Review
Barriers and facilitators to implementing electronic
prescription: a systematic review of user groups’
perceptions
Marie-Pierre Gagnon,1,2 Édith-Romy Nsangou,1 Julie Payne-Gagnon,1 Sonya Grenier,1
Claude Sicotte3
▸ Additional material is
published online only. To view
please visit the journal online
(http://dx.doi.org/10.1136/
amiajnl-2013-002203).
1
Correspondence to
Dr Marie-Pierre Gagnon,
Centre de recherche du CHU
de Québec, 10, rue de
l’Espinay, D6-726, Québec
(QC), Canada G1L 3L5;
marie-pierre.gagnon@fsi.ulaval.ca
Received 15 July 2013
Revised 5 September 2013
Accepted 3 October 2013
Published Online First
15 October 2013
INTRODUCTION
To cite: Gagnon M-P,
Nsangou É-R, Payne-Gagnon J
et al. J Am Med Inform Assoc
2014;21:535–541.
Prescription and renewal of patient drugs are among
the most commonly used treatments in primary
care.1 The prescription process is a major concern
for public health policies and efforts are required to
promote the continuous improvement of optimal and
adequate prescription in primary healthcare. Studies
have shown that errors related to drug prescription
are common and avoidable2; they are also the cause
of a high level of morbidity and mortality recorded
among populations.3–5 Taking into account the
increased complexity of health conditions caused by
an aging population and multi-morbidity, patients’
exposure to iatrogenic damage caused by drug
Gagnon M-P, et al. J Am Med Inform Assoc 2014;21:535–541. doi:10.1136/amiajnl-2013-002203
misuse and interactions is likely to grow in proportion to these changes. It is therefore essential to
improve the quality and safety of prescribing, as well
as optimize the use of medicines, making it a priority
for current health policies.2
In this context, the computerization of prescriptions based on modern information and communication technologies (ICT) is supported in many
developed countries.6 Electronic prescription
(e-prescribing) is intended to be an inter-operational
platform which facilitates the exchange of patients’
drug therapy information between health professionals and organizations in primary care and community pharmacies.7 E-prescribing can improve the
drug prescription process by responding to specific
user needs as well as reducing inconsistencies.2
E-prescribing is a promising technology that has the
potential to improve the quality of drug use especially in ambulatory and primary care, where treatments for chronic diseases are used for extended
periods.8
Motulsky et al9 indicate that stakeholders in
many countries have made considerable efforts
in order to promote the widespread use of
e-prescribing by health professionals. However,
despite major investments and widespread availability of e-prescribing systems, health providers do not
always make use of this technology for prescribing
and renewal of treatments.10–13
Cresswell et al2 assert that e-prescribing management computer systems implemented in medical
clinics vary considerably in terms of functionality,
level of interoperability, cost, and involvement of
stakeholders in the strategic choices related to the
implementation of these technologies. Problems such
as a predetermined deficit in norms governing the
attribution of public contracts, a lack of functional
specifications for choices that stakeholders have
adopted, and a lack of harmonization in the systems
implementation strategies may also accentuate the
degree of implementation of e-prescribing.14 15
As main users of e-prescribing systems, healthcare
professionals are best positioned to identify the barriers and facilitators they face in their work environment that could affect the success of these systems.
However, most studies related to e-prescribing
implementation in primary care are fairly recent and
few have addressed end-users’ perceptions of barriers and facilitators in the implementation process.7
Considering users’ perceptions of barriers and facilitators to the implementation of e-prescribing
systems could help reveal which implementation
strategy could be successful.
535
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Public Health and PracticeChanging Research, Centre de
recherche du CHU de Québec,
Québec, Canada
2
Faculty of Nursing Sciences,
Université Laval, Québec,
Canada
3
Department of Health
Management, Université de
Montréal, Montréal, Canada
ABSTRACT
Objective We conducted a systematic review
identifying users groups’ perceptions of barriers and
facilitators to implementing electronic prescription
(e-prescribing) in primary care.
Methods We included studies following these criteria:
presence of an empirical design, focus on the users’
experience of e-prescribing implementation, conducted
in primary care, and providing data on barriers and
facilitators to e-prescribing implementation. We used the
Donabedian logical model of healthcare quality (adapted
by Barber et al) to analyze our findings.
Results We found 34 publications (related to 28
individual studies) eligible to be included in this review.
These studies identified a total of 594 elements as
barriers or facilitators to e-prescribing implementation.
Most user groups perceived that e-prescribing was
facilitated by design and technical concerns,
interoperability, content appropriate for the users,
attitude towards e-prescribing, productivity, and available
resources.
Discussion This review highlights the importance of
technical and organizational support for the successful
implementation of e-prescribing systems. It also shows
that the same factor can be seen as a barrier or a
facilitator depending on the project’s own circumstances.
Moreover, a factor can change in nature, from a barrier
to a facilitator and vice versa, in the process of
e-prescribing implementation.
Conclusions This review summarizes current
knowledge on factors related to e-prescribing
implementation in primary care that could support
decision makers in their design of effective
implementation strategies. Finally, future studies should
emphasize on the perceptions of other user groups, such
as pharmacists, managers, vendors, and patients, who
remain neglected in the literature.
Review
In order to expose these barriers and facilitators, we conducted an exploratory systematic review on the implementation
of e-prescribing in the daily work setting of primary healthcare
providers. This review sought to answer this question: What are
users’ perceptions of barriers and facilitators to e-prescribing
implementation in primary care?
METHODS
Search strategy
An information specialist developed the literature search strategy
from the research question. We searched PubMed to identify
applicable articles published within a period of 10 years (from
January 1, 2002 to December 11, 2012), in order to focus on
more contemporary systems. See online supplementary appendix 1 for search parameters used.
Selection criteria
Screening, data extraction, and presentation
Two authors (ENS and SG) independently reviewed all titles
and abstracts and reached consensus on included studies.
A third author (MPG) confirmed included and excluded studies.
Full text review of the selected studies was done by three
authors ( JPG, ENS, and SG).
We used a validated data extraction grid from previous
research on the classification of barriers and facilitators to ICT
implementation in healthcare settings.16 The data extraction
grid developed used both inductive and deductive methods, following established theoretical concepts,17–19 particularly the
technology acceptance model20 and the diffusion of innovations
theory.21
We developed the data extraction grid in Microsoft Excel
2010. We took all included publications, and three reviewers
(ENS, JPG, and SG) independently read and identified sections
of the publications that presented a relevant barrier or facilitator
to the implementation of e-prescribing from the users’ perspective. ENS and JPG coded these selected sections in the program.
We also extracted data regarding: year of publication, country,
study design (quantitative, qualitative, or mixed-methods), theoretical framework ( present or absent), type of participants,
536
Study quality assessment
We used the mixed methods appraisal tool (MMAT)—a scoring
system which presents evaluation criteria for quantitative, qualitative, and mixed-methods studies—proposed by Pluye et al,25
for appraising the quality of included studies. Two authors (ENS
and JPG) independently screened each study and gave it a
quality score. No studies were excluded based on their scores
(results for quality assessment available on request).
RESULTS
Included studies
In total, we identified 230 references from bibliographic databases, of which we retained 44 publications for full-text review.
After applying the inclusion criteria, we excluded 10 of these
publications: four were not about e-prescribing, two did not
mention barriers or facilitators, two did not possess an empirical
design, and two did not concern primary care. The review
therefore included 34 publications,1 7 9 12 13 26–54 corresponding to 28 individual studies, because paired publications by
Abramson,28 34 Crosson,30 50 Grossman,7 33 Lapane and
Goldman,38 42 Weingart,44 47 and Tamblyn49 53 were considered
as one study. The number of studies included at various stages
of the review process is described in a study selection flow
diagram (figure 1).
Characteristics of included studies
The characteristics of included studies are summarized in online
supplementary appendix 2. The most frequent types of technology
covered
were:
e-prescribing
system
(n=20
studies),9 13 26 27 29–32 35 38–44 46–51 53 54 electronic health
records (EHR) with e-prescribing system (n=4),28 34 37 45 52 both
of these systems (n=3),1 7 12 33 and the personal digital assistant
(PDA)36 with prescribing software and drug information.
Computerized physician (or prescription, or provider) order entry
systems (CPOE) were considered in the search, but not included
since they are traditionally used in secondary and tertiary care
and are confined within hospital settings,55–58 which are not the
focus of this review.
The majority of studies took place in North America (n=22,
78.6%). Of those, 20 are from the USA1 7 12 13 26–31 33–39
41 42 44 47 48 50 51 54
and two are from Canada.9 49 53 A smaller
number of studies (n=5, 17.9%) were conducted in European
countries: Sweden (n=3)40 43 45 and the UK (n=2).32 52 We
also included one study from Singapore.46 All studies were published since 2005 and more than half of the included articles
were published since 2010 (n=20, 58.8%).
Twelve studies (42.9%) exclusively involved physicians,1 12 13 27 28 34 36 37 43–45 47 49 53 54 while another two
studies targeted exclusively pharmacists (7.1%).35 40 Six studies
included physicians and their staff (21.4%),30 31 38 39 41 42 50 52
three studies involved pharmacists and their staff
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We included studies with an empirical design, either qualitative,
quantitative, or mixed-methods. These studies should present a
clearly stated data collection process as well as research methods
and measurement tools used. As such, editorials, comments,
position papers, and unstructured observations were excluded
from this review.
Included studies focused on the users’ experience of eprescribing implementation. User groups considered included:
physicians, clinical staff (including nurses), pharmacists, pharmacy staff, and others ( patients, IT staff, and managers). We
included studies that took place in primary care (including
ambulatory or community healthcare settings). However, studies
involving secondary and tertiary care levels could also be
included, as long as there was a linkage of the e-prescribing
system with primary care settings.
Also, studies had to provide data on barriers and facilitators
to e-prescribing implementation in their results or discussion
sections to be included. These barriers or facilitators had to be
based on empirical evidence.
If a study was reported in more than one publication and presented the same data, we only included the most recent publication. However, if new data were presented in multiple
publications describing the same study, all were included.
Publications were not excluded based on language used.
care setting, technology used, objectives of the study, data collection methods, and main findings.
We used the logical model of healthcare quality proposed by
Donabedian, coupled to the themes proposed by Barber et al,22
as the analytical framework for summarizing our findings.23 24
We transposed extracted data into this framework using thematic analysis. This framework highlights e-prescribing users’
perceptions under the dimensions of system functionality,
human perspectives, and organizational factors defined by
Barber et al,22 23 which are classified according to the structure,
process, and outcomes categories from the Donabedian’s model,
thus providing a 3×3 thematic classification matrix.
Review
Figure 1 Study selection flow
diagram.
Results presentation
We grouped factors representing barriers and facilitators to
e-prescribing implementation into the nine broad themes of the
analytical framework. Each theme is divided into factors representing the content extracted from the publications (explanation
for each term used can be found in figure 2). Nearly all factors
were perceived both as a facilitator and as a barrier, depending
on the context. It is worthwhile to mention that overall more
facilitators (332) than barriers (264) were mentioned. The
majority of factors were common to all user groups. A summary
of extracted data is presented in table 1 (see online
Figure 2 Definition of the terms
used in the review.
Gagnon M-P, et al. J Am Med Inform Assoc 2014;21:535–541. doi:10.1136/amiajnl-2013-002203
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(10.7%),26 32 48 and five studies (17.9%) include more than one
of these groups and/or other types of users.7 9 29 33 46 51
Twelve of the studies (42.9%) were quantitative, primarily
using surveys.13 27 31 35 36 40 43 45 46 48 49 53 54 Eleven studies
(39.3%) had a qualitative research approach, using one or more
of the following data collection methods: interviews, focus
groups, questionnaires, observations, and document analysis.1 7 9 12 26 30 32 33 39 41 50–52 Five studies (17.9%) used a
mix of both approaches.28 29 34 37 38 42 44 47 More than one
third of the studies (35.7%) included a theoretical
framework.9 26 31 32 35 36 39 40 53 54
Review
supplementary appendix 3 for full classification). Results regarding each of the nine themes from our analytical framework are
presented below.
System functions
Structure
Design and technical concern aspects of e-prescribing implementation was the most frequently mentioned factor, extracted 82
times over the 90 elements of that theme. This factor was
mostly considered as a barrier to e-prescribing implementation
by all user groups. The most frequently mentioned barriers were
the limitations related to software or hardware, and system problems (ie, prescriber had to manually replace data, complexity
of the commercial system, or inadequacies of current
e-prescribing product).1 7 9 13 26–31 33 34 38 40–42 44 46–48
50 51 53 54
Other factors belonging to this theme were reported
by physicians and pharmacists who had concerns about the
system reliability or dependability (7)7 30 31 45 51 as well as
quality standard (1).38
Interoperability (43 elements), involving more than one organization and/or setting of care, was cited three times more frequently as a barrier (32 times)7 13 26–28 37 38 42 45–48 51 54 than
as a facilitator (11 times)7 28 29 39 42 44 46 48 54 for e-prescribing
implementation. Generally, inadequate interfacing with other IT
systems was considered as a barrier by users and was mainly
related to the uncertainty about which local pharmacies accept
electronic prescriptions. Content appropriate for the user (27)
was perceived as a barrier when prescribing history was not
updated,31 33 and did not present clinically relevant data allowing an overview of patient adherence to their prescriptions.33 49 51 An overwhelming number of different forms and
strand medications available in a search query or a low level of
confidence in formularies were also mentioned as barriers.1 7 26 42 52 Otherwise, the possibility to have an overview
of patient drugs,33 45 47 a follow-up of patient adherence to
their prescriptions,42 as well as access to lab results51 were mentioned as facilitators to e-prescribing implementation. Moreover,
reminders for patient with chronic disease52 and electronic
medication renewal38 47 were appreciated by physicians.
Outcome
Overall, the perception that e-prescribing would improve
patient security (21 elements) was a facilitator to its implementation.7 13 28 34 35 37 40 41 43–48 51 54 Moreover, physicians
reported that e-prescribing would increase the quality of
care.7 13 41 43–45 Satisfaction about content available
(21)1 7 9 13 26 28 30 33 36 39 44 45 51 54 and data accuracy and
legibility (22)7 13 26 36 37 39 40 44 46–48 were also reported as
important outcomes of the system function. Physicians
reported privacy and security concerns (7) as barriers at preimplementation, but the system is reported to be safe
post-implementation.9 39 40 43 54
Human perspective
Structure
Agreement with e-prescribing was the most cited factor of this
theme (31 elements). Resistance to change was observed
among physicians, particularly when they did not see an added
value of e-prescribing9 13 36 or when they perceived inadequate decision support.49 52 Also, they did not want to solve
implementation problems and believed this should be done by
clinical staff.41 50 51 Practice using both prescribing systems
(traditional and electronic) at the same time generally discontinued the implementation process of e-prescribing until the
expected final adoption.1 7 50 51 However, physicians and
pharmacists who were voluntarily enrolled in the program had
more favorable opinions and positive attitudes about the technology.7 30 37 45–47 50 53 54 Clinical staff considering the
e-prescribing benefits welcomed the opportunity to expand
their job responsibilities.1 39 51 Pharmacy owners were resistant
to e-prescribing implementation when it involved a top down
decision from pharmacy chains and preferred to trust their
Table 1 Users’ perception in relation to the principal factors raised in the studies
Factor raised by:
Factor raised by:
Themes
System function
P
CS
Ph
PhS
O
Human perspectives
P
CS
Ph
PhS
O
Organizational
factors
Structure
Design and technical
concerns
X
X
X
X
X
X
X
X
X
X
X
X
X
X
Process
Outcome
Interoperability
X
X
Content appropriate for
user
Alerts
X
Patient’s security
Satisfaction about
content available
Data accuracy and
legibility
X
X
X
X
X
X
X
X
X
X
Welcoming/resistance to
e-prescribing
Familiarity and ability
with IT
Perceived ease of use
Perceived usefulness
Perception of risk-benefit
equation
Productivity (efficiency)
X
X
X
X
Patient/clinician
interaction
Times issues
Observability
X
X
X
X
X
X
X
X
X
X
X
P
CS
Ph
PhS
Resources
X
X
X
X
X
X
X
X
X
Implementation
strategies
Macro organization
X
X
X
X
X
X
X
Professional
interaction
Work process
X
X
X
X
X
X
X
X
X
X
Organizational
support
Change in task
Cost issues
X
X
X
X
X
Factor raised by:
X
X
X
O
X
X
CS, clinical staff (nurses, practice staff); O, others (managers, patients, IT staff); P, physicians; Ph, pharmacists; PhS, pharmacy staff.
538
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Process
Alerts (17) were reported as barriers due to their frequency
and their lack of relevance,27 28 39 47 51 52 but were considered useful when prescribing an unfamiliar medication to
avoid harmful interactions, to look something up in a drug or
medical reference, or to change the way they monitored a
patient.28 34 44 46 47 51 Lack of generic substitution options
(5) or lack of its flexible options was also reported as a
barrier.9 27 33 53
Review
own systems regarding prescriber and practice contact
information.1 9
Factors specific to the e-prescribing structure also included perceived usefulness (12),33 36 37 40 41 47 51 ease of use
(13),13 26 28 33 36 39–41 44 45 47 familiarity with technology
in general or with e-prescribing (14),7 9 13 36 45 46 48–50 53
patients’ attitudes and preferences towards e-prescribing
(7),7 37 43 44 47 51 54 and self-efficacy (belief in one’s competence
to use the e-prescribing) (4),38 39 46 standing for half of the elements of this theme.
We found eight other factors related to human perspective
linked to the structure (representing a total of 38 elements), but
these were less cited in the studies (eg, socio-demographic characteristics like age, gender, and experience, and support and promotion of e-prescribing by colleagues).
Process
Outcomes
Time issues represented 16 of the 35 extracted elements for that
theme. Physicians and pharmacists have reported gains in time
at post-implementation stage,29 35 37 38 43 45 54 but this was not
the case at the pre-implementation or transition phases, where
they believe that it was not the best use of their time.27 41 50
However as an outcome expectancy (8), physicians and clinical
staff expected the system to be useful to improve patient care
with multiple, complex problems.35 39 50 Observability
(8)29 37 39 42 46 54 was seen as a facilitator since physicians were
able to view the medication traceability compliance of patients.
Finally, impact on professional security was also mentioned.9 43
Organizational context
Structure
The resources factor, including information technology support,
training, as well as material and human resources, accounted for
29 of the elements of that theme.1 7 9 12 28 29 35 37–39
42 46 47 50 51 54
Factors related to implementation strategies—
such as a strategic plan to implement e-prescribing, the participation of end-users in the implementation, organizational readiness, as well as incentive and innovation structures—stood for
17 of the extracted elements.27 29 32 39 41 42 50 51 53 54
Characteristics of the health structure factors, referring to setting
of care,35 54 practice size,12 status,12 54 physician salary structure,9 and workforce shortage9 accounted for seven elements
extracted. Staff skills such as the influence of leadership were
mentioned three times. Fifteen macro organizational elements
were extracted and are mainly related to financial
support29 47 51 and healthcare policies.27 33 35 37 51 53 54
Organizational context
Process
Work process was the most important factor of this theme (24
elements). When e-prescribing was integrated, work process was
facilitated and workflow was improved.1 13 33 37–42 53 However,
these are reported as barriers in the transition
phase.7 9 13 26 27 32 34 54 The organizational aspect of
Outcomes
Again, the outcomes at the post-implementation stage were
reported as improvements, but were seen as barriers during the
implementation process mainly for the time saving factor (23
elements). Time was saved, among others, by reducing staff time
spent processing prescriptions38–40 42 43 46 47 51 52 and their
renewal.7 53 The pattern of improvement perceived after implementation is observed for cost issues (11)7 13 27 35 38 43 51 53 54
and change in task (15),7 9 26–28 37 42 46 48 53 54 including additional tasks, work flexibility, and impact on business practices.
DISCUSSION
With this exploratory systematic review, we wanted to identify
users’ perception of barriers and facilitators to implementing eprescribing. From the 28 included studies, users’ perceptions
mostly relate to these factors: design and technical concerns,
interoperability, content appropriate for the users (relevance),
agreement with e-prescribing (welcoming/resistant), productivity
(efficiency), and resources. These factors reveal that users want a
functional, accessible, and supported e-prescribing system that
responds to their professional needs.33 34 39 46 51 Also, the
implemented system needs to possess features that enable facilitated exchange between organizations,37 38 but also allows a
more coordinated and effective care.39 Furthermore, the organization should put emphasis on education and training at the
pre-implementation stage to ensure a better transition.46 50 54
Users’ perception of productivity is prevalent in terms of facilitators. For 80% of the elements found under that factor,
e-prescribing seems to improve productivity, allowing overall
accessibility to the medication history as well as improving efficiency and quality of care. The same observation can be made
about the availability of resources, where 62% of the elements
are perceived as facilitators when users receive good support
and training in addition to an adequate access to material
resources.
On the other hand, users perceive more barriers than facilitators regarding interoperability (74.4%). Users believe that the
time taken to transmit a prescription to the pharmacy can be
longer, the compatibility of pharmacists’ and physicians’ systems
can be problematic, the connectivity with EHR is lacking, and
they perceive a gap in communication. The unavailability of a
way to externally purchase patient treatments that are not available at the pharmacy and the obligation to make a phone call to
obtain prior authorization to deliver a treatment afterwards are
also seen as important barriers to interoperability. Moreover,
design and technical concerns are also perceived more often as
barriers (65.9%). The elements that emerge from that are
mainly related to updating data, functional disorders of the
system, irrelevant alerts, the uncertainty on the real doses to
prescribe, and the impossibility to validate a prescription
electronically.
Moreover, some factors that can be seen as barriers in the
early stages or before the implementation may become facilitators later on in the process of implementation. The opposite is
also true. Some barriers that may arise during the first steps of
implementation have a solution in the next steps of the process,
such as initial transmission problems solved7 and pharmacies
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Productivity (efficiency) represented 25 of the 45 elements for
that theme and was perceived more frequently as a facilitator7 9 13 34 36 38 39 41 44–46 48 51 52 54 than a barrier.1 27 28 47
The other factors were patient/clinician interaction
(6),29 38 39 41 42 54 autonomy (4),1 51 perceptions of other professionals’ performance (3),1 9 38 confidence in e-prescribing
developer and vendor (3),42 47 50 impact on clinical uncertainty
(2),7 29 and risk–benefit equation (2).38 49
professional interaction, including team spirit,39 relation
between different health professionals,7 9 47 48 and collaboration
effort47 50 accounted for 10 of the extracted elements. The
other factors in that theme were barriers related to the lack of
organizational support to provide a central, up-to-date source of
data, drug code, and formularies.27 30 38 51 54
Review
model of factors affecting e-prescribing implementation. Finally,
the findings that are presented only relate to the content that
has been published. We did not contact authors of included
studies for supplementary information. We think that the
editing policies applied in the scientific press ensure that we had
access to sufficient content to meet our objectives. In the end,
we were able to conduct this exploratory review following the
standards of mixed-methods systematic reviews.25
CONCLUSION
The findings reported in this review provide evidence that
design and technical concerns, interoperability, relevance of the
data, attitude towards e-prescribing, productivity, and available
resources are important factors to the implementation of
e-prescribing for the users. Implementation strategies should
focus on these factors in order to facilitate the adoption of this
technology. It is interesting to note that some factors can be perceived as barriers or as facilitators depending on the implementation phase of e-prescribing, and can change in nature
(changing to a barrier or a facilitator) during the process of
implementation. Moreover, attitudes users and future users have
in relation to e-prescribing and its implementation may have an
influence on the success of the adoption of the technology.
Finally, future studies should put the emphasis on the perceptions of other user groups, such as pharmacists, managers,
vendors, and patients, whose perspectives remain overlooked in
the literature.
Contributors CS and MPG conceived the study. SG searched the database. ENS
and SG reviewed all titles and abstracts. MPG confirmed included studies. ENS, JPG,
and SG completed the full text review of selected studies. ENS, JPG, and SG
extracted and analyzed the data. ENS, JPG, and SG drafted the manuscript. All
authors revised the manuscript critically for important intellectual content and gave
final approval of the version to be published.
Funding This study is supported by a service contract from Canada Health Infoway
(No. 2284-002-R1). The funding source had no involvement in study design; in the
collection, analysis, and interpretation of data; in the writing of the report; and in
the decision to submit the paper for publication.
Competing interests None.
Provenance and peer review Not commissioned; externally peer reviewed.
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Limitations
Our results must be interpreted with some caution due to the
limitations of this review. First, we only used one bibliographic
database (PubMed) in the literature search. Thus, it is possible
that relevant studies published in journals that are not indexed
in PubMed are not included, but due to the explorative nature
of our review and the percentage of duplicates reported
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most current work related to e-prescribing implementation.
Second, since we based the analysis of our findings on a predetermined framework, the use of other theoretical or analytical
frameworks could reveal different perspectives. Nonetheless, we
deem that the chosen framework answers adequately the question of our systematic review and provides a logical and useful
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Desroches CM, Agarwal R, Angst CM, et al. Differences between integrated and
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(Millwood) 2010;29:2268–77.
Surescripts, LLC. Advancing healthcare in America: 2009 national progress report on
E-prescribing. Surescripts LLC, 2010.
Gagnon M-P, et al. J Am Med Inform Assoc 2014;21:535–541. doi:10.1136/amiajnl-2013-002203
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accepting more and more e-prescriptions.28 Also, time and efficiency can be gained with e-prescribing in the later stages,
whereas the opposite is observed during the beginning of implementation.7 26 28 39 47 On the other hand, some features may
seem interesting to the users at first glance but can cause some
serious problems when used: errors may arise using default settings,28 42 and some information may be unreliable,1 51 inconsistent,26 33 51 54 or even superfluous.7 26–28 39 47 51 52
Furthermore, the feature may not work.7 13 28
Studies on e-prescribing implementation are quite recent.
Indeed, the majority of studies were published since 2010. This
technology gained interest recently due to its promises for
improving patient care in a context of increased healthcare complexification.11 27 29 33 34 Moreover, one third of the studies
include a theoretical framework, which is superior to the 21%
reported in a systematic review on EHR implementation by
McGinn et al.59
It is worth mentioning that there is a change in users’ perceptions between the different phases of e-prescribing implementation. This is most apparent between the pre-implementation
phase, where non-users and future users have a less favorable
opinion of e-prescribing, and the transition and postimplementation phases, where the opinion on e-prescribing
becomes more favorable with more frequent use of the technology.13 39 43 45 48 50 51 54 More importantly, attitudes also have
an important influence on the adoption of e-prescribing.
Indeed, a positive attitude towards e-prescribing contributes to
its successful adoption. Conversely, users who believe that
e-prescribing has no value are less inclined to use the technology
when it is implemented. This attitude can also change during
the transition process, depending on the evolution of users’ perceptions regarding e-prescribing.53 The transition process is
decisive in the full adoption of e-prescribing by an organization:
a negative attitude can potentially lead to the abandonment of
the technology,1 7 9 36 41 50–52 whereas a positive attitude is
more likely to lead to a favorable adoption of
e-prescribing.1 7 30 39 45–47 50 53 54 These findings can be
addressed using Azjen’s theory of planned behavior.39 60
Even though the importance of health managers and public
involvement in innovative technology implementation and diffusion is recognized, their perceptions remain under-studied.61–63
In this review, physicians’ perceptions were addressed in 75%
of included studies (21.4% for clinical staff ), whereas those
of pharmacists (and their staff ) appeared in 28.6% of studies.
Perceptions from other user groups (managers, IT staff, and
patients) are almost absent from the reviewed literature,
accounting for 7% of studies, making it difficult to consider
their perspectives, even if they could influence the success of
e-prescribing implementation.54
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