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Int J Health Policy Manag 2019, 8(1), 40–48 doi 10.15171/ijhpm.2018.89

Original Article

Evaluation of Transition to Electronic Prescriptions in

Turkey: Perspective of Family Physicians
Sinan Bulut1*, Ahmet Yıldız2, Sıdıka Kaya3

Abstract
Article History:
Background: One of the most important steps of the health transformation program involves the application of
Received: 2 February 2018
electronic prescriptions (e-prescriptions) in health services. Information technologies are highly important in generating Accepted: 8 September 2018
e-prescriptions, which can be described as a document produced by authorized personnel electronically, containing ePublished: 23 September 2018
written information and instructions regarding a patient’s medication and its usage. E-prescribing has become
increasingly applied in recent years as a contributing application to prescribers and patients. The aim of this study was
to determine the level of satisfaction of family physicians providing primary care in Turkey regarding the application of
e-prescriptions, and reveal the related positive effects and problems encountered in the first months of implementation
of e-prescribing.
Methods: A questionnaire with eight questions was sent to e-mails of all family physicians working in Turkey in May
2013. A total of 1564 family physicians filled in the questionnaire form and sent it back by e-mail. The responses to open-
ended questions were evaluated by content analysis.
Results: It was observed that the most frequently indicated advantages of the application of e-prescriptions were speeding
up the prescription process and saving time (36.6%). The most commonly reported problems regarding the application
of e-prescriptions were found to be system-induced problems (26.5%) and internet problems (19.9%). In addition, the
mean score of satisfaction of the family physicians who did not report problems with the application of e-prescriptions
was higher than that of those who reported having problems with it. In the study, 77.8% of the family physicians were
satisfied with the application of e-prescriptions.
Conclusion: Although some problems were reported regarding the application of e-prescriptions in the first months
of the application, family physicians participated in the study were found to be satisfied with the application of
e-prescriptions, and identified positive effects on their work and processes.
Keywords: Family Physicians, Electronic Prescribing, Health Technology Assessment, Turkey
Copyright: © 2019 The Author(s); Published by Kerman University of Medical Sciences. This is an open-access article
distributed under the terms of the Creative Commons Attribution License (http://creativecommons.org/licenses/
by/4.0), which permits unrestricted use, distribution, and reproduction in any medium, provided the original work is
properly cited.
*Correspondence to:
Citation: Bulut S, Yıldız A, Kaya S. Evaluation of transition to electronic prescriptions in Turkey: perspective of family
Sinan Bulut
physicians. Int J Health Policy Manag. 2019;8(1):40–48.  doi:10.15171/ijhpm.2018.89 Email:
[email protected]

Key Messages
Implications for policy makers
• Prior to the implementation of the e-prescription system nationwide, it is important that the technical infrastructure is completely established
and the integration between institutions is fully achieved.
• Evaluating the opinions of users after a pilot study of the e-prescription system will help prevent problems that may arise after the application
has become widespread.
• E-prescribing provides important contributions in the prescribing process, especially in terms of saving time and eliminating handwriting
errors. In addition, e-prescription has important contributions to patient safety and medication safety.

Implications for the public

E-prescribing is a useful application for patient safety and satisfaction. Because it eliminates medication errors resulting from illegible handwritten
prescriptions, shortens the prescribing time and makes it easier for patients to get medication from pharmacy.

Background in healthcare services can make potential contributions to

Health information technology includes a variety of enhancing service quality, safety, efficiency and reducing
technologies that enable the management and transfer costs both for patients and service providers.2,3 Although
of information for patients, service providers, insurers, such contributions have been reported, technology usage by
payment institutions and all other groups related to health physicians and hospitals is still at a low level.2
and healthcare.1 The utilization of information technologies In Turkey, the Health Transformation Program, which

Full list of authors’ affiliations is available at the end of the article.

Bulut et al

includes initiatives for increasing the utilization of information well-structured. There are 2 periods in e-prescription practice
technologies in the provision of health services, aims to in UK primary healthcare. The first period is the period when
“put into practice the e-transformation project in the field the pilot was initiated in 2005 and the second is the period
of health” and, in this context, to promote the constitution, in which the electronic transmission is started in 2012. In
standardization, and classification of information systems, the second period, 99% of public pharmacies started using
and the integration and active use of data gathered from e-prescriptions.11 Electronic prescription (e-prescription)
different institutions.4 systems have become increasingly widespread in developing
Electronic prescription (e-prescription) is one of the countries in recent years.13-15 Health systems where there is a
important steps taken to use information systems in the field clear hierarchical structure and where healthcare is managed
of health in terms of facilitating communication between by a single authority are more successful in e-prescription
institutions in prescription processes, increasing patient safety adoption. In addition, each country’s specific legislation,
and satisfaction. Technology has the advantage of increasing regulation and stakeholder engagement play an important
people’s work performance and people can be stronger with role in the development of e-prescribing practices.14 In order
technology than they are alone. Thus human errors can for e-prescription applications to work well, it is important to
decrease.5 In addition, information technology plays a key set standards for data entry fields in e-prescription software.
role in providing better and safer care, and transformation These standards will ensure that the prescription is created in
of health services.6 That is why information technologies a clear and complete manner and will prevent physicians from
are highly important in generating e-prescriptions, which filling data entry fields in different ways.16
can be described as a document produced by authorized E-prescription is a software application that shares patients’
personnel electronically, containing written information information over a network that is open to the common use
and instructions regarding a patient’s medication and its of health service providers, and allows the storage, utilization
usage. by relevant staff, and transmission of this information
Despite the potential advantages, launching new through writing in an electronic environment.17 Additionally,
applications such as e-prescriptions does not mean that it e-prescribing can be described as producing a prescription by
can be successfully implemented. Human factors can play entering data (into a computer or a mobile portable device for
an important role in the success of the new technology, and instance) about the patient and medication in the automatic
user satisfaction is one of them. It is important for users to data entry system, instead of writing the prescription on
be satisfied with the new system to implement the system paper manually. According to the Centre of Medicare and
successfully. 7,8 Medicaid services in the United States, “E-prescribing means
Electronic systems for medicine prescribing and the transmission, using electronic media, of prescription or
administration are widely used in the United States. This prescription-related information between a prescriber, dispenser,
is probably due to the need for costing of medication pharmacy benefit manager, or health plan, either directly or
administration, in an insurance-based health system, and through an intermediary, including an e-prescribing network.”18
the need for risk management to reduce clinical risk to a E-prescription is defined by the Social Security Institution
minimum, to optimise audit trails in a highly litigious society, (SSI) in Turkey as “prescriptions generated by physicians on the
and to improve the quality of patient care.9,10 systems of the health service providers in accordance with the
Electronic prescribing, which is beginning to show more definitions and announcements of the SSI, and are electronically
and more positive effects in the United States, began to recorded in the MEDULA [Medikal Ulak] system and given the
spread later in Europe. The e-prescription was first used electronic prescription number.”19
routinely in Europe in 1983 in Sweden. The functionality of In the process of e-transformation in the field of health in
the e-prescription has expanded over time. With a national Turkey, the first preparation e-prescriptions was conducted in
postal box system launched in 2004, patients became 2011. Subsequently, studies on the application of e-prescriptions
able to take medicines from any pharmacist and to access intensified and in 2012, a pilot implementation was initiated
their prescriptions through an online portal. Like Sweden in 3 provinces. Following this pilot implementation, on July 1,
and Denmark, it can be seen among countries that have 2012, the e-prescription system used by the main repayment
adopted health information technology in the early period institution, the SSI, was extended to the whole country, and
and pioneered the use of this technology.11 In Denmark, on January 15, 2013 e-prescribing became compulsory except
the e-prescription system began in 1994 with the central in certain exceptional circumstances.20 The introduction of
e-Health organization Medcom, which sets the standards e-prescriptions has been successful, as indicated by the fact
for e-prescriptions and ensures stakeholder compliance. In that in the first half-period of the implementation 65% of
Denmark, over 99% of total prescriptions are e-prescription, all prescriptions were generated electronically, and 105 200
while in Sweden this rate is over 90%.11 Creating the required physicians obtained institutional passwords in order to create
standards, gaining agreement to use the standards and e-prescriptions.21
funding implementation of the standards are play a key role to The SSI has been conducting the application of
success e-prescription in Denmark.12 In the United Kingdom, e-prescriptions on the system of MEDULA (Also see Figure),
there is a great difference in terms of e-prescription between which is an integrated system including the General Health
primary and secondary healthcare services. In primary Insurance (GHI) and healthcare facilities in order to gather
healthcare, the electronic prescription system is relatively billing data electronically and make service payments without

International Journal of Health Policy and Management, 2019, 8(1), 40–48 41

Bulut et al

Figure. E-prescription Process in Medikal Ulak (MEDULA) System in Turkey.

interfering with internal processes.21 For example, before physician logs into AHBS, using their institutional password
the e-prescription application, SSI required that the paper obtained from the SSI. E-prescriptions are generated by
prescriptions be delivered to the institution within a certain accessing the patient’s information in MEDULA using the
period of time, checked if the prescription was signed and citizenship number of the patient. A code for the generated
if the medications were appropriate. With the application prescription is provided by the MEDULA system and this
of e-prescriptions, however, these procedures can be easily code is given to the patient by the physician. The patient can
carried out through the system. then obtain their medicine from any pharmacy of their choice
The system involves the use of patient information and (Also see Figure). While family physicians are the first step in
is available to physicians, pharmacies, and hospitals. The the e-prescription process at the primary level, SSI forms the
system ensures the flow of information without interfering second step by generating, transmitting and controlling the
with the processes of health institutions. Pharmacies, health prescription code, and pharmacies form the last step of the
centers, diagnostic and treatment centers and public and system as users of the e-prescription codes.
private hospitals have been integrated into MEDULA via This study, which was carried out in the first months of
web services. MEDULA system which provides accurate and the implementation of the e-prescription system in Turkey,
practical communication between health service providers intended to provide information about the functionality of
and SSI acts jointly with the GHI, the Central Population the implementation to the decision makers in Turkey and
Affairs System (Mernis) and the Ministry of Health.22 The in other countries planning to apply e-prescription systems.
integration of the MEDULA system with other institutions Specific aims of this study are to:
also provides the physician with information regarding the 1. Determine the positive effects of e-prescriptions on the
patient. By this means, when the physician enters a patient’s procedures of family physicians that provide primary
identification number into the system for e-prescription, the healthcare services,
patient’s identification information from the Mernis system 2. Determine the problems involved in e-prescription
appears on the screen. In addition, the physician can see the writing,
information regarding the patient’s social security on the 3. Determine the level of satisfaction of family physicians
screen. with the application of e-prescriptions.
Family physicians, who are primary healthcare service
providers, have been prescribing electronically except in Methods
accepted exceptional circumstances (prescriptions written Data Collection Tool
when providing mobile or home healthcare services, and A questionnaire developed specifically for this research was
when the MEDULA or healthcare service provider systems used in the study. To begin with, 30 family physicians were
do not work).23 Family physicians can create e-prescriptions interviewed face-to-face about the e-prescribing system they
on the family practice information system (AHBS), which is used; the convenience of the system, the challenges they
compatible with the MEDULA system and also provided by have experienced and their satisfaction with the system.
private companies, by obtaining an institutional physician A data collection tool was generated by the authors using
password provided by the SSI. Using this password, family these interviews as well as SSI communiqué on healthcare
physicians can access the reports of any patient, their reported practices,24 and informational correspondences for the use
or unreported medicines, test results, medical information, of e-prescribing written by the SSI and Public Health Agency
and repayment information on the MEDULA system. of Turkey. Since the interviewees stated that number of
The e-prescription process is carried out in a system questions should be kept minimum due to the heavy workload
involving health service providers, Social Security Institution of family physicians, the questionnaire was limited to only
and pharmacies. In the process of healthcare service providing, 8 questions. Then the questionnaire was pilot tested and
which starts with the patient’s visit to the family physician, the participants found the questions were understandable and

42 International Journal of Health Policy and Management, 2019, 8(1), 40–48

Bulut et al

feasible. In addition to the questions related to age, years of Accordingly, it can be said that the participants represent the
experience as a physician, number of e-prescriptions written family practitioner population in terms of age and gender
daily, and time taken to write an e-prescription, the following distribution.
questions were also included a 5-point Likert-type question
to determine the satisfaction level of physicians with the Data Analysis
application of e-prescriptions, and 2 questions to determine Professional and demographic information and the level
the positive effects of e-prescriptions on physicians’ processes of satisfaction with the application of e-prescriptions of
and whether problems with e-prescriptions were experienced, the family physicians in the research were analyzed using
“Has the application of e-prescriptions had positive effects on descriptive statistics such as mean, standard deviation,
your work and processes? If yes, what are these?” and “Are you frequency, and percentage. Significance testing (t test) of
having problems with the application of e-prescriptions? If the difference between 2 means was conducted in order to
yes, what are these?” The necessary permissions were obtained evaluate whether the level of satisfaction with the application
from the Ministry of Health, Public Health Institution of of e-prescriptions differed or not according to the “yes-
Turkey in order to conduct the study. no” answers of family physicians to the questions “Has the
application of e-prescriptions had positive effects on your
Population and Sampling work and processes?” and “Are you having problems with
In May 2013, when the research was conducted, 20 450 family the application of e-prescriptions?” Each response given by
physicians were working in Turkey. No sample was selected physicians to these questions were evaluated and content
and it was aimed to include as many family physicians as analysis was conducted. Responses that express the same
possible in the study. Data were collected using e-mails of problem or positive effect were grouped under the same
family physicians. The questionnaire form was forwarded heading. In this way, all the answers were examined and the
once to all family physicians via e-mail and responses were positive effects and problems were tabulated under certain
archived to be evaluated. A total of 1534 family physicians headings. Microsoft Excel was used to classify the answers to
(7.5%) participated in the study. It has been tested whether the open-ended questions related to the positive effects and
the participants represent the family practitioner population the problems experienced in relation to the application of
by using age and sex distributions of family physicians. e-prescriptions. The Statistical Package for the Social Science
According to the Ministry of Health, 68% (13 906) of the for Windows (SPSS 20.0) was used to perform the statistical
family physicians working in Turkey were male and 32% analyses.
(6544) were female as of the date of the research. 70.3% (1078)
of the family physicians participating in the survey were male Results
and 29.7% (456) were female. No statistically significant Family physicians’ age, years of experiences as a physician,
difference was found between the rates (χ2 = 3.999; P > .05). In number of e-prescriptions written per day, time taken to
addition, according to the data obtained from the Ministry of write an e-prescription, and level of satisfaction related to the
Health, the average age of the family physicians as of the date application of e-prescriptions are shown in Table 1. When
of the research was 40.62. The average age of family physicians examining the ages of all 1534 family physicians participating
participating in the survey was 41. There was no statistically in the research, it can be seen that family physicians’ mean age
significant difference between the averages. (t = 1.926; P > .05). was 40 years. The mean years of experiences as a physician

Table 1. Characteristics of the Family Physicians Participated in the Study (N = 1534)

  N Percent Mean ± SD (Max-Min)

≤35 394 25.7
Age (y) 36-45 666 43.4 41.00 ± 7.72 (66-24)
≥46 574 30.9
≤2 355 23.2
Time Working as Physician (y) 3-4 839 54.8 3.33 ± 1.39 (7-1)
≥5 338 22.1
≤35 367 24.0
Number of e-prescriptions written per day 36-50 700 45.8 47.20 ± 16.22 (120-6)
≥51 462 30.2
≤2 797 52.3
Time taken to write an e-prescription (min) 3-4 420 27.5 2.86 ± 2.12 (15-0.1)
≥5 308 20.1
1 33 2.2
2 45 2.9
Level of satisfactiona 3 247 16.1 4.15 ± 0.94 (5-1)
4 536 34.9
5 658 42.9
Abbreviation: SD, standard deviation.
a
1 = Absolutely not satisfied,…, 5 = Absolutely satisfied.

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Bulut et al

was nearly 3 years. In terms of the number of e-prescriptions said “yes” to the question “Are you having problems with
written per day, the mean number was approximately 50 the application of e-prescription?” was higher than those
prescriptions. The mean time taken by family physicians to who said “no.” The level of satisfaction with the application
write an e-prescription was nearly 3 minutes. Regarding the of e-prescriptions of those who said “yes” to this question
level of satisfaction with the application of e-prescriptions, was nearly 1 point lower than of that of those who said
a significant percentage was satisfied (77.8%) and a small “no,” with the difference also being statistically significant
percentage was not (5.1%). The mean score for the level of (P < .001). The higher number of physicians answering “yes”
satisfaction was calculated as 4.15 ± 0.943 and this score was to both questions suggests that although family physicians
evaluated as high. have problems with the application of e-prescriptions they
It can be seen that the number of physicians who answered also think that e-prescriptions have positive effects. This
“yes” to the question “Has the application of e-prescriptions demonstrates that e-prescription practice is beneficial but
had positive effects on your work and processes?” is nearly open to improvements. The high level of satisfaction of family
4 times higher than those who said “no” (Table 2). The level physicians who report no problems suggests that satisfaction
of satisfaction with the application of e-prescriptions of would generally increase if the problems with the application
those who said “yes” was nearly 1 point higher than that of of e-prescriptions were eliminated.
those who said “no,” with the difference being statistically The positive effects of the application of e-prescriptions
significant (P < .001). Similarly, the number of those who reported by the participants are shown in Table 3. Of the

Table 2. Distribution of Family Physicians’ Level of Satisfaction With Application of E-prescriptions According to Answers to Questions “Has the Application
of E-prescriptions Had Positive Effects on Your Work and Processes?” and “Are You Having Problems With the Application of E-prescriptions?”

Level of Satisfaction
  n t P
Mean SD
Has the application of e-prescriptions had positive effects on your Yes 1229 4.31 0.80
11.892 <.001
work and processes? No 290 3.45 1.17
Yes 987 3.89 0.98
Are you having problems with the application of e-prescriptions? -17.109 <.001
No 532 4.61 0.65
Abbreviation: SD, standard deviation.

Table 3. Family Physicians’ Answers to Question “Has the Application of E-prescriptions Had Positive Effects on Your Work and Processes?”

  Positive Effects n Percenta

A- Providing savings 1218 79.4
1 Speeding up prescription writing and saving time 561 36.6
2 Paper saving 438 28.6
3 Toner saving 219 14.3
B- Facilitating prescription writing 390 25.4
4 Removing handwriting and simplifying prescription writing 171 11.1
5 Being able to see former medicines and reports provided to patient, and information related to patient on the
123 8.0
system, and simplifying following-up the patient
6 Simplifying generation of prescription and allowing adding explanation to prescription 63 4.1
7 Being able to see the medicine, dosage, equivalents, and prices on the system and providing convenience to
24 1.6
physician in determining the medicine to be prescribed
8 Enabling prescription writing even in external environments (mobile services) where internet access is
9 0.6
provided
C- Increasing service quality and reliability 231 15.1
9 Reducing prescription writing errors, e-prescriptions being legible, exact, and complete, providing
143 9.3
convenience to pharmacist, and reducing the errors of providing incorrect medicine or dosage
10 E-prescriptions being safe, records being reliable, and no alterations to be made on prescription by others 88 5.7
D- Facilitating patient’s process to obtain medicine and increasing patient satisfaction 62 4.0
11 Simplifying patient’s process to obtain medicine 18 1.2
12 Increasing patient satisfaction 15 1.0
13 Reducing patient waiting time 11 0.7
14 Creating the perception of more contemporary, technological, and higher-quality service 10 0.7
15 Eliminating situations such as loss or tearing of prescription 8 0.5
E- Preventing physician-patient-pharmacist conflict 52 3.4
16 Reducing arguments over prescription writing with patient 27 1.8
17 Reducing arguments over prescription writing between physician and pharmacist 25 1.6
F- Other 22 1.4
18 Other 22 1.4
Total 1975
a
Since some physicians gave more than one answer to this question, the total of the percentage exceeds 100.

44 International Journal of Health Policy and Management, 2019, 8(1), 40–48

Bulut et al

1534 family physicians who participated in the survey, 1020 system, stopping of the system from time to time. Internet-
(66.49%) stated at least one positive effect of the application of related problems were also important. The implementation
e-prescriptions. A total of 1975 statements about the positive of e-prescription through the internet network requires the
effects of the application of e-prescriptions on the work and establishment of a robust internet infrastructure. Interrupting
processes of family physicians were collected. These statements or slowing down the connection to the Internet hinders
were gathered under 5 groups and 18 subgroups. Most of e-prescription application. Apart from these, problems with
the surveyed physicians (79.4%) stated that e-prescription regard to prescription writing (stemming from reasons such
application saves time, paper and toner. One in 4 physicians as absence of some desired medicines on the system or not
pointed out that e-prescribing facilitated prescription writing. being able to prescribe them; not being able to correct, add,
In addition, it was expressed that e-prescription application delete after the prescription has been sent; absence of some
increases the quality and reliability of service, increases medicines, medicine dosages or diagnosis in the system) were
patient satisfaction and prevents conflicts between physician- among the most common complaints.
patient and pharmacist about prescribing.
Of the 1534 family physicians who participated in the Discussion
study, 966 (62.97%) stated that they had experienced at In this study, family physicians’ opinions on e-prescription
least one problem with the application of e-prescriptions. A were evaluated. The most frequently stated contribution of
total of 1756 statements were collected about the problems the e-prescription application was speeding up prescription
experienced in the application of e-prescriptions. These writing and saving time. The most common complaints were
statements were gathered under 4 groups and 23 subgroups system-induced problems and internet problems. Despite
(Table 4). An important part of the complaints consisted some problems with e-prescription practice, it was found
of system-induced problems. More than a quarter (26.5%) that a significant portion of family physicians were satisfied
of the family physicians in the research complained about with e-prescription. When analyzing the studies conducted in
system-induced problems such as slow working of the other countries on e-prescriptions, it was seen that the level of

Table 4. Family Physicians’ Answers to Question “Are You Having Problems With the Application of E-prescriptions?”

Problems n Percenta
A- Infrastructure, system (software) and internet related problems 1148 74.8
1 System-induced problems 407 26.5
2 Internet problems 304 19.8
3 Not being able to obtain prescription code 231 15.1
4 Loss of time, waiting due to internet interruption or system failure 179 11.7
5 Problems with barcode 21 1.4
6 Power cut 16 1.0
7 Failure in functioning of computer (hardware) 6 0.4
8 Inadequacy of infrastructure 5 0.3
B- Problems with prescription writing 389 25.4
9 Absence of some desired medicines (magistral, unpaid, mixture, etc) on the system or not being able to prescribe them 112 7.3
10 Not being able to correct, add, delete after the prescription has been sent 74 4.8
11 Problems related with the medicine list 67 4.4
12 Not being able to prescribe some of the medical materials (catheter, diaper, etc) 45 2.9
13 Absence of desired medicine dosages on the system and not being able to prescribe them 29 1.9
14 Absence of some diagnoses in the system 18 1.2
15 Not being able to prescribe green prescription drugs electronically 17 1.1
16 Not being able to see the prescriptions that other physicians have written 6 0.4
C- Problems experienced by patients 100 6.5
17 Problems related to the fact that the patient cannot see the written prescription 40 2.6
18 Problems giving equivalent medicine 22 1.4
19 Not being able to generate e-prescriptions for foreign patients and patients with private insurance 12 0.8
D- Other 145 9.5
20 Being confused about some of the characters (Q, O, 0) in the prescription code and not being able read them 26 1.7
21 Being called by the patient or pharmacist to be asked to write the prescription and for the code of prescription 8 0.5
22 Not trusting e-prescriptions 8 0.5
23 Otherb 103 6.7
Total 1756
a
Since some physicians gave more than one answer to this question, the total of the percentage exceeds 100.
b
Some of the complaints made were mentioned rarely in terms of frequency (by only 1 or 2 family physicians), and were therefore gathered under the title
“Other.” Patients seeing physicians as responsible for waiting problems, leading to demotivation in physicians, and pain in right hand and neck due to computer
use can be given as examples of complaints stated by only a few family physicians.

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Bulut et al

satisfaction with e-prescriptions is quite high. In the studies by In this study, 9.3% of the family physicians pointed out
Tan et al8 in Singapore and Jariwala et al25 in America, it was that the application of e-prescriptions reduced errors in
determined that 87% of physicians and 83% of e-prescribers prescription writing, e-prescriptions were legible, exact, and
were satisfied with the application of e-prescriptions, complete, provided convenience to the pharmacist in reading
respectively. In studies conducted in Sweden,26 Austria,27 the prescription, and thus reduced errors of giving the
and England,7 it was found that a significant proportion incorrect medicine or dosage. Additionally, in the study by
of physicians think that the application of e-prescriptions Gimenes and Miasso28 the errors in generating prescriptions
is beneficial. Moreover, in a study by Gider et al17 with 248 have reduced with the application of e-prescriptions. In the
physicians in Turkey, 62% of the physicians supported the study by Gider et al17 nearly half of the participating physicians
application of e-prescriptions. were found to believe that the application of e-prescriptions
All of the factors in Table 3 can be interpreted as the reasons made a positive contribution to patient safety. As physicians
why the family physicians were satisfied with the application have a tendency to write prescriptions as soon as possible
of e-prescriptions, the most important factor of physicians’ due to their high workload, problems arise in relation to
satisfaction was the fact that e-prescriptions can be generated the information written on the prescription not being exact
faster than manual ones. More than 1 in 3 physicians (36.6%) or legible, such as medicine, patient’s name, diagnosis, date
indicated that e-prescriptions speeded up prescription of prescription, dosage of prescribed medicine, and daily
writing and saved time. According to this, the application of dosage. Missing information on the prescription or failure in
e-prescriptions shortens the prescription writing time and reading manually written prescriptions correctly might lead to
thus saves time to family physicians, and this time can then be returning the prescription to the physician. In this situation,
used for other work and processes (eg, patient examination, the physician might need to allocate time for rewriting the
etc). In a study by Gimenes and Miasso28 in Brazil with 84 prescription, thus leading to an increased workload, patient
health professionals, it was shown that among the biggest shuttling between the pharmacy and the healthcare facility,
advantages of e-prescriptions was the fact that they can be loss of time, and arguments between physician and patient,
generated faster. Other factors that help physicians save time and physician and pharmacist. A percentage of the physicians
are removing the handwriting; being able to see medicines in the research also indicated that e-prescriptions have
formerly prescribed to the patient, medicine equivalents, and reduced the arguments between patient and physician and
prices written on the system, which speeds up the physician’s between pharmacist and physician in relation to that issue.
decision-making process regarding which medicine to As e-prescriptions cannot be generated if there is essential
prescribe; simplifying corrections to the prescription; being information missing on the prescription, complete information
able to make additions to the prescription; and simplifying is thus ensured. It can be said that prescriptions being exact
the addition of explanations. and complete reduces relevant problems. Moreover, the
In this research, it was found that a family physician illegibility of the name of the prescribed medicine on manual
writes an average of 47 prescriptions per day, and writing prescriptions may cause the pharmacist to give the incorrect
an e-prescription takes 3 minutes. According to this, medicine to the patient, which may cause important problems
family physicians allocate an average of about 140 minutes for the patient. Yorulmaz30 suggested that prescriptions that
(47*3 = 141) per day to write prescriptions. It is known that are not complete and legible may also lead to treatments that
family physicians work 8 hours per day. Therefore, family are not effective or safe, recurrence and prolongation (leading
physicians spend an important part of their time (29.4%) to chronification) of diseases, complications, and suffering
generating prescriptions. When one considers that family of patients. Taking into consideration the issues associated
physicians do not prescribe medicines for some patients but with manual prescriptions, e-prescriptions seem to make
instead conclude the patient examination with counselling important contributions to preventing these errors.
or a referral, it can be seen that the number of patients seen In our study, another issue raised by family physicians
in 1 day by a family physician is higher than the number of regarding the benefits of e-prescriptions was being able to see
prescriptions written daily (mean = 47.2). Considering the previously prescribed medicines and reports provided to the
high workload of family physicians and the amount of time patient, and the simplification of accessing this information.
spent writing prescriptions, it is an important feature of The fact that physicians can easily access information on
e-prescriptions that they can be generated faster than manual previous medicines and tests in the system might provide the
ones. chance to pre-assess a treatment to be prescribed, in addition
With regard to the positive effects of the application of to preventing the repetition of tests.
e-prescriptions, saving on paper and toner are among the The family physicians in the present study drew attention
issues that the family physicians point out most frequently. to the benefits of the application of e-prescriptions in terms
A total of 28.6% and 14.3% of the family physicians in this of patients and pharmacists. In previous studies, it was found
research indicated that e-prescriptions provided savings that not only physicians, but also patients and pharmacists
on paper and toner, respectively. According to this, the were satisfied with the application of e-prescriptions.31,32
application of e-prescriptions has important positive effects Reducing patient waiting time, creating the perception of a
also in financial terms. Furthermore, in different studies high-quality service, removing the problem of tearing or loss
e-prescriptions have been found to be more cost-effective of paper prescriptions, reducing medicine or dosage errors,
than paper prescriptions.29 simplifying the process for patients to obtain their medicines,

46 International Journal of Health Policy and Management, 2019, 8(1), 40–48

Bulut et al

and general increase in patient satisfaction can be counted as practitioner population. Since this study was carried out via
benefits for the patient. E-prescriptions being exact, complete, e-mail, the number of questions were kept low and several
and legible, and reducing arguments with physicians over socio-demographic characteristics of the participants were
prescription writing can be considered benefits of the not asked. Open-ended questions, however, provided in-
application of e-prescriptions for the pharmacist. depth information on family physicians’ experiences with the
In spite of the aforementioned positive contributions of the effects of e-prescription. Future studies with more questions,
application of e-prescriptions, some related problems have including location of the physicians, may be conducted by other
been identified. The most common complaints of the family survey methods to gain more insight. In-depth interviews
physicians were failure to obtain an internet connection, may be conducted with fewer physicians to be identified by
slowness of the connection, disconnection, and failure to stratified sampling according to geographical distribution. It
obtain mobile internet services. Another problem related to is also suggested that further research be conducted with other
the internet was dependency. It is necessary to have an internet parties involved in the application of e-prescriptions such as
service to upload (forward) the generated e-prescription to patients, pharmacists, and administrators in order to extend
the system, to see the patient information in the system, in the scope and the validity of the results of this research.
brief, to be able to generate an e-prescription. For this reason,
it is a necessity to establish a strong internet infrastructure in Conclusion
order to be able to implement e-prescriptions reliably. When the statements of the family physicians about
Additionally, failure of the computer (hardware) and the benefits and problems related to the application of
insufficiency of the infrastructure were identified in this e-prescriptions are considered together, it can be seen that
study among the problems encountered in the application some statements are counted as both benefit and complaint.
of e-prescriptions. In the research by Gimenes and Miasso28 Statements such as saving time/loss of time, simplifying the
dependency on computers was indicated as one of the correction of prescription/not being able to make correction
disadvantages of e-prescriptions. As e-prescription generation on prescription, and e-prescriptions being safe/not trusting
takes place in an electronic environment, a computer is e-prescriptions are examples illustrating this point. It is
needed. Therefore, it is necessary that computers available in understood from this, some problems experienced in the
healthcare facilities have appropriate equipment (sufficiency) application of e-prescriptions (eg, problem of waiting) become
and their maintenance be performed regularly. an advantage (eg, facilitation of prescription writing and
Loss of time and waiting were found to be among the saving time with the application of e-prescriptions) in a well-
most common complaints in this study. Slowness or failure functioning implementation of e-prescriptions. Moreover, the
in obtaining an internet connection, failure in functioning of mean level of satisfaction of the family physicians that did not
computer (hardware), failure in functioning of the program experience problems with the application of e-prescriptions,
(software) developed for e-prescribing, and the user lacking was found to be higher in comparison to that of those who did
information may cause loss of time. Therefore, in addition experience problems. According to this, by eliminating the
to providing a reliable internet service and ensuring that problems encountered in the application of e-prescriptions,
computers and the e-prescription program function the level of related satisfaction might increase.
correctly, it can be useful that users be trained in generating
e-prescriptions. Craxford et al33 found in their study that Acknowledgements
providing training to new physicians in the application of The authors wish to acknowledge the contribution of the
e-prescriptions reduced errors in e-prescription writing and family physicians who participated in this study.
speeded up the process.
Additional problems with the application of e-prescriptions Ethical issues
Official approval were obtained from the Public Health Institution of Turkey.
found in this study were failure in generating e-prescriptions
for foreign patients and patients with private insurance,
Competing interests
failure in prescribing some medical equipment, some Authors declare that they have no competing interests.
medicines not being available or not being able to prescribe
them, the desired dosage not being available or not being able Authors’ contributions
to prescribe it, failure in prescribing green prescription drugs, SB: Conception and design, acquisition of data, analysis and interpretation
of data, drafting of the manuscript, critical revision of the manuscript for
existence of medicines in the system that are not available
important intellectual content, administrative, technical, or material support.
on the market, not being able to see prescriptions written by AY: Analysis and interpretation of data, drafting of the manuscript, critical
other physicians, unpaid medicines not being stated, and not revision of the manuscript for important intellectual content, statistical analysis,
being able to make corrections, additions, or deletions after administrative, technical, or material support. SK: Conception and design,
analysis and interpretation of data, drafting of the manuscript, critical revision
sending an e-prescription. Thus, it is necessary that the above
of the manuscript for important intellectual content, administrative, technical, or
problems be dealt with by technical experts that take charge of material support, supervision.
the launching and implementation of e-prescribing, so that it
can be re-designed in line with the needs of physicians. Authors’ affiliations
The study results are limited to the evaluations of the 1
Department of Health Care Management, Faculty of Health Sciences, Hitit
participating family physicians. However it was shown that University, Çorum, Turkey. 2Program of Health Institutions Management,
Vocational School of Health Services, Batman University, Batman, Turkey.
the participants was broadly representative of the family

International Journal of Health Policy and Management, 2019, 8(1), 40–48 47

Bulut et al

Department of Health Care Management, Faculty of Economics and

3
reçete (e-reçete) uygulamasinın değerlendi̇ ri̇ lmesi̇ ne yöneli̇ k bi̇ r
Administrative Sciences, Hacettepe University, Ankara, Turkey. araştirma (Research on orientation to evaluate the implementation
of electronic prescription (e-prescription) in healthcare). Journal of
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