Meeting user needs in national healthcare systems: lessons from early adopter community pharmacists using the electronic prescriptions service.

BACKGROUND: The Electronic Prescription Service release Two (EPS2) is a new national healthcare information and communication technology in England that aims to deliver effective prescription writing, dispensing and reimbursement service to benefit patients. The aim of the study was to explore initial user experiences of Community Pharmacists (CPs) using EPS2. METHODS: We conducted nonparticipant observations and interviews in eight EPS2 early adopter community pharmacies classified as 'first-of-type' in midlands and northern regions in England. We interviewed eight pharmacists and two dispensers in addition to 56 hours recorded nonparticipant observations as field notes. Line-by-line coding and thematic analysis was conducted on the interview transcripts and field notes. RESULTS: CPs faced two types of challenge. The first was to do with missing electronic prescriptions. This was sometimes very disrupting to work practice, but pharmacists considered it a temporary issue resolvable with minor modifications to the system and user familiarity. The second was to do with long term design-specific issues. Pharmacists could only overcome these by using the system in ways not intended by the developers. Some felt that these issues would not exist had 'real' users been involved in the initial development. The issues were: 1) printing out electronic prescriptions (tokens) to dispense from for safe dispensing practices and to free up monitors for other uses, 2) logging all dispensing activities with one user's Smartcard for convenience and use all human resources in the pharmacy, and, 3) problematic interface causing issues with endorsing prescriptions and claiming reimbursements. CONCLUSIONS: We question if these unintended uses and barriers would have occurred had a more rigorous user-centric principles been applied at the earlier stages of design and implementation of EPS. We conclude that, since modification can occur at the evaluation stage, there is still scope for some of these barriers to be corrected to address the needs, and enhance the experiences, of CPs using the service, and make recommendations on how current challenges could be resolved.

English community pharmacists' experiences of using electronic transmission of prescriptions: a qualitative study.

BACKGROUND: The Electronic Prescription Service Release 2 (EPS2) in England has been designed to provide electronic transmission of digitally-signed prescriptions between primary care providers, with the intent on removing the large amounts of paper currently exchanged. As part of a wider evaluation of the EPS service, we wished to explore pharmacists' experience with the new system and their perceptions of its benefits and any associated problems. METHODS: We conducted semi-structured telephone interviews with community pharmacists using EPS2. We used a purposive sampling technique to obtain views from pharmacists working in pharmacies with a range of sizes and locations and to include both independent pharmacies and multiples. Interviews were transcribed verbatim and coded using grounded theory to identify the main factors that have influenced deployment and implementation in the eyes of respondents. QSR Nvivo was used as to aid in this process. RESULTS: It became apparent from the analysis that respondents perceived a wide range of advantages of EPS including improved safety, stock control, time management and improved relationships between pharmacy and General Practice staff. Respondents did not perceive a large difference in terms of work processes or development of their professional role. A large number of problems had been experienced in relation to both the technology itself and the way it was used by General Practices. It became apparent that work-around procedures had been developed for dealing with these issues but that not all these problems were perceived as having been addressed sufficiently at source. This sometimes had implications for the extent of EPS2 use and also limited some of the potential advantages of the EPS2 system, such as reduced effort in the management of prescription reimbursement. Respondents made suggestions for future improvements to EPS2. While interview data demonstrated that there were some feedback procedures in place, these were not regarded as being sufficient by the majority of respondents. CONCLUSIONS: Whilst pharmacists perceived a wide range of benefits of EPS, a large number of problems had been experienced. Despite these difficulties, no pharmacists expressed an overall negative view.

A constructivist approach? using formative evaluation to inform the electronic prescription service implementation in primary care, England.

As part of the National Programme for IT (NPfIT) in England, the Electronic Prescription Service (EPS) is being implemented in two releases. The first release placed barcodes on prescriptions and is widely implemented. Release two (EPS2), the electronic transmission of prescriptions between GP, pharmacy and the reimbursement body, has just started implementation. On the NPfIT agenda, community pharmacies have been predicted to benefit from changes in work practice following the full EPS implementation. The study focused on how the advanced EPS (EPS2) might alter dispensing work practice in community pharmacies on issues such as workflow and workload; and the bearing of these issues on improvement in quality of service and safety. This paper demonstrates how findings of the pre-implementation study were used to provide formative feedback to the implementers. A mixed ethnographical method that combined non- participant observations, shadowing and interviews, before and after implementation, was used to qualitatively study eight community pharmacies across three early adopter Primary Care Trusts (PCTs) in England. Key implementation issues were fed-back to the PCTs as part of the EPS2 rolling-out process. Staff access to dispensing terminals needs to be improved if electronic dispensing is to be encouraged. Also, as a safety issue, pharmacists are planning to print off electronic prescriptions (tokens) and dispense from them. Although safer, this could increase workload. The EPS2 could positively alter work practice by improving certain demanding aspects of dispensing whilst reducing human errors. For example, the high demand of customers handing in prescriptions and waiting for them to be dispensed could be reduced through automation. Also, the extreme variation in workload during various times of the day could be evened out to improve workflow and provide a better service; however, in order for this to be fully realized, technical issues such as number of staff per dispensing station and dispensing from tokens would need to be addressed.

Delivering Digital Drugs: An Exploratory Study of the Digitalisation of Supply and Use of Medicines.

Medicines' supply and use is incresingly reliant on digital means and information. This poster presents exploratory research over five episodes of digitalisation of medicines across the supply network. We 'follow the drug' through this emerging field, providing an initial map of this new territory.

Networking Hospital ePrescribing: A Systemic View of Digitalization of Medicines' Use in England.

Medicine management is at the core of hospital care and digitalization of prescribing and administration of medicines is often the focus of attention of health IT programs. This may be conveyed to the public in terms of the elimination of paper-based drug charts and increased readability of doctors' prescriptions. Based on analysis of documents about hospital medicines supply and use (including systems' implementation) in the UK, in this conceptual paper electronic prescribing and administration are repositioned as only one aspect of an important wider transformation in medicine management in hospital settings, involving, for example, procurement, dispensing, auditing, waste management, research and safety vigilance. Approaching digitalization from a systemic perspective has the potential to uncover the wider implications of this transformation for patients, the organization and the wider health care system.

The effect of the electronic transmission of prescriptions on dispensing errors and prescription enhancements made in English community pharmacies: a naturalistic stepped wedge study.

OBJECTIVES: To compare prevalence and types of dispensing errors and pharmacists' labelling enhancements, for prescriptions transmitted electronically versus paper prescriptions. DESIGN: Naturalistic stepped wedge study. SETTING: 15 English community pharmacies. INTERVENTION: Electronic transmission of prescriptions between prescriber and pharmacy. MAIN OUTCOME MEASURES: Prevalence of labelling errors, content errors and labelling enhancements (beneficial additions to the instructions), as identified by researchers visiting each pharmacy. RESULTS: Overall, we identified labelling errors in 5.4% of 16,357 dispensed items, and content errors in 1.4%; enhancements were made for 13.6%. Pharmacists also edited the label for a further 21.9% of electronically transmitted items. Electronically transmitted prescriptions had a higher prevalence of labelling errors (7.4% of 3733 items) than other prescriptions (4.8% of 12,624); OR 1.46 (95% CI 1.21 to 1.76). There was no difference for content errors or enhancements. The increase in labelling errors was mainly accounted for by errors (mainly at one pharmacy) involving omission of the indication, where specified by the prescriber, from the label. A sensitivity analysis in which these cases (n=158) were not considered errors revealed no remaining difference between prescription types. CONCLUSIONS: We identified a higher prevalence of labelling errors for items transmitted electronically, but this was predominantly accounted for by local practice in a single pharmacy, independent of prescription type. Community pharmacists made labelling enhancements to about one in seven dispensed items, whether electronically transmitted or not. Community pharmacists, prescribers, professional bodies and software providers should work together to agree how items should be dispensed and labelled to best reap the benefits of electronically transmitted prescriptions. Community pharmacists need to ensure their computer systems are promptly updated to help reduce errors.

The fungibility of time in claims of efficiency: the case of making transmission of prescriptions electronic in English general practice.

OBJECTIVES: This paper presents a study of the effects of the implementation of the NHS Electronic Prescription Service (EPS) on time spent on repeat prescribing in English general practice. EPS is a new network service for the electronic transmission of primary care prescriptions, principally between GP practices and community pharmacies. This service is promoted on the basis of the importance of safe and timely supply of medicines, and the level of medicines use by many patients with treatable chronic conditions. The service is also based on presumptions of significant time-savings and efficiency gains for general practices and GPs. Our objective was to assess the time-related changes (including time savings) conditioned by digital transmission of prescriptions, specifically for repeat prescribing activity in primary care practices. METHODS: As part of the official evaluation of EPS in the English NHS we undertook a qualitative research design with field studies in four of the first GP practices adopting EPS. This research was based on interviews with clinical and administrative staff, and non-participant observation of repeat prescribing related activities. RESULTS: We found that the use of EPS reduced turnaround time and conditioned changes in the workflow, with time-savings found mainly in relation to administrative tasks. But the use of this technology also created additional tasks and shifted existing tasks and responsibilities. Thus elimination of tasks did not automatically correspond to potential staff savings or cost savings. Tasks that were eliminated and new tasks that were created were not equivalent in terms of time spent, quality of attention required, and roles involved. CONCLUSIONS: The wider claim that healthcare information technology saves time and increases efficiency is often based on assumptions of the fungibility of time and people - i.e. that units of time added or saved on different steps of the workflow can be summed up as if they were all of the same kind, and thus reveal any net efficiency gain. But workflow time savings involve changes in the quality of tasks, redistribution of work and responsibility that mean that time can hardly be added or subtracted to obtain 'efficiency totals'.

Community pharmacists' interventions with electronic prescriptions in England: an exploratory study.

BACKGROUND: Prescribing errors in primary care are problematic. The electronic prescription service (EPS) is an English electronic system linking prescribing, dispensing and reimbursement, designed to rectify some of the problems associated with paper-based prescribing. OBJECTIVE: To document the numbers and types of interventions made by community pharmacists and their staff using EPS release 2 (EPSR2), compare these with those made for other prescription types, and comment on potential effects of EPSR2 on pharmacy practice. METHODS: We invited staff in 15 community pharmacies to record problems encountered arising from failures in prescribing, dispensing or supply systems for prescribed medication, for a 2 week period. RESULTS: Eight pharmacies participated, of which five used EPSR2. These pharmacies reported 69 problems with 68 prescriptions (median 7.5 problems per pharmacy, range 2-22). A total of 33 problems were clinical in nature and 6 were organisational or logistical in origin. Thirty unsigned prescriptions were reported, all non-EPSR2. Of the 69 problems, eight were primarily related to EPSR2 functionality. CONCLUSION: EPSR2 should reduce the number of unsigned prescriptions in circulation. However, prescribers should avoid the use of Latin abbreviations that cannot be interpreted directly by patients, and consider the compatibility of regularly prescribed items with the NHS dictionary of medicines and devices.