between doctors and patients as consultations become prescription orientated with minimal in-person contact or follow up. Our participants talked about the potential overuse of telehealth consultations and a reduction in regular physical examination opportunities, and increased likelihood of misdiagnosing or sub-optimal prescribing. Broader issues of telemedicine disrupting doctor-patient relationships and doctors’ ability to perform physical examination, and the risks of increased morbidity and mortality rates are ongoing concerns for many medical practitioners (Burroughs et al. 2020).

Some participants perceived an absence of governmental regulations for e-prescription and were concerned about their increased risks and liability of privacy and information breaches. A review of the impact of e-prescription on pharmacists and patients likewise found virus attacks, patients’ privacy invasion, and criminal compromise of the system to be concerns (Lanham et al. 2016).

The continual uncertainty of government subsidies and speculation that e-prescription costs will eventually be passed to prescribers were concerning for some GP participants (Australian Medical Association 2021, 2022; Liotta 2022). This concern is congruent with the findings of a systematic review that suggested implementation cost to be a financial toll (Porterfield et al. 2014). Long-term vision and a sustainable funding model are critical to providing clarity and confidence for HCPs to support provision and uptake of e-prescription beyond the COVID-19 era (Liotta 2022). In March 2022, the Department of Health requested tender applications from electronic prescribing service providers to try to ensure the ongoing improvement and continuation of e-prescription (Australian Government 2022). This 4 year contract was awarded in May 2023 to pharmacy IT solutions provider Fred IT who promised that the e-prescription service would continue without additional financial burden for patients, HCPs, and prescribing and dispensing software vendors (Ang 2023; Australian Government Department of Health and Aged Care 2023).

Our findings suggest that education and training are needed to promote and assist in the transition from paper to e-prescriptions. The Australian Digital Health Agency currently fills this gap by providing online e-prescription training and resources for HCPs (Australian Digital Health Agency 2023). Other possible facilitators include shifting e-prescriptions to a more streamlined system, creating a universal app that allows better access, and a clearer and more secure process of changeover. The provider tendered eventually to provide the e-prescription service in Australia should take these facilitators into consideration (Australian Government 2022). Not only is Fred IT promising increased cyber security and greater protections against clinical risks, enhanced capacity for all users will also be expected as part of their deliverables. With appropriate improvement, e-prescription will be the way of the future.

Considering the different factors through the lens of TAM helps us to understand the reasons HCPs and patients choose to use e-prescription (Davis 1989). There are other variables, including attitudes, professional opinions, and economic considerations, outside the TAM that drive individuals’ acceptance and usage of e-prescription. We need to enhance or resolve these perceptions and explore solutions to increase adoption by potential users. With appropriate improvement, e-prescription will be the way of the future.

The main strength of this study is the in-depth qualitative approach and the use of the TAM to organise the facilitator and barrier factors to gain a comprehensive understanding of e-prescription from the perspectives of GPs and community pharmacists. However, our participants were predominantly from the Greater Sydney region which may limit generalisability of the findings. We also did not collect information on whether the GP participants worked in bulk-billing, mixed-billing, group, or solo practices which may have aided further understanding of nuances between the groups. Furthermore, we did not manage to recruit any participant with no experience of e-prescription, which would have added perspectives from another angle. However, this research was conducted more than 2 years after the introduction of e-prescription and so most HCPs would have used e-prescription by then.

Conclusions

Transition from the established paper prescription to the more technology-driven e-prescription had sparked mixed opinions from HCPs. In general, HCPs perceive e-prescription to improve the quality of patient care, and there are several facilitators and barriers. These enable us to understand their perceptions of usefulness and ease of use, and other factors that influence their adoption of e-prescription. Findings may inform future promotion and use of e-prescription, and ensure continued optimisation of the system particularly post-COVID-19 pandemic. Further research should explore consumer perspectives of e-prescription.