Original Article

Evaluation of Electronic Prescription Implications in Turkey: An Investigation of the Perceptions of Physicians ¨ Omer Gіder, PhD • Saffet Ocak, PhD • Mehmet Top, PhD

ABSTRACT Keywords electronic prescription, health information technology, physicians

Background: Electronic prescribing (e-prescribing) is an evolving area of healthcare information technology that aims to support physician decision-making by capturing, reviewing, and issuing medical prescriptions with high potential for improving the quality and safety of the process. Purpose: To describe physician perception of e-prescription use in healthcare organizations that work with social security and to evaluate their infrastructures for MEDULA (an information system for billing and other health informatics) in healthcare organizations in Turkey. Methods: A cross-sectional survey design was used for this study. A convenience sample of physicians in eight general hospitals and in two oral and dental health centers of the Ministry of Health in Turkey were surveyed. Results: Survey response rate was 47% (248/425). The majority of physicians (62%) support eprescribing but have not used an electronic signature for prescriptions (78.2%). Almost half of them believe that e-prescriptions would positively contribute to patient safety (43%) Linking Evidence to Action: Our study provides a first look at the perceptions of physicians regarding the implications of e-prescriptions, which became mandatory on January 15, 2013, in Turkey. Advocates of e-prescribing have suggested that additional efforts are needed to strengthen clinical decision systems. Physicians and nurses are better able to adopt e-prescribing systems and to view them positively if they recognize the limitations of paper-based prescribing and understand the utility of electronic systems in addressing some of these limitations. This study represents a starting point for government and related organizations to improve their knowledge on how well the implied benefits of e-prescriptions are realized in their acquisition, appraisal, and use in health policy decision-making and health systems.

INTRODUCTION Using an evidence-based approach to prescribing medication is relatively new to physicians, nurses, and other non medical prescribers. The introduction of clinical governance, disease management, and guidelines emphasizing accountability, quality, and efficiency means that it is no longer acceptable to base clinical decisions on personal opinion. Although e-prescribing itself may only represent one stage in making a treatment decision, this practice too requires a fully structured and evidence-based approach (Granby, 2005). Public and private efforts are underway to promote e-prescribing in an effort to improve safety, quality, efficiency, and cost control in healthcare organizations and social security organizations (Grossman, Gerland, Reed, & Fahlman, 2007). Electronic prescribing has been reported to reduce errors and medical harms in all patient groups (Fortescue et al., 2003; Kaushal, Barker, & Bates, 2001). This practice can also promote evidence-based practice, patient care, and nursing care while delivering and

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supporting clinical audit and decision-making (Jani et al., 2008; United Kingdom Department of Health, 2003). Electronic prescribing has recently begun to gain importance within informational systems of health care and has become a standard implementation. E-prescribing is regarded as one of the most extensive supplementary electronic medical systems (Riccioli, Cacciabue, Campanini, Jung, & Marcilly, 2011). For instance, in 2011, more than one-third (230,000) of office-based prescribers in the United States of America use electronic prescriptions. The practice of e-prescribing is regarded as one of the most significant changes to have recently occurred in the healthcare industry. Due to increasingly elevated costs, healthcare systems and industries tend to adopt cost restriction strategies and patient-oriented practices. Health information technologies and systems are considered a significant managerial means of restricting costs and increasing effectiveness and efficiency in health care. Electronic prescription is defined as a process by which physicians

Worldviews on Evidence-Based Nursing, 2015; 12:2, 88–97.  C 2015 Sigma Theta Tau International

Original Article distribute their patients’ prescriptions online using electronic information systems, especially computers (NHS Connecting for Health, 2009). Electronic prescriptions enable the physician to see the previous drugs that have been prescribed to the patient and establish a cooperative relation between the pharmacy and institution that pays for the prescription. Furthermore, physicians are able to see the drugs, their contents, and the diseases for which they are prescribed, all online (Agency for Healthcare Research and Quality, 2012; American Medical Association et al., 2011). An electronic prescription application software program should include the following modules (NHS Connection for Health, 2009): medical drug dictionary information on drug formula, dose failure, monitoring drug allergy, monitoring drug dose according to kidney function, monitoring dose for patient’s age, the ability to prescribe medications for patients with comorbidities, and following up on previous prescriptions. Electronic prescriptions are designated as those created on healthcare service providers’ systems by physicians in the manner specified by the Social Security Institution (SSI). They first must receive an electronic prescription number that is electronically saved on MEDULA (http://www.sgk.gov.tr). In other words, electronic prescriptions are created on an automated system that provides the same drug information that exists on manual prescriptions. The implementation of e-prescriptions has also allowed the electronic transfer of typed saved information among the prescriber, pharmacists, and patients eliminating the need for paper-based prescribing. Physicians submit prescriptions with a patient tracking number to pharmacists, who are able to view which physicians prescribed which drugs Crosson et al., 2011. The creation of electronic prescriptions consists of two stages, the first of which is carried out by the physician, and the second, by the hospital. The first stage is similar to the action of writing a manual prescription. Then, the hospital must provide each patient with a MEDULA tracking number on his or her application to the hospital. From this point forward, any information obtained at that stage is added to the e-prescription automatically as it is composed. Still, the procedures differ for red, green, purple, and orange prescriptions. These colors indicate that prescriptions contain narcotic drugs and psychotropic substances and are observed legally by Turkish Ministry of Health. These types of prescriptions are still written by the physician manually, in accordance with the legislations of Ministry of Health. The implementation of e-prescribing enables all procedures to be carried out in a digital environment that can verify a patient’s identity while eliminating the need for health record books and referral papers. By means of electronic prescriptions, the SSI can check all of the information within an electronic environment and classify the data statistically. This system provides many benefits such as minimizing human errors, saving time for the patient and the healthcare provider, improving patient follow-up, decreasing health expenses, controlling unnecessary drug use, heightening the convenience of inspection, Worldviews on Evidence-Based Nursing, 2015; 12:2, 88–97.  C 2015 Sigma Theta Tau International

and preventing possible abuses. Before the implementation of electronic prescriptions, it was possible for any health institution or physician to obtain information about a patient and to write an unlawful prescription. The use of e-prescriptions and identity verification systems combined reduces the possibility of prescriptions being written without the physician’s knowledge. Electronic prescriptions have not been implemented in certain institutions that lack the necessary infrastructure, including workplace clinics, institutional clinics, health institutions, and the staff clinic of the Turkish Armed Forces. In all of these units, prescriptions are still written manually. Additionally, the prescriptions written in Tuberculosis (TB) Prevention Dispensaries, Maternity and Child Health Centers and Family Planning Centers, Society Health Centers, Emergency Centers, and Medicosocial Centers in Universities are included among the exceptional locations permitting manual prescriptions to be written. The e-prescription computer applications were developed based on the equity capital of the institution. The shift from manual to electronic prescriptions has been occurring at a greater pace since January 1, 2012, which was the legislated commencement date of the application in Turkey. “While 39.25% of the prescriptions recorded in such systems were electronic in August 2012, 79.28% of the prescriptions were electronic in January 2013” (Social Security Institution, 2013, p. 3). It should be emphasized that handwritten, illegible instructions can lead to an incorrect drug or dosage being dispensed (NCC MERP, 2006; Santell & Cousins, 2005); such errors can be prevented using electronic prescriptions. Tamblyn et al. (2006) claimed that electronic prescription practices have many advantages, such as decreasing the rising expenses of drugs, preventing drug dispensing errors, assuring patient safety, and improving the quality of care. The Turkish Ministry of Health introduced Decree Law number 663 to indicate that they intend to move forward by improving electronic services within a greater effort to improve the quality of health care (e-saglik.gov.tr). The issue is that a small number of physicians who have a positive outlook on electronic prescriptions believe that e-prescribing has only a minor effect on decreasing the errors (Dainty, Adhikari, Kiss, Quan, & Zwarenstein, 2011). Numerous studies (Bell, Cretin, Marken, & Landman, 2004; Lipton, Miller, & Wimbush, 2003; Schiff & Rucker, 1998) have indicated that a proper integration of electronic drug management and e-prescribing software system can reduce errors in preparing and prescribing drugs. E-prescribing increases the quality of patient safety and care (Crosson et al., 2011). By means of e-prescribing, the number of returns stemming from incorrect prescriptions decreases, patient safety increases in terms of drug treatment, and the costs of drug-related expenses are minimized. For these reasons, eprescribing is regarded as a means of decreasing the overall costs of health care. Finally, e-prescribing can increase patient safety, accelerate physician services, save time and money, facilitate payer mechanisms (SSI and foundations) with its better

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management of expenses, and improve the quality of health care (NHS Connecting for Health, 2009). E-prescribing systems have the capability to warn physicians about the antagonistic interactions or synergistic effects of drugs, preventing such possible errors as incorrect medications and dosages that might occur due to differences among patients such as of age and gender (Goldman, Dube, & Lapane, 2010). The benefit of e-prescribing can be time-saving and taskfacilitating for physicians, as well as decreasing the possibility for contradictions between physicians and pharmacies. One of the most important obstacles facing e-prescribing stems from its use of software systems. Tamblyn et al. (2006) made the following recommendations, which have been integrated into drug software systems, for successfully improving drug safety and preventing the preparation of the wrong drugs with the help of electronic prescribing systems:

r Drug software systems should indicate demographic information about patients, and integration of this information should be ensured.

r The drugs that are launched should be displayed on

Public health institutions began to use the system on September 1, 2007. Since then, all health institutions have sent their claims for reimbursement through this electronic environment (Coucheir & Hauben, 2011). Using medical information technologies marks an attempt to improve the efficacy and efficiency of health care in Turkey. Dependence on information systems and technologies in healthcare services has been steadily increasing, further promoting the importance of e-prescribing. Although this practice decreases labor and costs and better prevents lost, illegal, abused, and forged prescriptions, the physicians’ view of e-prescribing in the Turkish healthcare system has had only minimal research. The purpose of this study is to describe the perceptions and beliefs of physicians regarding e-prescriptions in Turkey based on the terms of the MEDULA infrastructure in healthcare institutions. This study is the first to investigate physician perceptions and beliefs on e-prescriptions in Turkey. It should be noted that nurses were not included in the studied population because only physicians and dentists can legally write prescriptions in Turkey.

the system and should also be available.

r The system should warn the user automatically about therapeutic duplications, overdoses, and dose adjustments based on the age, gender, weight, and kidney functions of patients. Prescriptions for conditions involving these issues as well as drug-allergies and contraindications should be prevented via automatic warnings.

r The system should make it possible to follow up regu-

METHODS Design and Sample A cross-sectional survey design was used. This survey was conducted and planned in a single university hospital, in eight general hospitals of the Ministry of Health, and in two oral and dental health centers of the Ministry of Health. The sampling frame included 72 university hospital physicians and 343 public hospital physicians (N = 425).

lar drug users and their medical treatment outcomes.

r An integrated e-prescribing system should avoid transcription errors. In Turkey, the SSI introduced the MEDULA system to establish an informational infrastructure for the universal health insurance. MEDULA optic and pharmacy applications have been added to the MEDULA hospital program. MEDULA acts as an integrated system between the SSI and healthcare providers to collect prescription data and to pay electronically for the reimbursement of treatment costs for hospitals, opticians, pharmacies, and individuals. As such, e-prescriptions have been integrated into MEDULA (Social Security Institution, 2013). The purpose of the MEDULA information system is to record and monitor healthcare payments and to provide the statistical information necessary for health insurance policies, ultimately establishing an integrated and sustainable system covering all health institutions in Turkey. The information on electronic payments between providers and insurers within the healthcare system that MEDULA collects then aids the SSI in developing its health insurance policies. Private healthcare institutions were required to begin using MEDULA on June 15, 2007, when the Health Implementing Notification came into effect.

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Instrument and Data Collection Data were collected via a cross-sectional and descriptive survey methodology. The items included in the questionnaire were determined considering such components as the objectives of electronic prescription, situations that might occur when they are being written, and rules to follow when writing a prescription. The questionnaire included 21 items about e-prescription implications using the following response format: (1) yes, (2) I don’t know, or (3) no. A pilot study, which involved 20 physicians, was performed. Official permission for the survey was provided with the confirmation form by Secretary General of State Hospitals Unity on May 9, 2013. After obtaining permission to enter the hospitals from the general directors of hospitals following explanation of the study, three researchers distributed questionnaires to the departments in the hospitals. A cover letter was attached with each of the questionnaires. The survey was administered to physicians, all of whom provided written informed approval. The survey was conducted in June-September 2013. All physicians were informed that their involvement was completely voluntary. They were also informed via consent form that the study was a research study only and that the findings were to Worldviews on Evidence-Based Nursing, 2015; 12:2, 88–97.  C 2015 Sigma Theta Tau International

Original Article Table 1. Characteristics of Physicians (n = 248)

Information Specialty

Number Percentage Internal Medicine

97

39.1

Surgery

82

33.1

Dentist

43

17.3

Practitioner

26

10.5

34

13.7

6–10 years

59

23.8

11 years or more

155

62.5

Female

73

29.4

Male

175

70.6

Professional experience 1–5 years

Gender

be limited to research-oriented purposes without influencing the working conditions in their hospital.

Data Analysis A statistical analysis was conducted using the chi-square test. The Fisher’s exact Chi-square table was used when the number of subjects in each cell was less than five. To determine the reliability coefficient (internal consistency), Cronbach’s alpha was used.

RESULTS Survey response rate was 47.2% (248/425). Twenty-two surveys were excluded due to missing data. Table 1 describes the characteristics of the physician sample. Participating physicians are predominately specialized in internal medicine (39.1%); 62.5% had professional experience of 11 or more years; and 70.6% are male. The age range of the physicians was 24–64 years, and the average age of the participants was 34.4 years. Table 2 illustrates the participating physicians’ evaluations of electronic prescriptions. Overall, the physicians’ opinions (patient safety, cost, medical information, drug information, etc.) were positive. Physicians expected the system to be useful and had no concerns about it having a negative impact. Overall, 194 of 248 participants (78.2%) reported that they did not use electronic signatures when writing e-prescriptions, whereas the remaining 33 physicians (13.3%) said that they did use an electronic signature. (Do physicians put an electronic signature when they write an e-prescription?) In contrast, 21 (8.5%) of the physicians stated that because e-prescribing is a recent practice, they did not know whether an electronic signature was compulsory. A total of 207 (83.5%) of the participating physicians stated that the drugs they prescribed using e-prescriptions were available on MEDULA. (Is the drug prescribed by the physician Worldviews on Evidence-Based Nursing, 2015; 12:2, 88–97.  C 2015 Sigma Theta Tau International

included in MEDULA?) According to 171 (69.0%) physicians, when they write e-prescriptions, the drug list appears on the computer screen for a short time, and 155 (62.5%) physicians confirmed that the drugs included in an e-prescription are entered into MEDULA by the physicians. One hundred forty-nine (60.1%) physicians remarked that e-prescription practices and the software system are easy to use. (Do you think e-prescribing is a simple system for users?) The physicians were not clear as to whether e-prescribing facilitates patient understanding of the procedures they should follow; (Do you think e-prescribing facilitates the procedures for patients?) approximately 55% expressed a positive response to the claim, whereas 31% felt negatively. Half of the participating physicians believed that e-prescribing would reduce pharmacies’ expenditures on stationery, whereas 36% held the opposite belief. (Do you think e-prescribing will decrease drug expenses of SSI?) Although e-prescribing is practiced as a means of reducing total health expenses, 58% of participating physicians did not believe that eprescribing would reduce the drug expenditures of the SSI. The results showed that 62% of physicians supported e-prescribing, whereas 23.8% did not (Do you support e-prescribing?). Moreover, no consensus was found among physicians in terms of the effects of e-prescribing on patient safety. Approximately 43% of physicians believed that e-prescriptions would contribute to patient safety, but 35% disagreed. (Do you think e-prescribing will contribute to patient safety?) The remaining 21% of physicians had no opinion on the effects of e-prescription on patient safety. One criticism of the MEDULA infrastructure is related to information technology issues. Overall, 73% of physicians stated that they were able to see the drugs that have been previously prescribed to patients using e-prescription practices. (Are you able to view previously prescribed drugs of the patient with e-prescribing?) When asked whether e-prescribing was timesaving in their practice, 56.5% of the physicians answered “no,” whereas 38% answered “yes.” (Is e-prescribing less time consuming compared to paper prescriptions?) Half of the respondents stated that when there are errors (i.e., dose adjustment, usage), the MEDULA system does not send appropriate warnings (While prescribing electronically does MEDULA system send an automatic correction notice when an error [dose adjustment, usage, etc.] is detected?), and 48% criticized the eprescribing software for not including certain critical pharmacological properties such as the active ingredient found in drugs on the market. Table 3 illustrates a comparison of the answers to the questions of the physicians, according to their specialties and gender. There were differences by physician specialty:

r Do physicians themselves enter e-prescriptions to MEDULA?

r Do you think e-prescribing facilitates the procedures for patients?

r Are you able to view previously prescribed drugs of the patient with e-prescribing?

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Table 2. Frequencies of Item Response (n = 248)

Questions Do physicians put an electronic signature when they write an e-prescription?

Is the drug prescribed by the physician included in MEDULA?

Does the drug module appear rapidly on the screen while the Physician prescribes/Pharmacist prepares the prescribed drug?

Do you think physicians themselves should enter e-prescriptions to MEDULA?

Do you think e-prescribing is a simple system for users?

Do you think e-prescribing facilitates the procedures for patients?

Do you think e-prescribing will decrease paperwork expenses of both the Pharmacy and the Hospital?

Do you think e-prescribing will decrease drug expenses of SSI?

Do you support e-prescribing?

Do you think e-prescribing will contribute to patient safety?

Are you able to view previously prescribed drugs of the patient with e-prescribing?

Does e-prescribing module software facilitate physicians with prescribing drugs?

Is e-prescribing less time consuming compared to paper prescriptions?

While prescribing electronically does MEDULA system send an automatic correction notice when an error (dose adjustment, usage, etc.) is detected?

Does the system give warnings if an erroneous (improper to age, gender diagnosis, etc.) prescription is written?

Yes

I don’t know

No

Number (%)

Number (%)

Number (%)

33

21

194

(13.3)

(8.5)

(78.2)

207

32

9

(83.5)

(12.9)

(3.6)

171

45

32

(69.0)

(18.1)

(12.9)

155

16

77

(62.5)

(6.5)

(31.0)

149

16

83

(60.1)

(6.5)

(33.5)

138

31

79

(55.6)

(12.5)

(31.9)

124

34

90

(50.0)

(13.7)

(36.3)

57

17

144

(23.0)

(19.0)

(58.0)

156

33

59

(62.9)

(13.3)

(23.8)

107

52

89

(43.1)

(21.0)

(35.9)

181

28

39

(73.0)

(11.3)

(15.7)

131

21

96

(52.8)

(8.5)

(38.7)

96

7

145

(38.7)

(2.8)

(56.5)

98

26

124

(39.5)

(10.5)

(50.0)

58

57

133

(23.4)

(23.0)

(53.6) (Continued)

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Worldviews on Evidence-Based Nursing, 2015; 12:2, 88–97.  C 2015 Sigma Theta Tau International

Original Article Table 2. Continued

Questions Do you experience difficulties stemming from information technologies while writing e-prescriptions?

Do you think e-prescribing is an overdue practice in health care in our country?

Is there an instant update on the system when drugs are recently launched or removed off the market?

Are pharmacological properties (active ingredient, etc.) of drugs indicated on e-prescription module?

Do patients or accompanying people make requests for a paper prescription along with the e-prescription?

Do you support an electronic signature for e-prescriptions?

r Do you experience difficulties stemming from information technologies while writing e-prescriptions?

r Do you support an electronic signature for eprescriptions?

r Compared to general practitioners, specialists had a more positive approach to e-prescribing. Gender differences were also present for the following questions: Do physicians put an electronic signature when they write an e-prescription? Are pharmacological properties (e.g., active ingredient of drugs) indicated on the e-prescription module? These findings revealed that gender had an important effect on physicians’ opinions regarding e-prescriptions for only two items.

DISCUSSION This study describes physician perceptions of e-prescription use in healthcare organizations that work with social security and evaluates their infrastructures for MEDULA (an information system for billing and other health informatics) in healthcare organizations in Turkey. Results indicate that physicians in Turkey do not yet have any clear opinion as to whether eprescriptions actually facilitate treatment for the system’s users Worldviews on Evidence-Based Nursing, 2015; 12:2, 88–97.  C 2015 Sigma Theta Tau International

Yes

I don’t know

No

Number (%)

Number (%)

Number (%)

179

20

49

(72.2)

(8.1)

(19.8)

99

46

103

(39.9)

(18.5)

(41.5)

49

79

120

(19.8)

(31.9)

(48.4)

54

30

164

(21.8)

(12.1)

(66.1)

111

11

126

(44.8)

(4.4)

(50.8)

118

36

94

(47.6)

(14.5)

(37.9)

and patients alike. Furthermore, these results suggest that eprescriptions do not reduce the drug expenses of the SSI. Most of the physicians participating in the survey believe that patient safety will improve if a drug list is provided within the e-prescription practices. A standardized drug list could lead to significant improvements in patient safety. The participating physicians stated that the system did not include a comprehensive list of drugs and recommended that all previously prescribed drugs be integrated into their patients’ records on e-prescribing software systems. A similar study investigating clinician perceptions of the effects of e-prescribing on patient safety (Lapane, Waring, Dube, & Schneider, 2011) emphasized the positive effects of e-prescription practices on patient safety. Drug lists included in e-prescriptions should be accurate, and the system should include patient follow-up regarding medications that were previously prescribed (Lapane et al., 2011), Hider (2002, p. iv) stated that “The effect of electronic prescribing on patient outcomes is not clear although there is some evidence that it can reduce the frequency of adverse drug reactions and shorten length of hospital stay.” The study conducted by Dainty et al. (2011) found that the number of physicians adopting electronic prescriptions was small and that they had a low opinion of their capacity to reduce errors in writing prescriptions. On the other hand, Crosson et al. (2011) claim that e-prescribing may contribute to

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Table 3. Distribution and Comparison of Answers to the Questions According to Specialty (Internal medicine, Surgery, Dentist, Practitioner) and Gender

Specialty

Gender

Chi-square

p

Chi-square

p

Do physicians put an electronic signature when they write an e-prescription?

5.714

.456

7.274

.026*

Is the drug prescribed by the physician included in MEDULA?

5.471

.485

2.370

.306

Does the drug module appear rapidly on the screen while the Physician prescribes/Pharmacist prepares the prescribed drug?

8.822

.184

.060

.970

45.362

.000*

.275

.872

9.995

.125

.516

.772

Questions

Do physicians themselves enter e-prescriptions to MEDULA? Do you think e-prescribing is a simple system for users? Do you think e-prescribing facilitates the procedures for patients?

*

13.825

.032

1.775

.412

Do you think e-prescribing will decrease paperwork expenses of both the Pharmacy and the Hospital

8.156

.227

3.568

.168

Do you think e-prescribing will decrease drug expenses of SSI?

7.755

.451

4.356

.113

Do you support e-prescribing?

5.751

.452

3.406

.182

Do you think e-prescribing will contribute to patient security?

1.492

.960

.188

.910

Are you able to view previously prescribed drugs of the patient with e-prescribing?

16.133

*

.013

1.782

.392

Does e-prescribing module software facilitate physicians with prescribing drugs?

6.385

.382

2.317

.314

Is e-prescribing less time consuming compared to paper prescriptions?

10.205

.116

2.351

.309

While prescribing electronically does MEDULA system send an automatic correction notice when an error (dose adjustment, usage, etc.) is detected?

12.195

.058

1.592

.451

8.234

.221

2.801

.246

Do you experience difficulties stemming from information technologies while writing e-prescriptions?

15.155

.019*

1.104

.576

Do you think e-prescribing is an overdue practice in health care in our country?

12.936

.044

3.081

.214

Is there an instant update on the system when drugs are recently launched or removed off the market?

2.033

.917

4.187

.123

Are pharmacological properties (active ingredient, etc.) of drugs indicated on e-prescription module?

12.261

.056

12.377

.002*

Do patients or accompanying people make requests for a paper prescription along with the e-prescription?

16.507

.052

3.171

.205

Do you support an electronic signature for e-prescriptions?

13.031

.043*

4.262

.119

Does the system give warnings if an erroneous (improper to age, gender diagnosis, etc.) prescription is written?

*p < .05 significant difference.

improving healthcare information systems and is necessary to enhance the quality of patient safety and care. With the implementation of electronic prescription, the number of returns stemming from erroneous prescribing has been reduced, patient safety has been increased, and there have been decreases in the costs of medications. According to the study conducted by Goldman et al. (2010), electronic prescribing pro-

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vides alerts in situations such as antagonist or synergistic effect drug interactions. The authors noted that its warning system may be able to prevent potential errors occurring as a result of prescribing the wrong dose or wrong drug for a patient’s age, gender, or condition. One study found that e-prescribing took on average 29 seconds longer than handwriting for new prescriptions in ambulatory settings and presented only

Worldviews on Evidence-Based Nursing, 2015; 12:2, 88–97.  C 2015 Sigma Theta Tau International

Original Article limited time-savings for renewing prescriptions (Devine et al., 2010). Wang et al. (2009) found that fewer than half of the physicians they sampled were familiar with accessing certain functions in the e-prescribing systems, such as medication history information. Cohen, Bancilhon, and Jones (2013) stated that the diffusion of e-prescribing into physician practices and the consequent realization of its potential benefits will depend on whether physicians are willing to accept and engage with the technology. We found that physicians generally accepted the practice of e-prescribing in the Turkish healthcare system. However, a low level of trust in the technology on the part of physicians has been reported, as many still felt more comfortable with their manual efforts (Smith, 2006). Cohen et al. (2013) found a general acceptance of eprescribing among physicians in South Africa, noting that physicians’ performance expectations and perceptions of the system’s capacity to facilitate prescriptions had direct significant effects on acceptance, with trust and effort expectancy having important indirect effects. Social insurance and price value perceptions did not add additional explanatory power to the study. Pag´an, Pratt, and Sun (2009) found that specialties with a proportional high-intensity use of e-prescriptions included internal medicine, family or general medicine, and pediatrics. They also found large differences across subgroups of physicians in both the availability and the intensity of use of e-prescription information technologies. Devine et al. (2010) found that e-prescribing took on average 29 seconds longer than handwriting for new prescriptions in ambulatory settings and presented only limited time-saving effects for renewing prescriptions. Various computerized tools, such as reminders or feedback and recommendations for treatment, and patient care based on guidelines can improve physician prescribing (Hider, 2002). E-prescribing advocates suggest that additional efforts are needed to strengthen clinical decision-making support tools. Additionally, payment incentives or other financial supports may be required to not only lower the costs of adoption but also to drive the routine use of the information technology features that have the potential to fundamentally influence how physicians prescribe medications (Grossman et al., 2007; Kuperman, Reichley, & Bailey, 2006). These points are important to ensuring that trust in information technology is built and, consequently, to improving physician perceptions of the utility and efficiency of e-prescribing (Cohen et al., 2013). This study has several limitations, and conclusions should be interpreted with caution. The survey used was developed for use in this study, and no estimates of validity evaluated. Statistical conclusion validity may be a risk, as respondents were from eight hospitals and the analytic approach does not control for differences between respondents within organizations. Because this study was conducted only on physicians working in a single province, it is not possible to generalize results to all physicians in Turkey. Moreover, e-prescriptions were only recently implemented in Turkey, so survey results reflect early implementation efforts. This study was conducted Worldviews on Evidence-Based Nursing, 2015; 12:2, 88–97.  C 2015 Sigma Theta Tau International

among physicians, who are the only legal prescribers in Turkey. Nurses have no prescribing rights in the Turkish healthcare system. In a number of other countries, only nurses with a particular specialization (diabetes, chronic obstructive pulmonary disease, and oncology nurses) can obtain prescribing rights (Kroezen, Francke, Groenewegen, & Dijk, 2012).

CONCLUSIONS E-prescribing is a new practice in Turkey. Its implementation must be accompanied by on-service training for the affected personnel, particularly physicians, to improve the implementation of e-prescriptions. To inform the public about e-prescribing, public service broadcasting should discuss the practice on national media sources. Furthermore, to eliminate problems with e-prescription software systems, it is vital that the pharmacological properties of all available drugs on the market are included in this system, including drugs that were prescribed earlier and their doses. To monitor this implementation process, e-prescription software must be integrated into pharmacies, SSI information systems, and MEDULA. When compiling a comprehensive list of all possible drug prescriptions, particular regulations must be made for those that were written on red or green prescriptions. To provide solutions for the problems occurring in e-prescription implementation, nation-based extensive research and projects, including physicians, healthcare workers, and the public, should be conducted. This study constitutes one of the earliest studies conducted after e-prescription implementation was put into practice in Turkey. Subsequent studies should be conducted on a national basis to ascertain the opinions and expectations of physicians and nurses and their solutions to any emerging problems. Further research and national-scale projects to investigate the satisfaction levels of both physicians and the public with eprescriptions should be conducted. Research topics, such as the evaluation of e-prescriptions by physicians, patients, society, and pharmacies, could be given precedence. Quantitative research on the effects of e-prescription implementation, primarily on patient satisfaction, patient safety and costs, can be conducted. Moreover, a comparison between e-prescription implementation in Turkey and e-prescription implementation in other countries can be proposed. Insights from this study could be used to identify adoption barriers and to develop targeted interventions to accelerate the implementation of e-prescription systems in physician practices among the family healthcare centers and hospitals in Turkey. WVN

LINKING EVIDENCE TO ACTION r Physicians in Turkey must realize the performance advantages of e-prescribing for physician practices and evidence-based medicine.

r E-prescribing systems must therefore be designed to bring direct benefits to physicians, nurses,

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Electronic Prescription and Physicians

and patients in the form of improved productivity, evidence-based medical decision-making, and more effective prescribing processes.

r The reliability of e-prescribing must be demonstrated to physicians, nurses, health administrators, social security managers, and patients.

r Studies should be conducted on a national basis to ascertain the opinions and expectations of physicians and nurses and their evaluations of solutions to this problem. Further research and national-scale projects to investigate the satisfaction levels of both physicians and the public regarding e-prescriptions should be performed.

r Electronic prescribing involves the use of computers and pocket phones to generate prescriptions and often relies on the assistance of computerized decision-making support and evidence-based disease management. Electronic prescribing may improve physician performance, patient safety, and effectiveness, and should result in better health outcomes.

Author information ¨ Omer Gіder, Associate Professor, Mu˘gla University, School of Health, Department of Health Care Management, Mu˘gla, Turkey; Saffet Ocak, Assistant Professor, Mu˘gla University, School of Health, Department of Health Care Management, Mu˘gla, Turkey; Mehmet Top, Associate Professor, Hacettepe University, Faculty of Economics and Administrative Sciences, Department of Health Care Management, Ankara, Turkey ¨ Address correspondence to Dr. Omer Gіder, Associate Professor, Mu˘gla University, School of Health, Department of Health Care Management, 48100 – Mu˘gla, Turkey; [email protected] Accepted 5 September 2014 C 2015, Sigma Theta Tau International Copyright 

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doi 10.1111/wvn.12082 WVN 2015;12:88–97

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Evaluation of electronic prescription implications in Turkey: an investigation of the perceptions of physicians.

Electronic prescribing (e-prescribing) is an evolving area of healthcare information technology that aims to support physician decision-making by capt...
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