Swedish pharmacists value ePrescribing: a survey of a nationwide implementation

JPHSR 2010, 1: 23–32� 2010 The AuthorsJournal compilation � 2010Royal Pharmaceutical Societyof Great BritainReceived October 1, 2009Accepted January 18, 2010DOI 10.1211/jphsr/01.01.0012ISSN 1759-8885

Correspondence: Tora Hammar,eHealth Institute, School ofHealth and Caring Sciences,Linnaeus University,SE-391 82 Kalmar, Sweden.E-mail: [email protected]

Research Paper

Swedish pharmacists value ePrescribing:

a survey of a nationwide implementation

Tora Hammara, Sofie Nystroma,b, Göran Peterssona, Tony Rydbergb,c

and Bengt Astranda,b,c

aeHealth Institute, School of Health and Caring Sciences, Linnaeus University, Kalmar, bApoteket AB(National Corporation of Swedish Pharmacies), Stockholm and c(current address) Vårdapoteket i NordenAB, Malmö, Sweden

Abstract

Objective To evaluate Swedish pharmacists’ attitudes towards ePrescribing, including thetransfer of ePrescriptions, electronic storing of prescriptions and mail-order prescriptions.Method This study was conducted as a web-based survey among 500 randomly selectedSwedish community pharmacists. The questionnaire included open-ended questions,multiple-choice questions and statements to which respondents gave their degree ofagreement on a six-point Likert-type rating scale. Free-text answers were categorized intothe most commonly mentioned opinions. Differences in respondents’ general character-istics and their level of satisfaction with ePrescribing were tested for significance using χ2

test. The survey had a response rate of 52% (259/500). 96% (248/259) of the respondentswere female, and 76% (196/259) were aged 40–64 years.Key findings Swedish community pharmacists were generally satisfied with ePrescribing(98%, 253/259). No significant (P > 0.05) difference in the general satisfaction could beexplained by the respondents’ age, gender or years in practice. A majority of the respondentsregarded ePrescriptions and electronic storing of prescriptions as being safe for patients (95 and93% respectively), providing patient benefits (96 and 95% respectively), being cost-effectivefor the pharmacy (92 and 91% respectively) and contributing to better communication andrelationshipswith both patients and prescribers (62–88%). The positive aspects of ePrescribingmost frequently mentioned in free-text answers were being safe (72%, 187/259) and time-saving (55%, 143/259). However, several weaknesses with ePrescribing were also describedby the respondents, as well as suggestions for improvement.Conclusion Our nationwide survey of Swedish community pharmacists’ attitudestowards ePrescribing shows that pharmacists are generally satisfied with it, including thetransfer of ePrescriptions, electronic storing of prescriptions and to a lower degree mail-order prescriptions.Keywords community pharmacies; electronic prescribing; health informatics;information technology; pharmacists; prescriptions

Introduction

The role of the pharmacist has been subject to considerable changes, due to modifiedpatient needs and technical developments.[1] The pharmacist preparing and mixingointments and medicines has transformed into being a distributor of drugs with theindustrialization of drug production. More recently, the role of the pharmacist has gonethrough additional important transformations including the introduction of the conceptpharmaceutical care. Today, pharmacists are responsible for safe dispensing of prescriptionmedicines, as well as being important providers of pharmaceutical care. They act to preventdrug therapy problems and improve patients’ quality of life, and their modification ofprescription errors has been shown to be of clinical value.[1–4] However, the role of thepharmacist may still be developing due to demands for new services and changes ininformation technology.[1,5]

Currently, drug prescribing is at a transitional stage between the traditional writtenprescription and the electronically transferred prescription (ePrescription).[6] The handwrittenprescription has a number of well-recognized weaknesses, including risk of misinterpretationof poorly written prescriptions and risk of falsification, as well as unidirectional

23

communication.[7,8] The adaptation of the traditional process inthe electronic era offers new opportunities and challenges forthe actors involved.[6,7] ePrescribing has been proposed as animportant strategy to improve safety, quality, efficiency andcost-effectiveness in prescribing and dispensing processes.[6–16]

However, weaknesses with paper prescriptions are notnecessarily solved with ePrescribing; for example, unidirec-tional communication remains a weakness with many ePre-scribing systems.[7,17] In addition, ePrescribing may create newerrors as a result of abbreviations, omitted information, choiceof drug with a product number that no longer exists, andePrescriptions not being transmitted.[7,15,16,18] A prescription,no matter the route of transfer, functions to communicatedecisions on drug therapy from the physician to the pharmacistdispensing the medication. It should be unambiguous, correctand complete, and the pharmacist is obliged to examineprescriptions before dispensing.[7] The electronic handling ofprescriptions in healthcare and at pharmacies enables the use ofcomputerized tools to assist physicians and pharmacists indecision-making and dispensing.[19,20]

In 2004 the Commission of the European Communitiesset a goal that the majority of European health organizations

and health regions should be able to provide online services,such as ePrescribing, by the end of 2008.[21] The experienceof ePrescribing in Sweden began in 1981, but it took 20yearsfor the tipping point of this new technology to occur.[22]

Since a new strategy with collaborative national and regionalimplementation teams was introduced in Sweden at the endof the 1990s, the development of ePrescriptions hasaccelerated rapidly (see Figure 1a).[22] In 2008 more than70% of all new prescriptions in Sweden were transmittedelectronically.[22] To increase the quality of ePrescriptions,and thereby patient safety, as well as to facilitate futuredevelopment of related services, a National ePrescriptionFormat (NEF) was implemented.[17,23,24] Since its nation-wide implementation in June 2009, the NEF has introducedmore formal requirements with automated quality checks ofall ePrescriptions.

The National Online Prescription Repository, a nationalmailbox for ePrescriptions, allows patients to store all theirprescriptions electronically and to access their storedprescriptions at any pharmacy.[17,22] By means of securedigital authentication, electronically stored prescriptions canbe accessed by the patients on the Internet as well, which

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Figure 1 (a) The number of ePrescriptions in Sweden, 1983–2008, and (b) the number of individuals storing their prescriptions in the Online Prescription

Repository in Sweden, June 2006–June 2009. The first ePrescription in Sweden was sent in 1983. The tipping point for this technology came after

approximately 20years, following a new national strategy[6,22] (National Corporation of Swedish Pharmacies, unpublished data, for 2007 and 2008).

Presently about 65% of Swedish individuals store prescriptions electronically (National Corporation of Swedish Pharmacies, unpublished data, June 2009)

24 Journal of Pharmaceutical Health Services Research 2010; 1: 23–32

introduces the opportunity for services like mail-orderprescriptions.[17,22] Presently, about 65% of Sweden’spopulation store prescriptions electronically in the OnlinePrescription Repository (National Corporation of SwedishPharmacies, unpublished data, June 2009) (see Figure 1b).

An important part in the outcome of the implementationof ePrescriptions is the attitudes of the involved actors(patients, prescribers and pharmacists) towards the newtechnique, including the perceived advantages ePrescribingoffers compared to the traditional method.[8] Several studieshave evaluated ePrescriptions from the pharmacists’ point ofview.[1,8,15,16,25–28] It has been proposed that ePrescribing canhave a positive effect on the professionalization of commu-nity pharmacists by enhancing the quality of informationavailable and by improving the quality of prescriptions theyare executing.[1] To improve the quality of ePrescribing thepharmacists’ point of view must be explored.

The aim of this study was to evaluate Swedishpharmacists’ attitudes towards ePrescribing, including thetransfer of ePrescriptions, electronic storing of prescriptionsand mail-order prescriptions.

Methods

Type of study

This study was conducted as a web survey of attitudes amongSwedish pharmacists, and all data were provided by surveyrespondents. Ethical approval was granted by the ethicscommittee of Southeastern Sweden.

Definitions

In this nationwide survey, pharmacists’ attitudes wereevaluated towards ePrescribing. Figure 2 shows a flowchartdescribing the process of ePrescribing in Sweden; howePrescriptions are transmitted, stored and dispensed.[17]

By ePrescriptions, we refer to prescriptions electronicallytransferred from the physician’s office to the pharmacy. Faxprescriptions and prescriptions printed at the prescriber’soffice are not included in our definition of ePrescriptions.ePrescriptions are not routinely printed at the pharmacy.Instead, in most cases, the pharmacists perform the entiredispensing process from the computer screen. All ePrescrip-tions are transmitted to the Online Prescription Repository,and at the pharmacy the patients can choose to continuestoring their prescription electronically, or to have it printedas a valid paper prescription. Prescriptions can be storedelectronically for the entire period of validity (iterationsincluded). Original handwritten prescriptions can be includedin the Online Prescription Repository as well, a serviceprovided by pharmacists. Patients can get their medicationfrom electronically stored prescriptions dispensed at anypharmacy with the presentation of valid identification, andthe prescriptions can also be accessed via the Internet bymeans of secure digital authentication.

By mail-order prescriptions, we refer to the service bywhich patients can get mail-order prescription drugs fromprescriptions stored electronically via the pharmacies’ home-page or customer service by telephone. The medications canbe sent directly to the patient’s home or be picked up at achosen pharmacy in a prepared blue bag.

Patient

Pharmacistat pharmacy

or mail-order pharmacyPrescriber

RequestMedicalneed

Dispensed drug

Online prescriptionrepository

ePrescriptionstored

ePrescriptiontransmitted

ePrescriptiondispensedePrescription

ePrescriptioninformation

ClarificationCancellation

ePrescriptioninformationon the web

Figure 2 Schematic illustration of ePrescribing in Sweden. The patient contacts the prescriber due to a medical need. An ePrescription is

transmitted from the prescriber to the Online Prescription Repository. The patient can then get the prescription dispensed from a pharmacist at any

Swedish pharmacy or via a mail-order pharmacy, and can get information on the Internet about the ePrescriptions directly via the Online Prescription

Repository. Broken lines indicate direct pharmacist-to-physician contact. This contact is not necessary but occurs if, for example, the prescriber

wishes to cancel a prescription, or if the pharmacist needs clarification regarding a prescription. As ePrescribing is implemented in Sweden today

there is no electronic mechanism for this communication. Adapted with permission from Hellström et al.[17]

Swedish survey on ePrescribing Tora Hammar et al. 25

In this study, we use the term pharmacist when referringto the two categories of licensed pharmacists in Sweden: thepharmacists with 5years of university education, andprescriptionists with 3years of university education. Bothare licensed pharmacy practitioners with similar legal rightsand obligations.[29]

Setting and inclusion criteria

Licensed pharmacists, employed at any of Sweden’sapproximately 900 community pharmacies that handleprescription medicines, and who had an employee e-mailaddress, were included in the study population. At the time ofthe study, all community pharmacists in Sweden wereemployed by the government-owned pharmacy chain (TheNational Corporation of Swedish Pharmacies), with onlya few exceptions lacking an employee e-mail address. Froma database of all employed Swedish community pharmacists,we received a Microsoft Excel document with all e-mailaddresses of pharmacists meeting our inclusion criteria(n = 4674). In Excel we used the RAND function to obtaina random number between 1 and 20 000 for each pharmacist,and chose the 500 pharmacists with the lowest number to beincluded in our study.

Survey development

The questionnaire was developed for the purpose of thisstudy and included 12 questions or statements in Swedish.The questionnaire was estimated to take about 6min tocomplete. The survey was conducted online with the web-based questionnaire tool Easyresearch (Easyresearch Scandi-navia AB, Stockholm, Sweden). The questionnaire had threeopen-ended questions where the respondents were askedto share their opinion regarding (1) positive aspectsof ePrescribing, (2) shortcomings with ePrescribing and (3)suggestions for improvement of ePrescribing. The open-endedquestions were placed in the first section of the questionnaireto reduce the risk of remaining questions affecting theresponses.

The respondents were asked to rate their level ofsatisfaction with ePrescribing in general, on a six-pointLikert-type rating scale, where 1 represented ‘not satisfied atall’ and 6 represented ‘very satisfied’. A grade of 1–3 wasconsidered as ‘not satisfied’ and 4–6 as ‘satisfied’. Therespondents were also asked to evaluate three services –

ePrescribing, the Online Prescription Repository and mail-order prescriptions – from seven aspects: (1) safety,(2) patient benefits, (3) cost-effectiveness for the pharmacy,communication with (4) patient and (5) physician, andrelation with (6) patient and (7) physician. Respondents wereasked to give their degree of agreement with sevenstatements (based on the aspects described above) for eachof the three services. Their degree of agreement was given ona six-point Likert-type rating scale where 1 represented‘do not agree at all’ and 6 represented ‘completely agree’.A response of 1–3 was considered as not agreeing and 4–6 asagreeing with the statement. The six-point Likert-type scalewas chosen to achieve a forced choice since no middle optionwas available.

To detect whether any characteristics affected theirattitudes, respondents were asked to complete general

questions regarding age, gender and years employed at apharmacy. The respondents were also asked how often theywork with prescriptions and to estimate the proportion ofePrescriptions among those prescriptions. The generalquestions were multiple choice in nature.

Pilot survey

To validate the questionnaire before the large-scale study, asmaller pilot study was conducted. In the pilot study, thequestionnaire was sent to 12 pharmacists and after theirparticipation they were asked to comment and provide theiropinion of the questionnaire. After minor adjustments, thequestionnaire was used in the large-scale survey.

Survey implementation

An e-mail was sent to 500 pharmacists randomly selectedfrom a total of 4674 Swedish pharmacists who met theinclusion criteria. In the e-mail, the purpose of the survey wasdescribed as well as the handling of data and confidentiality.The questionnaire could be reached from an attached link inthe e-mail and instructions on how to navigate thequestionnaire were included. Based on their response to thefirst question, the participants decided whether to participatein the study or not. Survey responses were collected duringone month (6 April–4 May 2009) after the initial e-mail wassent to the study population. During this month, threereminder e-mails were sent to individuals who had not yetresponded.

Analysis of results

Collected survey answers were analyzed using MicrosoftExcel (version 2003; Microsoft, Seattle, WA, USA) andstatistical analyses were performed using SPSS (version 17for Windows; SPSS Inc, Chicago, IL, USA). All analyseswere performed on a group level so that personal identity ofresponders would be protected. Free-text answers werecategorized into the most commonly mentioned opinions.Categories were not decided in advance, but emerged duringanalysis of the free-text answer’s meaning and content. If thefree-text answers included comments of different themes,they were divided into more than one category. Comments toother sections of the questionnaire are reported in case ofrelevancy. All results from multiple choice and Likert-scalequestions were regarded as nominal- or ordinal-level dataand statistical methods were chosen accordingly.[30] Differ-ences in respondents’ general characteristics and their levelof satisfaction with ePrescribing were tested for significanceusing the χ2 test. Statistical significance was determinedfor P < 0.05.

Results

In the study, 500 pharmacists were selected randomly. Ofthe total of 279 pharmacists who replied to the questionnaire,20 were excluded from the results because they did notanswer any of the questions about general characteristics.The 259 pharmacists answering at least the questions aboutgeneral characteristics were regarded as the respondentsof the survey, giving a response rate of 52%. Of the259 respondents, 95.8% were female and 75.7% were aged


40–66 years. The majority (73.4%) of the respondents hadbeen employed by a pharmacy for more than 10 years and96.1% stated that they worked with prescriptions daily. To thequestion ‘How large a proportion do you estimate thatePrescriptions represents among the prescriptions you workwith?’ the majority (59.8%) of the respondents estimated thatePrescriptions represented more than 75%. Table 1 shows thegeneral characteristics of the study population.

Attitudes towards ePrescriptions

Almost all (98%) of the respondents were generally satisfiedwith ePrescriptions. The median response on the six-pointLikert-type scale was 5. The respondents had a similar degreeof satisfaction regardless of gender, age or years in practice.No significant (P > 0.05) difference in the general satisfactioncould be explained by any of the baseline general character-istics of the respondents. Figure 3 shows the respondents’overall satisfaction on the six-point scale.

A majority of the respondents regarded ePrescriptionsas being safe for patients (95%, median response 5), providingpatient benefits (96%, median response 5) and being cost-effective for the pharmacy (92%, median response 6). Inaddition, the majority of the respondents perceivedthat ePrescriptions contributed to improved relationshipsand communication with patients (81 and 87% respectively,

median response 5) and prescribers (62 and 65% respectively,median response 4). Figure 4 shows details about the respon-dents’ degree of agreement with the positive statements.

Attitudes towards electronic storingof prescriptions

The respondents’ attitudes towards electronic storing ofprescriptions showed a high degree of similarity to theirattitude towards ePrescriptions (Figures 4 and 5). Amajority ofthe respondents regarded theOnline PrescriptionRepository asbeing safe for patients (93%, median response 5), providingpatient benefits (95%, median response 5) and being cost-effective for the pharmacy (91%, median response 6). Themajority of the respondents also perceived that the OnlinePrescription Repository contributed to improved relationshipsand communication with patients (84 and 88% respectively,median response 5) and prescribers (65 and 66% respectively,median response 4). See Figure 5 for details.

Attitudes towards mail-order prescriptions

A majority of the respondents agreed with statementsabout mail-order prescriptions being safe for patients (69%,median response 5), providing patient benefits (85%, medianresponse 5) and being cost-effective for the pharmacy (63%,median response 5). However, about half of the respondents(46–55%) disagreed, or answered ‘I don’t know’, to thepositive statements regarding relationship and communicationwith patients and prescribers. A large proportion (7–28%)answered with ‘I do not know’ to all statements about mail-order prescription. Figure 6 shows details about the respon-dents’ degree of agreement with the positive statements.

Strengths of ePrescribing

The question ‘What do you think is good with ePrescribing?’was answered in free text by 248 respondents, who togethermentioned 483 perceived strengths, giving 1.9 mentionedstrengths per answer. The responses showed a high degree ofsimilarity and were divided into six main categories and sixsubcategories. The most frequently mentioned strengths ofePrescribing were that it was safe (72%, 187/259), time-saving (55%, 143/259) and convenient to use (31%, 79/259).The most common reasons for increased safety were theimproved legibility of ePrescriptions compared with hand-written prescriptions (42%, 108/259) and a decreased risk offalsification (5%, 14/259). Some responses (22%, 56/259)

Table 1 General characteristics of respondents

Characteristics Number of respondents %a

Genderb

Male 11 4.2

Female 248 95.8

Age (years)

18–24 0 0.0

25–39 55 21.2

40–64 196 75.7

65+ 8 3.1

Years in practice

<1 6 2.3

1–3 24 9.3

4–10 39 15.0

>10 190 73.4

Working with prescriptions…

Daily 249 96.1

Every week 9 3.5

Less than once a week 1 0.4

Estimated percentage of

ePrescriptionsc

<10 1 0.4

10–24 1 0.4

25–49 9 3.5

50–75 92 35.5

>75 155 59.8

No response 1 0.4

aPercentage of the number of respondents participating in the survey

(n = 259). bPresently approximately 95% of Swedish community

pharmacists are female. cAnswer to the question ‘How large a proportion

do you estimate that ePrescriptions represents among the prescriptions

you work with?’

21 Notsatisfied

at all

0%

10%

20%

30%

Res

po

nd

ents

(%

)

40%

50%

60%

3 4 5 6 Verysatisfied

Figure 3 The respondents’ overall satisfaction with ePrescribing


described positive characteristics of computerized tools orrelated services enabled by ePrescribing, like the OnlinePrescription Repository and interaction checks. The respon-dents’ opinions on strengths of ePrescribing are presented inTable 2.

Weaknesses of ePrescribing

The question ‘What shortcomings do you think there are withePrescribing?’ was answered in free text by 246 respondents,who together mentioned 390 perceived weaknesses, dividedinto 17 categories. Themost frequentlymentionedweakness of

ePrescribing was that it was more inconvenient to makechanges or corrections with ePrescriptions than with paperprescriptions (28% of the respondents, 72/259), and that it wastroublesome or unacceptable that the technique or systemsometimes did not work, leaving them unable to access theePrescription system (20%, 51/259). Many respondents werebothered by prescribers not having the same supply register asthe pharmacy (13%, 33/259), or that the prescriber useddifferent abbreviations than the pharmacist (11%, 29/259). All17 categories with the respondents’ opinions on weaknesses ofePrescribing are presented in Table 3.

Are safe for patientsePrescriptons:

Provide patient benefits

Are cost effective

Contributes to better communication with patient

Contributes to better communication with prescriber

Contributes to better relation with patient

Contributes to better relation with prescriber

0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Don’t know

1 Don’t agree at all 42 53 6 Completely agree

Figure 4 Attitudes towards ePrescriptions. Respondents (n = 259) gave their degree of agreement with statements on a six-point Likert-type

rating scale

Is safe for patientsElectronic storing of prescriptions:


Is cost effective





0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Don’t know


Figure 5 Attitudes towards electronic storing of prescriptions. Respondents (n = 259) gave their degree of agreement with statements on a six-point

Likert-type rating scale


Improvements to ePrescribing

In one question, the respondents were asked to givesuggestions for improvements in free text. The question wasanswered by 194 pharmacists, but since many referred to theirprevious answers in the survey, all answers or comments infree text were reviewed to detect suggestions for improve-ments. Among the most common suggestions for improve-ments were increased coordination between healthcare andthe pharmacies, better possibilities for the prescriber to view,

change or cancel ePrescriptions, and increased reliabilityof the systems or technique necessary for ePrescribing. Therespondents sometimes gave different suggestions address-ing the same issue, and the suggestions were not alwayscompatible with each other. Suggestions for improve-ments based on the pharmacists’ responses are presented inTable 4.[31]

Discussion

Our study showed Swedish community pharmacists to begenerally satisfied with ePrescribing, independent of their age,gender or years in practice. A majority of the respondentsregarded ePrescriptions, electronic storing of prescriptionsand mail-order prescriptions as being safe for patients,providing patient benefits and being cost-effective for thepharmacy. In addition, the majority of the respondentsperceived ePrescriptions and the electronic storing ofprescriptions as contributing to better communication andrelationships with both patients and prescribers. However,respondents agreed with positive statements about commu-nication or relations with prescribers to a lower extent thanwith corresponding statements regarding patients.

The respondents’ attitudes towards mail-order prescrip-tions were less positive than for ePrescriptions and electronicstoring of prescriptions. However, the respondents’ answersmay not reflect dislike of this service but a lack of experience.Most of the contacts with patients using mail-order prescrip-tions are handled by pharmacists at the centralized pharmacycustomer service centre, and our study included communitypharmacists only. In addition, the service of mail-orderprescriptions is still at an early stage of implementation andused in smaller scale than the other services.

The pharmacists’ most frequently mentioned strengths ofePrescribing were that it was safe, time-saving and convenient

Are safe for patientsMail order prescriptions:


Are cost effective





0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100%

Don’t know


Figure 6 Attitudes towards mail-order prescriptions. Respondents (n = 259) gave their degree of agreement with statements on a six-point Likert-

type rating scale

Table 2 Respondents’ perceived strengths of ePrescribing

Strengths associated with

ePrescribing

Number %a

1. Safe 187 72

Improved legibility 108 42

Less risk of falsification 14 5

2. Time-saving 143 55

Prescription complete 10 4

3. Convenient 79 31

Convenient for patients 28 11

4. Good computerized tools or

related services

56 22

Overview of medication with

Online Prescription Repository

39 15

Interaction checks 12 5

5. Everything is good 7 3

6. Other 11 4

Total 483

Answers given in free text were categorized into six categories and six

subcategories. A respondent’s answer could contain several different

categories or subcategories. A total of 483 strengths were mentioned in

the 248 answers, giving 1.9 mentioned strengths per answer. Complete-

ness rate, 0.96 (248/259). aPercentage of the number of respondents

participating in the survey (n = 259).


to use. Two recent studies evaluating Swedish prescribers’attitudes towards ePrescribing showed that the prescribers toowere satisfied with ePrescribing, and that they also regardedePrescribing as safe and time-saving.[17,31] Even if the vastmajority of pharmacists in our present study were satisfied,several weaknesses were mentioned in the survey. The mostfrequently mentioned weaknesses of ePrescribing were that itwas more inconvenient to make changes or corrections thanwith paper prescriptions, and the technique or system necessarysometimes did not work so they could not access theePrescriptions. Several of the pharmacists’ mentioned weak-nesses were related to those reported from the studies amongSwedish prescribers.[17,31]

Many pharmacists were bothered by prescribers nothaving the same supply register as the pharmacy or theprescriber using abbreviations in the prescription other thanthe pharmacy. Two recent Swedish studies showed thatePrescriptions needed contact with prescribers for clarifica-tion more often than paper prescriptions, mainly due toproblems with the dosage text. This was explained, at leastto some extent, by prescribers’ widespread use of

abbreviations.[7,18] These findings support the need forstandardization of abbreviations and coordination betweenhealthcare providers and pharmacists.

Respondents’ comments and open answers revealed thatthey made no clear distinction between electronic transmis-sion of prescriptions and electronic storing of prescriptions.This indicates that electronic storing of prescriptions hasbecome a natural extension in the implication of ePrescrip-tions in Sweden, at least for pharmacists.

We regard our study population as being representative ofSwedish community pharmacists, since they were randomlyselected from a database including all, or almost all, Swedishcommunity pharmacists (n = 4674). The study population inthis survey was relatively large, increasing the reliability ofthe results. The gender distribution of our study populationcorresponds to the distribution of the entire population ofSwedish community pharmacists. However, the low numberof males in the study limits the conclusions that can be drawnregarding gender differences. The relatively low responserate (52%) might have biased the results of the study.Pharmacists choosing to answer a web survey may perhapshave a more positive attitude towards using technology ingeneral, compared with the total study population. However,

Table 3 Respondents’ perceived weaknesses of ePrescribing

Weaknesses associated with ePrescribing Number %a

1. Inconvenient to make changes or corrections

at the pharmacy

72 28

2. Troublesome that the technique or system

sometimes does not work

51 20

3. Different supply registers used by prescriber

and pharmacy

33 13

4. Prescriber using abbreviations, different

than the pharmacy

29 11

5. Prescriber cannot cancel or change ePrescription,

pharmacy sometimes gets duplicate prescriptions

27 10

6. Too many prescriptions to choose from

in prescription repository

23 9

7. Inconvenient for unregistered drugs, extemporaneous

preparations or ApoDosb21 8

8. Patients lacking knowledge about ePrescribing 20 8

9. Prescribers lacking knowledge about ePrescribing 19 7

10. Shortcomings with computerized tools 19 7

11. Problems with patients without social security

number

12 5

12. No weaknesses 8 3

13. Increased risk of failing to discover errors 8 3

14. Harder to see history for prescription 7 3

15. Increased risk of prescription being issued

to the wrong person

5 2

16. Worse communication between prescriber

and patient

4 2

17. Other 32 12

Total 390

Answers in free text were categorized into 17 categories. An answer

could contain several different categories. A total of 390 perceived

weaknesses were identified among the 246 free-text answers, giving 1.7

mentioned weaknesses per answer. Completeness rate, 0.95 (246/259).aPercentage of the number of respondents participating in the survey

(n = 259). bApoDos is a service with multidose packaged drugs from all

of a patient’s prescriptions, with prescriptions accessible

electronically.[31]

Table 4 Pharmacists’ recommendations for improvements to

ePrescribing

Recommendations

1. Increase reliability of the systems or technique necessary for

ePrescribing: system breakdowns should not be allowed to occur

2. Prescriber should be able to

change or cancel an ePrescription after being sent

access the Online Prescription Repository and view, change or

remove a patients prescriptions

3. Enable convenient ePrescribing of unregistered drugs,

extemporaneous preparations or ApoDosa

4. Enable ePrescribing for patients without social security number

alternative ways of searching for ePrescription

5. Coordination of pharmacy and health-care

use the same supply register

use the same abbreviations, or else no abbreviations should be allowed

6. Enable two-way communication between prescriber and dispensing

pharmacist

prescriber should be able to send a comment to their prescription

pharmacists should be able to send a message to prescribers about

prescriptions

7. Make it easier to change or correct ePrescriptions at the pharmacy

8. Support functions for dispensing system should be even more

user-friendly

more reliable interaction checks

easier to reach drug information

original prescription should be reachable all the time

reduce number of keystrokes or mouse clicks

9. Extended education or information to prescribers and patients

about ePrescribing, to increase knowledge and acceptance and

cause fewer misunderstandings and mistakes

The recommendations were categorized into nine areas that were

commonly mentioned as being in need of improvement. aApoDos is a

service with multidose packaged drugs from all of a patient’s prescrip-

tions, with prescriptions accessible electronically.[31]


all pharmacists have Internet access at the pharmacy and getwork-related information via their e-mail, and we believethat our chosen method was the best to reach the pharmacistswith our questionnaire. Since Sweden has come a long waywith ePrescribing, and because there are differences betweenthe drug prescribing and dispensing systems in Swedencompared with other nations, the generalizability to othercountries may be limited. The study might nevertheless be ofvalue in the implementation of ePrescribing in othercountries.

When comparing the results of our study with previousstudies (examples described below) it is important to keep inmind that most studies differ in the ePrescribing system theyevaluate and the stage of implementation, and may differ inthe definition of ePrescribing.

A number of surveys of attitudes among pharmacistssupports the main findings of our study, namely thatpharmacists view ePrescribing in a positive way.[1,8,15,27,28]

In 1996, when ePrescribing was still emerging, a studyconducted at a meeting for community pharmacists showedthat pharmacists believed ePrescribing to decrease medica-tion errors and save time, but less than half of thepharmacists indicated they would welcome ePrescribing.[27]

A more recent study, measuring the attitudes towardsePrescribing in six US states, showed pharmacy personnelto prefer ePrescriptions over conventional prescriptions.[15]

In this study, some of the pharmacists’ most commonly citedpositive features (e.g. improved legibility and speed) andnegative features (e.g. prescribing errors and technicalproblems) of ePrescribing, resembles the opinions expressedin free-text by pharmacists in our study. From a surveyamong community pharmacists in Canada, who had partici-pated in an ePrescribing pilot project, it was concluded thatcommunity pharmacists viewed the influence of ePrescribingin a favourable light, and believed it could have a positiveeffect on their professionalization.[1] A recent study eval-uated user satisfaction with ePrescribing after its implemen-tation in a primary care group in Singapore.[8] The resultsshowed both prescribers and pharmacy personnel to besatisfied with ePrescribing, perceiving a reduction inprescribing errors and interventions, with no desire to returnto a paper-based system.

In a study using work sampling to evaluate the effects ofePrescribing on pharmacist work patterns, ePrescribing wasshown to result in major changes in the type of workperformed, the reason for their work, and small changes intheir work contacts with other people.[25] Another studyshowed ePrescribing to result in fewer prescribing errorsand pharmacist interventions.[10] The study also identifiedprescribing errors specific for ePrescribing. In a recent studyof community-chain pharmacists’ interventions on ePrescrip-tions, it was concluded that ePrescribing can improve safetyand effectiveness of patient care.[16] A systematic reviewfurther supports the pharmacists’ perceived strengths shown inour study, when concluding that ePrescribing reduces the riskof medication errors and adverse drug events.[9]

Even though the pharmacists in our study were generallysatisfied with ePrescribing, several issues warranting theneed for improvement were identified. Based on ourfindings, we suggest the following: (1) abbreviations used

in ePrescriptions should not be allowed or should bestandardized and coordinated between healthcare institutionsand pharmacies; (2) prescribers should have updated supplyregisters coordinated with pharmacies, including informationabout which drugs are included in the discount system;(3) prescribers should have access to, and regularly check,receipts when a prescription is successfully transmitted;(4) there should be standardized instructions for prescribersto handle cancellation of an ePrescription and handlesituations where ePrescription transfer is disrupted, in aneffort to avoid duplicate prescriptions; (5) ePrescribingshould be enabled or simplified for people without a Swedishsocial security number, for unregistered drugs, extempora-neous preparations and other more complex parts ofprescribing, like the Swedish service ApoDos[32], and (6)possibilities for implementation of electronic two-waycommunication between prescribers and pharmacists shouldbe investigated.

ePrescribing in Sweden has now been evaluated fromprescribers[17,31] and pharmacists’ points of view in recentstudies. To evaluate ePrescribing from the last, and perhapsmost important actor in ePrescribing, a study of Swedishpatients’ attitudes towards ePrescribing is currentlyunderway.

Conclusions

Our nationwide survey shows that Swedish communitypharmacists are generally satisfied with ePrescribing,including the transfer of ePrescriptions, electronic storingof prescriptions and, to a somewhat lesser degree, mail-orderprescriptions. However, several perceived weaknesses withePrescribing warrant further improvement. The perceivedstrengths and weaknesses identified in this study can behelpful in the improvement of Swedish ePrescribing, andmight be of use for successful implementation of ePrescrib-ing in other nations as well.

The pharmaceutical care provided by pharmacists isimportant for safe treatment with prescription medications.ePrescribing and related services have affected pharmacists’work and perhaps also transformed their role. If ePrescribingcan contribute to safer and more efficient dispensing, asperceived by pharmacists in our study, its implementationshould be welcomed and appreciated by pharmacists acrossthe world.

Sweden has come a long way with ePrescribing and thebenefits are reflected in the satisfaction of pharmacists.However, to ensure successful implementation of ePrescrib-ing, it should be evaluated with continuous monitoring ofuser satisfaction.

Declarations

Conflict of interest

During this study, three of the authors (SN, TR, and BA)have been employed by the National Corporation of SwedishPharmacies (Apoteket AB).


Funding

This work was supported by the National Corporation ofSwedish Pharmacies (Apoteket AB), eHealth Institute,County Council of Kalmar, Regional Council of Kalmar,Municipality of Kalmar and the Linnaeus University.

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Documents

Swedish pharmacists value ePrescribing: a survey of a nationwide implementation