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Chinese medicine students’ views on electronic prescribing: A survey in Hong Kong
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ScienceDirect European Journal of Integrative Medicine 7 (2015) 47–54
Original article
Chinese medicine students’ views on electronic prescribing: A survey in Hong Kong Warrington Wen Qiang Hsu a , Esther Wai Yin Chan a , Zhang Jin Zhang b , Zhi Xiu Lin c , Zhao Xiang Bian d , Ian Chi Kei Wong a,∗ a
Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong Special Administrative Region b School of Chinese Medicine, The University of Hong Kong, Hong Kong Special Administrative Region c School of Chinese Medicine, The Chinese University of Hong Kong, Hong Kong Special Administrative Region d School of Chinese Medicine, Hong Kong Baptist University, Hong Kong Special Administrative Region Received 27 March 2014; received in revised form 25 August 2014; accepted 10 September 2014
Abstract Introduction: Electronic prescribing (e-prescribing) can potentially improve the quality of patient care in traditional Chinese medicine (TCM) by facilitating clinical tasks. Published survey studies investigating e-prescribing use were mostly conducted in conventional medicine, but these findings cannot be entirely generalised to TCM practice. It is important, therefore, to investigate e-prescribing in the TCM context. Purpose: To investigate Chinese medicine students’ attitudes and perceptions of e-prescribing use in Hong Kong. Method: Questionnaires were distributed to TCM students in three Hong Kong universities between January and May 2013. There were 259 participants in this study. Questionnaires were distributed and collected during lectures. The data was analysed using descriptive statistics. Results: The overall response rate was 89.3%. Only 21.2% of survey respondents had previously used an e-prescribing system. However, 86.5% of the respondents stated they want to use e-prescribing after they qualify as TCM practitioners. Patient care efficiency was rated as the most favourable outcome of e-prescription compared to handwritten prescriptions. The reliability of the e-prescribing system was rated as a major concern. Conclusion: TCM students in Hong Kong were generally supportive of e-prescribing uptake. However, this study raised concerns and potential barriers to e-prescribing use. Factors that may facilitate e-prescribing uptake in TCM are also suggested. Further studies investigating TCM practitioners’ views will be required to identify further facilitators and barriers to the uptake of e-prescribing. © 2014 Elsevier GmbH. All rights reserved. Keywords: Electronic prescribing; Chinese Medicine; Questionnaire; Survey
Introduction Electronic prescribing (e-prescribing) enables clinical practitioners to manage and transfer prescriptions via computers. When e-prescribing systems were first developed, their main purpose was to ease the input and access of prescription data [1], and to issue prescriptions in conventional medicine. Many e-prescribing systems have incorporated functions that support ∗ Corresponding author at: Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, 2/F Laboratory Block, 21 Sassoon Road, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong Special Administrative Region. Tel.: +852 3917 9441. E-mail address: [email protected] (I.C.K. Wong).
http://dx.doi.org/10.1016/j.eujim.2014.09.134 1876-3820/© 2014 Elsevier GmbH. All rights reserved.
clinical management decisions. A well-designed e-prescribing system has the potential to facilitate clinical tasks and improve the quality of patient care. For example, e-prescribing data can be stored as part of a patient’s electronic health record (EHR). Access to up-to-date patient health records can support health practitioners in clinical decision-making. The use of Electronic Health Record Systems (EHRSs) by office-based physicians in the United States (US) has increased from 2001 to 2012 [2–4]. In recent years, EHRSs has evolved into powerful tools for pharmacovigilance and medication safety research [5–8]. Although many studies have demonstrated how e-prescribing can reduce the risk of medication error and adverse drug events in conventional medicine [9–12], concerns prevail surrounding patient data security and confidentiality [13]. Health
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providers may not implement computerised systems on the assumption that changes in practice may result in reduced productivity [13,14]. Survey studies in conventional medicine have investigated health providers’ attitudes and perceptions towards e-prescribing [15,16]. Information obtained from survey data is potentially useful for planning policies on the uptake of health information technology. To date, studies into the perceptions of traditional Chinese medicine (TCM) practitioners are limited, although in some areas, information technology is applied to current TCM study and practice [17–19]. Since the findings obtained from survey studies investigating e-prescribing in conventional medicine cannot be entirely generalised to TCM practice, a survey study in this context is required. Therefore, an investigation into Chinese medicine students’ views of electronic prescribing was carried out in Hong Kong. The study also looked at identifying the facilitators and barriers to uptake of e-prescribing systems in TCM. Future research into the appropriateness of EHRs for TCM research by these future practitioners was also examined. Method Sampling of students In Hong Kong, the Bachelor of Chinese Medicine (BChinMed) programme aims to train TCM practitioners to meet the standard of Chinese Medicine Council of Hong Kong (CMCHK). BChinMed programmes are offered at three publicfunded universities, including the University of Hong Kong (HKU), the Chinese University of Hong Kong (CUHK) and Hong Kong Baptist University (HKBU). The annual intake for each university programme is approximately 30 students. Due to a major overhaul of the Hong Kong education system in 2012, a new six-year curriculum was launched [20]. This programme combines taught courses with clinical practice. On completion of the BChinMed, students are eligible to sit the Chinese Medicine Practitioners Licensing Examination (CMPLE) [21]. Candidates meeting CMPLE criteria are eligible to register as a TCM practitioner of the CMCHK. Master of Chinese Medicine (MCM) programmes enable degree holders to develop TCM clinical skills and be eligible to sit the CMPLE. TCM practice is regulated and is part of the publicly funded healthcare system in Hong Kong [22]. With formalised TCM education and licensing examination, TCM practitioner in Hong Kong is considered a healthcare professional parallel to Western medicine practitioner. The study investigators (ZJZ, ZXL and ZXB) recruited Chinese Medicine students from HKU, CUHK and HKBU in 2013. Only students enrolled in a taught programme from January to May of that year were eligible. Those on clinical placement during this period were excluded. Surveys were distributed to students on a range of courses and at levels of advancement. • HKU: undergraduate 1st/2nd/3rd/4th • CUHK: undergraduate 1st/2nd/3rd and MCM 2nd year • HKBU: 2nd/3rd/4th
The 5th year students at all three universities and 4th year students at CUHK were on clinical placement during the study period; hence they were not included in the study. Questionnaire design and outcomes A self-administered questionnaire was designed to investigate TCM students’ views on e-prescribing and consisted of 12 questions that explored: • Student demographics and previous experiences of eprescribing • Expectations of e-prescribing systems • Comparison between e-prescribing and handwritten prescribing • Positive features to uptake of e-prescribing • Negative features to uptake of e-prescribing • Views on provision of prescription data to third parties The questions were set to elicit the proportion of TCM students who had used e-prescribing systems previously, the types of system, and the clinical settings where they were used. The question on comparison between e-prescribing and handwritten prescribing was adapted from a study investigating e-prescribing in chain community pharmacies in the US [15]. The question’s wording on outcomes (e.g. “Effectiveness” and “Efficiency”) was deliberately set to be broad, and open to respondents’ interpretation. These outcomes aimed to explore the effects of e-prescribing on daily TCM practice in terms of quality of patient care, and communications/relationships with patients/staff. This question was modified slightly from the original with the term “Clinical Staff” replacing “Physician” to reflect the TCM context. Questions on the positive and negative features of eprescribing consisted of four and seven items respectively. Students were asked whether the listed items were positive or negative features of e-prescribing. The last question on sharing prescription data explored conditions where prescription data might be provided to third parties. A Likert-type scale was used for the question comparing eprescribing to handwritten prescribing [23]. The options were 1 (much worse), 2 (somewhat worse), 3 (no change), 4 (somewhat better) and 5 (much better). The scale was also applied to questions on the positive and negative features of e-prescribing. The options were 1 (strongly disagree), 2 (disagree), 3 (neutral), 4 (agree) and 5 (strongly agree). A check box format was used, with the exception of two questions that used free text. Additional comments could be written in free text for some questions. The questionnaires were available in Chinese and English. All respondents completed the questionnaires in Chinese, which were subsequently translated to English for data analysis. A pilot study was conducted by distributing draft questionnaires to six TCM students at HKU. After completion, discussion between an investigator (WH) and the students identified questions that were ambiguous or could be misinterpreted. The questionnaire was modified accordingly with the final
W.W.Q. Hsu et al. / European Journal of Integrative Medicine 7 (2015) 47–54 Table 2 Previous experiences and expectations of e-prescribing.
Table 1 Questionnaire response and student demographics. Count Student demographics Female (%a ) Questionnaire response Total number of students enrolled in target classes Total number of returned questionnaires Overall response rate (%) HKU Number of students enrolled in target classes Number of completed questionnaires Response Rate (%) a b
49
149b
(57.53)
290 259 89.31 CUHK
HKBU
83
118
89
81
92
86
97.59
77.97
96.63
% Percentage with respect to the total number of questionnaires returned One student did not complete this item.
version consisting of twelve questions on four pages. The questionnaires were distributed and collected during lectures.
Count Number of students who used e-prescribing previously (%a ) E-prescribing system usedb HerbMiners Nong’s Ktop Computer Corporation iTechnology Other/Not sure
10 31 0 1 18
Location of e-prescribing usec Hospital organisations Clinics University clinics Private clinics Internship Other
20 10 7 3 7 3
Number of students who supported use of e-prescribing in daily practice (%a )
223e (86.10)
Number of students stating they want to use e-prescribing after qualifying as TCM practitioners (%a )
224f (86.49)
a
Questionnaire analysis
b c
The information from the completed questionnaires were entered into two computer databases by two investigators independently. Data cleaning was conducted by comparison of the two datasets. Differences were checked against the original questionnaire. Descriptive analyses were conducted using R v2.15 (R Core Team). Parametric statistics was used to analyse Likert-type data [23]. For questions using the Likert-type scale, the mean and standard deviation (sd) were calculated for each item.
55d (21.24)
d e f
%: Percentage in respect of the total number of questionnaires returned. Participants were allowed to select more than one option. Five students did not complete this item. One student did not complete this item. Seven students did not complete this item. Three students did not complete this item.
and HKBU respectively. One hundred and forty-nine (57.5%) respondents were female.
Questionnaire response
Previous experience and expectations of e-prescribing systems Fifty-five respondents (21.2%) had used an e-prescribing system before (Table 2). A total of 20 students stated they had used an e-prescribing system in clinics, and a further 20 said they had used e-prescribing in hospital settings. In this study, 223 (86.1%) survey respondents agreed that e-prescriptions should be used in daily TCM practice, and 224 (86.5%) stated they want to use e-prescriptions after they qualify as TCM practitioners. The most common reasons for not using eprescriptions were related to input issues (Supplementary Table 1), including inadequate typing and computer skills. Compared to e-prescribing, handwritten prescriptions were perceived to be faster. Five students cited reasons related to ‘keeping the tradition’. Supplementary Table 1 related to this article can be found, in the online version, at http://dx.doi.org/10.1016/j.eujim. 2014.09.134.
The total number of students enrolled in the target classes was 290, and 259 students attended the classes on the days of survey distribution (Table 1). All students who attended the selected classes completed the surveys, giving an overall response rate of 89.3% (259/290). As Table 1 illustrates, 81 (31.3%), 92 (35.5%) and 86 (33.2%) survey respondents were from HKU, CUHK
Comparison between e-prescriptions and handwritten prescriptions E-prescribing was rated as more favourable than handwritten prescribing for all outcomes, with all mean ratings greater than three (Table 3). The most favourable outcome was efficiency of patient care (mean rating = 3.9), followed by communication
Ethics approval Ethics approval for this study was granted by the Institutional Review Board of the University of Hong Kong/Hospital Authority Hong Kong West Cluster (ref: UW 13-255), Joint Chinese University of Hong Kong-New Territories East Cluster Clinical Research Ethics Committee (ref: CRE-2013.260), and Hong Kong Baptist University Ethics Committee on the Use of Human Subjects for Teaching and Research (Approval no.: HASC/13-14/0011). Results
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Table 3 Comparison between e-prescriptions and handwritten prescriptions. Counta (%b )
Safety of patient care Effectiveness of patient care Efficiency of patient care (including workflow and staff productivity) Communication with the patient Communication with clinical staff Overall relations with the patient Overall relations with clinical staff a b c d
Mean rating (sdd )
Much better
Somewhat better
No change
Somewhat worse
Much worse
NAc
28 (11.02) 20 (7.87) 57 (22.44)
98 (38.58) 85 (33.46) 143 (56.30)
115 (45.28) 141 (55.51) 37 (14.57)
13 (5.12) 8 (3.15) 17 (6.69)
0 (0) 0 (0) 0 (0)
5 5 5
3.56 (0.76) 3.46 (0.69) 3.94 (0.80)
23 (9.06)
79 (31.10)
104 (40.94)
44 (17.32)
4 (1.57)
5
3.29 (0.91)
40 (15.75)
143 (56.30)
54 (21.26)
13 (5.12)
4 (1.57)
5
3.80 (0.82)
19 (7.48)
83 (32.68)
126 (49.61)
26 (10.24)
0 (0)
5
3.37 (0.77)
25 (9.84)
111 (43.70)
104 (40.94)
14 (5.51)
0 (0)
5
3.58 (0.74)
Five students did not complete the whole question. %: Percentage with respect to the total number of students who answered this item. NA: Did not respond to this item. sd: Standard deviation.
with clinical staff. Students rated communications with patients (mean rating = 3.3) as the least favourable outcome, followed by overall relations with patients. Positive features of e-prescriptions There was agreement that all four items were positive features of e-prescribing (Table 4). The ratings for items related to time saving, storage space reduction and medical information provision were close, with storage space reduction rated highest (mean rating = 4.1). Although patient confidentiality was rated towards the agreement side, this was clearly lower than the other three items. Fifteen students stated that a positive feature of e-prescribing was the legibility of records (Supplementary Table 1). Some students observed that the risk of misinterpretation was reduced compared to handwritten prescribing. Others noted the convenience of e-prescribing in terms of record retrieval and performing statistical analyses. Three students said e-prescribing was environmentally friendly. Negative features of e-prescriptions Five items were rated towards agreement, while two were rated towards disagreement (Table 5). The item of key concern in e-prescribing was the reliability of the system (mean rating = 3.9), followed by inadequate technical support. Difficulties learning to use the program were of least concern (mean rating = 2.8), followed by disruption of interaction with patients. Five students suggested that e-prescribing would foster dependency on computers (Supplementary Table 1). Some concern was raised that dependence on technology would interfere with independent clinical judgement and decision making. Conditions for provision of prescription data to third parties In this study, 188 (72.6%) survey respondents concurred that prescription data could be given to third parties for research purposes in universities. Thirty-five (13.5%) students agreed that data could be provided to third parties for research purposes in
commercial organisations. One hundred and sixty-four (63.3%) students agreed that signing a confidentiality agreement with third parties is required for data sharing. Students indicated that patient consent, teaching and information sharing purposes were extra conditions (Supplementary Table 1). Three students stated that under no circumstances should prescription data be provided to third parties. Discussion Data from 259 TCM students were obtained to investigate their attitudes and perceptions on electronic prescribing in Hong Kong. Only 21.2% of the students had used an e-prescribing system previously. This suggests that e-prescribing is not currently common practice in Hong Kong and training might be inadequate in the taught course component of TCM programmes. Despite the low proportion of use among students, their views towards e-prescribing were generally positive. In this study, 86.1% of respondents agreed that e-prescriptions should be used to prescribe traditional Chinese medicine, and 86.5% of students stated that they want to use e-prescriptions after qualifying as TCM practitioners. This indicates that students were generally supportive of e-prescribing and were keen for the system to be implemented. As such, it may be appropriate for students to experience e-prescribing at an earlier stage of TCM study. Increasing e-prescribing training may facilitate uptake of e-prescribing systems in TCM. Although e-prescribing and electronic patient records are used in both western medical and TCM practice in the Hospital Authority (HA), non-governmental organisations (NGOs) and academic institutes in Hong Kong [24–26]; uptake of e-prescribing is expected to be less common among independent TCM practitioners. The high proportion of supportive students may indicate a group of new TCM practitioners who are prepared to use e-prescribing in the near future. Preference for e-prescriptions over handwritten prescriptions was further investigated in the question comparing the
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Table 4 Positive features of e-prescribing. Counta (%b )
Saves time by simplifying tasks (e.g. use of stock control system) Protects patient confidentiality Reduces document storage space Provides medical information (such as drug information) to TCM practitioners a b c d
Mean rating (sdd ) Strongly disagree
NAc
8 (3.17)
2 (0.79)
7
4.02 (0.75)
105 (41.67)
26 (10.32)
2 (0.79)
7
3.46 (0.85)
133 (52.78)
36 (14.29)
9 (3.57)
0 (0)
7
4.08 (0.76)
143 (56.97)
38 (15.14)
6 (2.39)
1 (0.40)
8
4.04 (0.73)
Strongly agree
Agree
Neutral
Disagree
59 (23.41)
150 (59.52)
33 (13.10)
28 (11.11)
91 (36.11)
74 (29.37) 63 (25.10)
Eight students did not complete the whole question %: Percentage with respect to total number of students who answered this item NA: Did not respond to this item sd: Standard deviation
two approaches. Efficiency of patient care was rated the most favourable outcome of e-prescription compared to handwritten prescription (mean rating = 3.9). This concurs with Rupp and Warholak’s study [15], which examined the attitudes of pharmacy staff towards e-prescribing in chain community pharmacies in the US. In that study, a subgroup analysis was carried out to investigate the attitudes of pharmacists, technicians and student interns. Efficiency of patient care was also rated the most favourable outcome of e-prescribing compared to conventional prescriptions in the student intern group (mean rating = 4.1). This rating was higher than that of the pharmacists group (mean rating = 3.9) and the technicians group (mean rating = 3.7). It is interesting to note that student groups in both Rupp and Warholak’s study, and our study rated efficiency as the most favourable outcome. It is possible that current students, who are generally younger, might be more at ease with computer technology compared to those already in practice.
As a result, the perception may be that e-prescribing improves efficiency by facilitating workflow and increasing staff productivity. This may also be reflected in another question exploring whether simplifying tasks saves time and is therefore, a positive feature of e-prescribing. Almost 83% of a total of 252 students “strongly agreed” or “agreed” with this statement. A survey conducted by Jariwala et al. investigated the encouraging and discouraging factors of e-prescribing among conventional medicine physicians [27]. In that study, software features were rated the most encouraging factor, followed by technology. Since increased efficiency of patient care and time saving were both highly rated in our study, the combined results suggest that an efficient software design with time-saving software features could facilitate e-prescribing uptake. A user-friendly e-prescribing system with high speed data input and retrieval might encourage more TCM professionals to implement this approach.
Table 5 Negative features of e-prescribing. Counta (%b ) Strongly agree Difficulties in learning to use the program Need to change current way of working A computer program would disrupt the way I interact with my patients Cost of the program Patient confidentiality Inadequacy of technical support Reliability of the system (e.g. database system down or unavailable when needed) a b c d
Mean rating (sdd ) Agree
Neutral
Disagree
Strongly disagree
NAc
10 (3.92)
52 (20.39)
90 (35.29)
89 (34.90)
14 (5.49)
4
2.82 (0.95)
9 (3.53)
75 (29.41)
104 (40.78)
55 (21.57)
12 (4.71)
4
3.05 (0.92)
13 (5.10)
61 (23.92)
85 (33.33)
84 (32.94)
12 (4.71)
4
2.92 (0.98)
22 (8.66) 12 (4.72) 22 (8.76)
96 (37.80) 76 (29.92) 105 (41.83)
104 (40.94) 118 (46.46) 88 (35.06)
24 (9.45) 39 (15.35) 31 (12.35)
8 (3.15) 9 (3.54) 5 (1.99)
5 5 8
3.39 (0.89) 3.17 (0.87) 3.43 (0.89)
52 (20.55)
134 (52.96)
53 (20.95)
12 (4.74)
2 (0.79)
6
3.88 (0.81)
Eleven students did not complete the whole question. %: Percentage with respect to the total number of students who answered this item. NA: Did not respond to this item. sd: Standard deviation.
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Succeeding efficiency, the second and third most favourable outcomes of e-prescribing compared to handwritten prescriptions were “communication with clinical staff” and “overall relations with clinical staff”. On the other hand, “communication with the patient” and “overall relations with the patient” were the least favourable outcomes. E-prescribing has the potential to facilitate communication and relationships between clinical staff by reducing errors due to handwriting misinterpretation and by reducing phone calls between staff for conventional medicine [28]. Fifteen students commented on the ease of reading records on e-prescribing systems in relation to facilitating staff communication. On the other hand, e-prescribing could potentially impede communication and relationships between healthcare providers and patients. One study investigated the views of conventional medicine physicians on electronic medical records (EMRs) [29]. Findings from semi-structured interviews indicate that EMRs were considered to affect quality of care as physicians spent less time with patients. In our study, one student mentioned that conservative patients might think prescribing by hand was more professional than e-prescribing. Another student suggested that e-prescribing may reduce eye contact between practitioners and patients. Approximately 29% of students agreed or strongly agreed that, “a computer programme would disrupt interactions with patients”. The possibility of disruption to the patient-healthcare provider relationship is a potential barrier to the uptake of e-prescribing. Concern over reliability of the system was rated the top negative feature of e-prescribing, followed by inadequate technical support. Developing computer reliance was seen as a negative feature of e-prescribing. Although errors from misinterpreted handwriting could be reduced with e-prescribing, there is also potential for computer error. System breakdown or software bugs not only disrupt practitioner and patient relations, they also compromise patient safety. A poorly designed e-prescribing system could introduce unexpected medication errors [30], and failure to identify these could lead to patient safety hazards. Therefore, a properly designed e-prescribing system with adequate technical support is important to the uptake of e-prescribing in TCM practice. Patient confidentiality protection was rated the least favourable positive feature of e-prescriptions in this study. It has been suggested that some patients may refuse to disclose full health information if they have concerns about the security of e-prescribing systems [28]. Patient data leakage and loss may be caused by poor system design or human error. Suppliers and users of e-prescribing systems will need make every effort to ensure patient confidentiality. Access to and use of prescription data is a sensitive issue. Approximately 73% of respondents stated that prescription data could be provided to third parties for university research purpose. However, only 14% of the respondents agreed it was appropriate to provide data for research conducted by commercial organisations. This indicates the different views held by TCM students towards data sharing in academic institutes and commercial organisations. Approximately two-thirds of respondents selected signing a confidentiality agreement as a condition for data provision.
Well-planned data sharing policies has the potential to encourage medical research. E-prescribing data has already been used in research in conventional medicine [31,32]. A study was conducted in Europe that connected and extracted anonymous medical data from EHR databases in four European countries [32]. The research group then used prescription data to study the association between non-steroidal anti-inflammatory drugs (NSAIDs) and upper gastrointestinal bleeding (UGIB). It is technically possible to integrate e-prescribing data from different TCM clinics for research [18]. However, appropriate data security and patient privacy policies will need to be implemented [33]. Besides data sharing among TCM professionals, the use of EHR could also promote interprofessional collaboration by allowing information exchange between Chinese and Western medicine professionals [34]. The results of this study could provide support for developing EHR sharing policy between health professionals [35]. It is worth noting that some students stated that maintaining traditional practice was a reason for not using e-prescriptions, and this may reflect the importance of cultural values in TCM [36]. Although a TCM practitioner may agree that e-prescribing has benefits over handwritten prescribing, traditional TCM cultural values may prevail to the exclusion of e-prescribing. In this study, difficulties in learning to use an e-prescribing system and the need to change the current way of working were not rated as major negative features. The results may be different if TCM practitioners were the focus of this study. Further survey studies on the views of TCM practitioners are needed to confirm this supposition. Such studies will also be useful for a comparison between the attitudes of students and practitioners, and to obtain a better understanding of e-prescribing use in TCM. Studies have investigated the attitudes of healthcare providers towards health information technology in conventional medicine [15,37], but few studies have explored electronic prescribing in a TCM context. Students in this study were recruited as they are potential future TCM practitioners. Understanding their attitudes and perceptions towards e-prescriptions is crucial to identifying the facilitators and barriers to uptake of this approach. Strengths and weakness The study’s strength lies in the high response rate, which was achieved as the survey was conducted during lectures. All students who attended the selected lectures completed the questionnaires. One limitation is that not all study levels were included. Some student groups were on clinical placement during the study period. Since the concept of e-prescribing was not delivered directly to students as a taught component, students who had not commenced their clinical placement were likely to complete the questionnaire based on their perception rather than experience of using e-prescribing. In contrast, students who had formal clinical placement experience (university-arranged clerkship and internship) or informal clinical experience (part-time work or summer placement) were more likely to be exposed to e-prescribing and respond to questions based on their
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experience. There is potential for selection bias as those students may have a better understanding of e-prescribing, and their views may differ widely from those who have no clinical experience. Further studies are needed to ascertain the perceptions of student interns who may have relatively more clinical experience. Inclusion of more students with clinical experience will allow informative comparison between two student groups, that is, those who had used e-prescribing and those who had not. Conclusion Traditional Chinese medicine students in Hong Kong were generally supportive to the uptake of e-prescribing with 86.5% of survey respondents indicating that they want to use e-prescriptions after qualifying as TCM practitioners. However, there are notable concerns and potential barriers to the uptake of e-prescribing. These include the possibility of disruption to the patient-healthcare provider relationship and concerns surrounding patient confidentiality. Conflict of interest Mr. Warrington Wen Qiang Hsu’s position was partly funded by HerbMiners Informatics Limited. References [1] Kannry J. Effect of e-prescribing systems on patient safety. Mt Sinai J Med 2011;78(6):827–33. [2] Jamoom E, Beatty P, Bercovitz A, Woodwell D, Palso K, Rechtsteiner E. Physician adoption of electronic health record systems: United States, 2011; NCHS Data Brief, no 98; 2012. p. 1–8. [3] Hsiao CJ, Hing E. Use and characteristics of electronic health record systems among office-based physician practices: United States, 2001–2012; NCHS data brief, no 111; 2012. p. 1–8. [4] Patel V, Jamoom E, Hsiao CJ, Furukawa MF, Buntin M. Variation in electronic health record adoption and readiness for meaningful use: 2008–2011. J Gen Intern Med 2013;28(7):957–64. [5] Rani FA, Byrne P, Cranswick N, Murray ML, Wong IC. Mortality in children and adolescents prescribed antipsychotic medication a retrospective cohort study using the UK general practice research database. Drug Saf 2011;34(9):773–81. [6] Ackers R, Besag FM, Hughes E, Squier W, Murray ML, Wong IC. Mortality rates and causes of death in children with epilepsy prescribed antiepileptic drugs: a retrospective cohort study using the UK general practice research database. Drug Saf 2011;34(5):403–13. [7] McCarthy S, Cranswick N, Potts L, Taylor E, Wong IC. Mortality associated with attention-deficit hyperactivity disorder (ADHD) drug treatment: a retrospective cohort study of children, adolescents and young adults using the general practice research database. Drug Saf 2009;32(11): 1089–96. [8] Wong IC, Murray ML. The potential of UK clinical databases in enhancing paediatric medication research. Br J Clin Pharmacol 2005;59(6): 750–5. [9] Ammenwerth E, Schnell-Inderst P, Machan C, Siebert U. The effect of electronic prescribing on medication errors and adverse drug events: a systematic review. J Am Med Inform Assoc 2008;15(5):585– 600. [10] Jani YH, Barber N, Wong IC. Paediatric dosing errors before and after electronic prescribing. Qual Saf Health Care 2010;19(4):337–40.
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[11] Jani YH, Ghaleb MA, Marks SD, Cope J, Barber N, Wong IC. Electronic prescribing reduced prescribing errors in a pediatric renal outpatient clinic. J Pediatr 2008;152(2):214–8. [12] Conroy S, Sweis D, Planner C, Yeung V, Collier J, Haines L, et al. Interventions to reduce dosing errors in children: a systematic review of the literature. Drug Saf 2007;30(12):1111–25. [13] Menachemi N, Collum TH. Benefits and drawbacks of electronic health record systems. Risk Manag Healthc Policy 2011;4:47–55. [14] Han H, Lopp L. Writing and reading in the electronic health record: an entirely new world. Med Educ Online 2013;18:1–7. [15] Rupp MT, Warholak TL. Evaluation of e-prescribing in chain community pharmacy: best-practice recommendations. J Am Pharm Assoc 2008;48(3):364–70. [16] McInnes DK, Saltman DC, Kidd MR. General practitioners’ use of computers for prescribing and electronic health records: results from a national survey. Med J Aust 2006;185(2):88–91. [17] Liu B, Zhou X, Wang Y, Hu J, He L, Zhang R, et al. Data processing and analysis in real-world traditional Chinese medicine clinical data: challenges and approaches. Stat Med 2012;31(7):653–60. [18] Zhou X, Chen S, Liu B, Zhang R, Wang Y, Li P, et al. Development of traditional Chinese medicine clinical data warehouse for medical knowledge discovery and decision support. Artif Intell Med 2010;48(2–3): 139–52. [19] Lukman S, He Y, Hui SC. Computational methods for traditional Chinese medicine: a survey. Comput Methods Prog Biomed 2007;88(3):283–94. [20] Education Bureau. New academic structure web bulletin: introduction of new academic structure; 2013. Available from: http://334.edb.hkedcity. net/EN/intro.php [accessed 22.07.13]. [21] Chinese Medicine Council of Hong Kong. Regulation of Chinese medicine practitioners: licensing examination; 2013. Available from: http://www.cmchk.org.hk/cmp/eng/#main rcmp02.htm [accessed 10.07.13]. [22] Griffiths SM, Chung VC, Tang JL. Integrating traditional Chinese medicine: experiences from China. Australas Med J 2010;3(7):385–96. [23] Norman G. Likert scales, levels of measurement and the laws of statistics. Adv Health Sci Educ Theory Pract 2010;15(5):625–32. [24] Chui CS, Man KK, Cheng CL, Chan EW, Lau WC, Cheng VC, et al. An investigation of the potential association between retinal detachment and oral fluoroquinolones: a self-controlled case series study. J Antimicrob Chemother 2014;69(9):2563–7. [25] Man KK, Ip P, Hsia Y, Chan EW, Chui CS, Lam MP, et al. ADHD drug prescribing trend is increasing among children and adolescents in Hong Kong. J Atten Disord 2014, http://dx.doi.org/10.1177/1087054714536047. [26] He Y, Chan EW, Man KK, Lau WC, Leung WK, Ho LM, et al. Dosage effects of histamine-2 receptor antagonist on the primary prophylaxis of non-steroidal anti-inflammatory drug (NSAID)-associated peptic ulcers: A retrospective cohort study. Drug Saf 2014;37(9):711–21. [27] Jariwala KS, Holmes ER, Banahan BF, McCaffrey DJ. Factors that physicians find encouraging and discouraging about electronic prescribing: a quantitative study. J Am Med Inform Assoc 2013;20(E1):E39–43. [28] Webster L, Spiro RF. Health information technology: a new world for pharmacy. J Am Pharm Assoc 2010;50(2):e20–31, quiz e2-4. [29] Holden RJ. Physicians’ beliefs about using EMR and CPOE: In pursuit of a contextualized understanding of health IT use behavior. Int J Med Inform 2010;79(2):71–80. [30] Khajouei R, Jaspers MW. CPOE system design aspects and their qualitative effect on usability. Stud Health Technol Inform 2008;136:309–14. [31] Coloma PM, Avillach P, Salvo F, Schuemie MJ, Ferrajolo C, Pariente A, et al. A reference standard for evaluation of methods for drug safety signal detection using electronic healthcare record databases. Drug Saf 2013;36(1):13–23. [32] Coloma PM, Schuemie MJ, Trifirò G, Gini R, Herings R, Hippisley-Cox J, et al. Combining electronic healthcare databases in Europe to allow for large-scale drug safety monitoring: the EU-ADR Project. Pharmacoepidemiol Drug Saf 2011;20(1):1–11. [33] Weng C, Appelbaum P, Hripcsak G, Kronish I, Busacca L, Davidson KW, et al. Using EHRs to integrate research with patient care: promises and challenges. J Am Med Inform Assoc 2012;19(5):684–7.
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ScienceDirect European Journal of Integrative Medicine 7 (2015) 47–54
Original article
Chinese medicine students’ views on electronic prescribing: A survey in Hong Kong Warrington Wen Qiang Hsu a , Esther Wai Yin Chan a , Zhang Jin Zhang b , Zhi Xiu Lin c , Zhao Xiang Bian d , Ian Chi Kei Wong a,∗ a
Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, The University of Hong Kong, Hong Kong Special Administrative Region b School of Chinese Medicine, The University of Hong Kong, Hong Kong Special Administrative Region c School of Chinese Medicine, The Chinese University of Hong Kong, Hong Kong Special Administrative Region d School of Chinese Medicine, Hong Kong Baptist University, Hong Kong Special Administrative Region Received 27 March 2014; received in revised form 25 August 2014; accepted 10 September 2014
Abstract Introduction: Electronic prescribing (e-prescribing) can potentially improve the quality of patient care in traditional Chinese medicine (TCM) by facilitating clinical tasks. Published survey studies investigating e-prescribing use were mostly conducted in conventional medicine, but these findings cannot be entirely generalised to TCM practice. It is important, therefore, to investigate e-prescribing in the TCM context. Purpose: To investigate Chinese medicine students’ attitudes and perceptions of e-prescribing use in Hong Kong. Method: Questionnaires were distributed to TCM students in three Hong Kong universities between January and May 2013. There were 259 participants in this study. Questionnaires were distributed and collected during lectures. The data was analysed using descriptive statistics. Results: The overall response rate was 89.3%. Only 21.2% of survey respondents had previously used an e-prescribing system. However, 86.5% of the respondents stated they want to use e-prescribing after they qualify as TCM practitioners. Patient care efficiency was rated as the most favourable outcome of e-prescription compared to handwritten prescriptions. The reliability of the e-prescribing system was rated as a major concern. Conclusion: TCM students in Hong Kong were generally supportive of e-prescribing uptake. However, this study raised concerns and potential barriers to e-prescribing use. Factors that may facilitate e-prescribing uptake in TCM are also suggested. Further studies investigating TCM practitioners’ views will be required to identify further facilitators and barriers to the uptake of e-prescribing. © 2014 Elsevier GmbH. All rights reserved. Keywords: Electronic prescribing; Chinese Medicine; Questionnaire; Survey
Introduction Electronic prescribing (e-prescribing) enables clinical practitioners to manage and transfer prescriptions via computers. When e-prescribing systems were first developed, their main purpose was to ease the input and access of prescription data [1], and to issue prescriptions in conventional medicine. Many e-prescribing systems have incorporated functions that support ∗ Corresponding author at: Centre for Safe Medication Practice and Research, Department of Pharmacology and Pharmacy, 2/F Laboratory Block, 21 Sassoon Road, Li Ka Shing Faculty of Medicine, University of Hong Kong, Hong Kong Special Administrative Region. Tel.: +852 3917 9441. E-mail address: [email protected] (I.C.K. Wong).
http://dx.doi.org/10.1016/j.eujim.2014.09.134 1876-3820/© 2014 Elsevier GmbH. All rights reserved.
clinical management decisions. A well-designed e-prescribing system has the potential to facilitate clinical tasks and improve the quality of patient care. For example, e-prescribing data can be stored as part of a patient’s electronic health record (EHR). Access to up-to-date patient health records can support health practitioners in clinical decision-making. The use of Electronic Health Record Systems (EHRSs) by office-based physicians in the United States (US) has increased from 2001 to 2012 [2–4]. In recent years, EHRSs has evolved into powerful tools for pharmacovigilance and medication safety research [5–8]. Although many studies have demonstrated how e-prescribing can reduce the risk of medication error and adverse drug events in conventional medicine [9–12], concerns prevail surrounding patient data security and confidentiality [13]. Health
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providers may not implement computerised systems on the assumption that changes in practice may result in reduced productivity [13,14]. Survey studies in conventional medicine have investigated health providers’ attitudes and perceptions towards e-prescribing [15,16]. Information obtained from survey data is potentially useful for planning policies on the uptake of health information technology. To date, studies into the perceptions of traditional Chinese medicine (TCM) practitioners are limited, although in some areas, information technology is applied to current TCM study and practice [17–19]. Since the findings obtained from survey studies investigating e-prescribing in conventional medicine cannot be entirely generalised to TCM practice, a survey study in this context is required. Therefore, an investigation into Chinese medicine students’ views of electronic prescribing was carried out in Hong Kong. The study also looked at identifying the facilitators and barriers to uptake of e-prescribing systems in TCM. Future research into the appropriateness of EHRs for TCM research by these future practitioners was also examined. Method Sampling of students In Hong Kong, the Bachelor of Chinese Medicine (BChinMed) programme aims to train TCM practitioners to meet the standard of Chinese Medicine Council of Hong Kong (CMCHK). BChinMed programmes are offered at three publicfunded universities, including the University of Hong Kong (HKU), the Chinese University of Hong Kong (CUHK) and Hong Kong Baptist University (HKBU). The annual intake for each university programme is approximately 30 students. Due to a major overhaul of the Hong Kong education system in 2012, a new six-year curriculum was launched [20]. This programme combines taught courses with clinical practice. On completion of the BChinMed, students are eligible to sit the Chinese Medicine Practitioners Licensing Examination (CMPLE) [21]. Candidates meeting CMPLE criteria are eligible to register as a TCM practitioner of the CMCHK. Master of Chinese Medicine (MCM) programmes enable degree holders to develop TCM clinical skills and be eligible to sit the CMPLE. TCM practice is regulated and is part of the publicly funded healthcare system in Hong Kong [22]. With formalised TCM education and licensing examination, TCM practitioner in Hong Kong is considered a healthcare professional parallel to Western medicine practitioner. The study investigators (ZJZ, ZXL and ZXB) recruited Chinese Medicine students from HKU, CUHK and HKBU in 2013. Only students enrolled in a taught programme from January to May of that year were eligible. Those on clinical placement during this period were excluded. Surveys were distributed to students on a range of courses and at levels of advancement. • HKU: undergraduate 1st/2nd/3rd/4th • CUHK: undergraduate 1st/2nd/3rd and MCM 2nd year • HKBU: 2nd/3rd/4th
The 5th year students at all three universities and 4th year students at CUHK were on clinical placement during the study period; hence they were not included in the study. Questionnaire design and outcomes A self-administered questionnaire was designed to investigate TCM students’ views on e-prescribing and consisted of 12 questions that explored: • Student demographics and previous experiences of eprescribing • Expectations of e-prescribing systems • Comparison between e-prescribing and handwritten prescribing • Positive features to uptake of e-prescribing • Negative features to uptake of e-prescribing • Views on provision of prescription data to third parties The questions were set to elicit the proportion of TCM students who had used e-prescribing systems previously, the types of system, and the clinical settings where they were used. The question on comparison between e-prescribing and handwritten prescribing was adapted from a study investigating e-prescribing in chain community pharmacies in the US [15]. The question’s wording on outcomes (e.g. “Effectiveness” and “Efficiency”) was deliberately set to be broad, and open to respondents’ interpretation. These outcomes aimed to explore the effects of e-prescribing on daily TCM practice in terms of quality of patient care, and communications/relationships with patients/staff. This question was modified slightly from the original with the term “Clinical Staff” replacing “Physician” to reflect the TCM context. Questions on the positive and negative features of eprescribing consisted of four and seven items respectively. Students were asked whether the listed items were positive or negative features of e-prescribing. The last question on sharing prescription data explored conditions where prescription data might be provided to third parties. A Likert-type scale was used for the question comparing eprescribing to handwritten prescribing [23]. The options were 1 (much worse), 2 (somewhat worse), 3 (no change), 4 (somewhat better) and 5 (much better). The scale was also applied to questions on the positive and negative features of e-prescribing. The options were 1 (strongly disagree), 2 (disagree), 3 (neutral), 4 (agree) and 5 (strongly agree). A check box format was used, with the exception of two questions that used free text. Additional comments could be written in free text for some questions. The questionnaires were available in Chinese and English. All respondents completed the questionnaires in Chinese, which were subsequently translated to English for data analysis. A pilot study was conducted by distributing draft questionnaires to six TCM students at HKU. After completion, discussion between an investigator (WH) and the students identified questions that were ambiguous or could be misinterpreted. The questionnaire was modified accordingly with the final
W.W.Q. Hsu et al. / European Journal of Integrative Medicine 7 (2015) 47–54 Table 2 Previous experiences and expectations of e-prescribing.
Table 1 Questionnaire response and student demographics. Count Student demographics Female (%a ) Questionnaire response Total number of students enrolled in target classes Total number of returned questionnaires Overall response rate (%) HKU Number of students enrolled in target classes Number of completed questionnaires Response Rate (%) a b
49
149b
(57.53)
290 259 89.31 CUHK
HKBU
83
118
89
81
92
86
97.59
77.97
96.63
% Percentage with respect to the total number of questionnaires returned One student did not complete this item.
version consisting of twelve questions on four pages. The questionnaires were distributed and collected during lectures.
Count Number of students who used e-prescribing previously (%a ) E-prescribing system usedb HerbMiners Nong’s Ktop Computer Corporation iTechnology Other/Not sure
10 31 0 1 18
Location of e-prescribing usec Hospital organisations Clinics University clinics Private clinics Internship Other
20 10 7 3 7 3
Number of students who supported use of e-prescribing in daily practice (%a )
223e (86.10)
Number of students stating they want to use e-prescribing after qualifying as TCM practitioners (%a )
224f (86.49)
a
Questionnaire analysis
b c
The information from the completed questionnaires were entered into two computer databases by two investigators independently. Data cleaning was conducted by comparison of the two datasets. Differences were checked against the original questionnaire. Descriptive analyses were conducted using R v2.15 (R Core Team). Parametric statistics was used to analyse Likert-type data [23]. For questions using the Likert-type scale, the mean and standard deviation (sd) were calculated for each item.
55d (21.24)
d e f
%: Percentage in respect of the total number of questionnaires returned. Participants were allowed to select more than one option. Five students did not complete this item. One student did not complete this item. Seven students did not complete this item. Three students did not complete this item.
and HKBU respectively. One hundred and forty-nine (57.5%) respondents were female.
Questionnaire response
Previous experience and expectations of e-prescribing systems Fifty-five respondents (21.2%) had used an e-prescribing system before (Table 2). A total of 20 students stated they had used an e-prescribing system in clinics, and a further 20 said they had used e-prescribing in hospital settings. In this study, 223 (86.1%) survey respondents agreed that e-prescriptions should be used in daily TCM practice, and 224 (86.5%) stated they want to use e-prescriptions after they qualify as TCM practitioners. The most common reasons for not using eprescriptions were related to input issues (Supplementary Table 1), including inadequate typing and computer skills. Compared to e-prescribing, handwritten prescriptions were perceived to be faster. Five students cited reasons related to ‘keeping the tradition’. Supplementary Table 1 related to this article can be found, in the online version, at http://dx.doi.org/10.1016/j.eujim. 2014.09.134.
The total number of students enrolled in the target classes was 290, and 259 students attended the classes on the days of survey distribution (Table 1). All students who attended the selected classes completed the surveys, giving an overall response rate of 89.3% (259/290). As Table 1 illustrates, 81 (31.3%), 92 (35.5%) and 86 (33.2%) survey respondents were from HKU, CUHK
Comparison between e-prescriptions and handwritten prescriptions E-prescribing was rated as more favourable than handwritten prescribing for all outcomes, with all mean ratings greater than three (Table 3). The most favourable outcome was efficiency of patient care (mean rating = 3.9), followed by communication
Ethics approval Ethics approval for this study was granted by the Institutional Review Board of the University of Hong Kong/Hospital Authority Hong Kong West Cluster (ref: UW 13-255), Joint Chinese University of Hong Kong-New Territories East Cluster Clinical Research Ethics Committee (ref: CRE-2013.260), and Hong Kong Baptist University Ethics Committee on the Use of Human Subjects for Teaching and Research (Approval no.: HASC/13-14/0011). Results
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Table 3 Comparison between e-prescriptions and handwritten prescriptions. Counta (%b )
Safety of patient care Effectiveness of patient care Efficiency of patient care (including workflow and staff productivity) Communication with the patient Communication with clinical staff Overall relations with the patient Overall relations with clinical staff a b c d
Mean rating (sdd )
Much better
Somewhat better
No change
Somewhat worse
Much worse
NAc
28 (11.02) 20 (7.87) 57 (22.44)
98 (38.58) 85 (33.46) 143 (56.30)
115 (45.28) 141 (55.51) 37 (14.57)
13 (5.12) 8 (3.15) 17 (6.69)
0 (0) 0 (0) 0 (0)
5 5 5
3.56 (0.76) 3.46 (0.69) 3.94 (0.80)
23 (9.06)
79 (31.10)
104 (40.94)
44 (17.32)
4 (1.57)
5
3.29 (0.91)
40 (15.75)
143 (56.30)
54 (21.26)
13 (5.12)
4 (1.57)
5
3.80 (0.82)
19 (7.48)
83 (32.68)
126 (49.61)
26 (10.24)
0 (0)
5
3.37 (0.77)
25 (9.84)
111 (43.70)
104 (40.94)
14 (5.51)
0 (0)
5
3.58 (0.74)
Five students did not complete the whole question. %: Percentage with respect to the total number of students who answered this item. NA: Did not respond to this item. sd: Standard deviation.
with clinical staff. Students rated communications with patients (mean rating = 3.3) as the least favourable outcome, followed by overall relations with patients. Positive features of e-prescriptions There was agreement that all four items were positive features of e-prescribing (Table 4). The ratings for items related to time saving, storage space reduction and medical information provision were close, with storage space reduction rated highest (mean rating = 4.1). Although patient confidentiality was rated towards the agreement side, this was clearly lower than the other three items. Fifteen students stated that a positive feature of e-prescribing was the legibility of records (Supplementary Table 1). Some students observed that the risk of misinterpretation was reduced compared to handwritten prescribing. Others noted the convenience of e-prescribing in terms of record retrieval and performing statistical analyses. Three students said e-prescribing was environmentally friendly. Negative features of e-prescriptions Five items were rated towards agreement, while two were rated towards disagreement (Table 5). The item of key concern in e-prescribing was the reliability of the system (mean rating = 3.9), followed by inadequate technical support. Difficulties learning to use the program were of least concern (mean rating = 2.8), followed by disruption of interaction with patients. Five students suggested that e-prescribing would foster dependency on computers (Supplementary Table 1). Some concern was raised that dependence on technology would interfere with independent clinical judgement and decision making. Conditions for provision of prescription data to third parties In this study, 188 (72.6%) survey respondents concurred that prescription data could be given to third parties for research purposes in universities. Thirty-five (13.5%) students agreed that data could be provided to third parties for research purposes in
commercial organisations. One hundred and sixty-four (63.3%) students agreed that signing a confidentiality agreement with third parties is required for data sharing. Students indicated that patient consent, teaching and information sharing purposes were extra conditions (Supplementary Table 1). Three students stated that under no circumstances should prescription data be provided to third parties. Discussion Data from 259 TCM students were obtained to investigate their attitudes and perceptions on electronic prescribing in Hong Kong. Only 21.2% of the students had used an e-prescribing system previously. This suggests that e-prescribing is not currently common practice in Hong Kong and training might be inadequate in the taught course component of TCM programmes. Despite the low proportion of use among students, their views towards e-prescribing were generally positive. In this study, 86.1% of respondents agreed that e-prescriptions should be used to prescribe traditional Chinese medicine, and 86.5% of students stated that they want to use e-prescriptions after qualifying as TCM practitioners. This indicates that students were generally supportive of e-prescribing and were keen for the system to be implemented. As such, it may be appropriate for students to experience e-prescribing at an earlier stage of TCM study. Increasing e-prescribing training may facilitate uptake of e-prescribing systems in TCM. Although e-prescribing and electronic patient records are used in both western medical and TCM practice in the Hospital Authority (HA), non-governmental organisations (NGOs) and academic institutes in Hong Kong [24–26]; uptake of e-prescribing is expected to be less common among independent TCM practitioners. The high proportion of supportive students may indicate a group of new TCM practitioners who are prepared to use e-prescribing in the near future. Preference for e-prescriptions over handwritten prescriptions was further investigated in the question comparing the
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51
Table 4 Positive features of e-prescribing. Counta (%b )
Saves time by simplifying tasks (e.g. use of stock control system) Protects patient confidentiality Reduces document storage space Provides medical information (such as drug information) to TCM practitioners a b c d
Mean rating (sdd ) Strongly disagree
NAc
8 (3.17)
2 (0.79)
7
4.02 (0.75)
105 (41.67)
26 (10.32)
2 (0.79)
7
3.46 (0.85)
133 (52.78)
36 (14.29)
9 (3.57)
0 (0)
7
4.08 (0.76)
143 (56.97)
38 (15.14)
6 (2.39)
1 (0.40)
8
4.04 (0.73)
Strongly agree
Agree
Neutral
Disagree
59 (23.41)
150 (59.52)
33 (13.10)
28 (11.11)
91 (36.11)
74 (29.37) 63 (25.10)
Eight students did not complete the whole question %: Percentage with respect to total number of students who answered this item NA: Did not respond to this item sd: Standard deviation
two approaches. Efficiency of patient care was rated the most favourable outcome of e-prescription compared to handwritten prescription (mean rating = 3.9). This concurs with Rupp and Warholak’s study [15], which examined the attitudes of pharmacy staff towards e-prescribing in chain community pharmacies in the US. In that study, a subgroup analysis was carried out to investigate the attitudes of pharmacists, technicians and student interns. Efficiency of patient care was also rated the most favourable outcome of e-prescribing compared to conventional prescriptions in the student intern group (mean rating = 4.1). This rating was higher than that of the pharmacists group (mean rating = 3.9) and the technicians group (mean rating = 3.7). It is interesting to note that student groups in both Rupp and Warholak’s study, and our study rated efficiency as the most favourable outcome. It is possible that current students, who are generally younger, might be more at ease with computer technology compared to those already in practice.
As a result, the perception may be that e-prescribing improves efficiency by facilitating workflow and increasing staff productivity. This may also be reflected in another question exploring whether simplifying tasks saves time and is therefore, a positive feature of e-prescribing. Almost 83% of a total of 252 students “strongly agreed” or “agreed” with this statement. A survey conducted by Jariwala et al. investigated the encouraging and discouraging factors of e-prescribing among conventional medicine physicians [27]. In that study, software features were rated the most encouraging factor, followed by technology. Since increased efficiency of patient care and time saving were both highly rated in our study, the combined results suggest that an efficient software design with time-saving software features could facilitate e-prescribing uptake. A user-friendly e-prescribing system with high speed data input and retrieval might encourage more TCM professionals to implement this approach.
Table 5 Negative features of e-prescribing. Counta (%b ) Strongly agree Difficulties in learning to use the program Need to change current way of working A computer program would disrupt the way I interact with my patients Cost of the program Patient confidentiality Inadequacy of technical support Reliability of the system (e.g. database system down or unavailable when needed) a b c d
Mean rating (sdd ) Agree
Neutral
Disagree
Strongly disagree
NAc
10 (3.92)
52 (20.39)
90 (35.29)
89 (34.90)
14 (5.49)
4
2.82 (0.95)
9 (3.53)
75 (29.41)
104 (40.78)
55 (21.57)
12 (4.71)
4
3.05 (0.92)
13 (5.10)
61 (23.92)
85 (33.33)
84 (32.94)
12 (4.71)
4
2.92 (0.98)
22 (8.66) 12 (4.72) 22 (8.76)
96 (37.80) 76 (29.92) 105 (41.83)
104 (40.94) 118 (46.46) 88 (35.06)
24 (9.45) 39 (15.35) 31 (12.35)
8 (3.15) 9 (3.54) 5 (1.99)
5 5 8
3.39 (0.89) 3.17 (0.87) 3.43 (0.89)
52 (20.55)
134 (52.96)
53 (20.95)
12 (4.74)
2 (0.79)
6
3.88 (0.81)
Eleven students did not complete the whole question. %: Percentage with respect to the total number of students who answered this item. NA: Did not respond to this item. sd: Standard deviation.
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Succeeding efficiency, the second and third most favourable outcomes of e-prescribing compared to handwritten prescriptions were “communication with clinical staff” and “overall relations with clinical staff”. On the other hand, “communication with the patient” and “overall relations with the patient” were the least favourable outcomes. E-prescribing has the potential to facilitate communication and relationships between clinical staff by reducing errors due to handwriting misinterpretation and by reducing phone calls between staff for conventional medicine [28]. Fifteen students commented on the ease of reading records on e-prescribing systems in relation to facilitating staff communication. On the other hand, e-prescribing could potentially impede communication and relationships between healthcare providers and patients. One study investigated the views of conventional medicine physicians on electronic medical records (EMRs) [29]. Findings from semi-structured interviews indicate that EMRs were considered to affect quality of care as physicians spent less time with patients. In our study, one student mentioned that conservative patients might think prescribing by hand was more professional than e-prescribing. Another student suggested that e-prescribing may reduce eye contact between practitioners and patients. Approximately 29% of students agreed or strongly agreed that, “a computer programme would disrupt interactions with patients”. The possibility of disruption to the patient-healthcare provider relationship is a potential barrier to the uptake of e-prescribing. Concern over reliability of the system was rated the top negative feature of e-prescribing, followed by inadequate technical support. Developing computer reliance was seen as a negative feature of e-prescribing. Although errors from misinterpreted handwriting could be reduced with e-prescribing, there is also potential for computer error. System breakdown or software bugs not only disrupt practitioner and patient relations, they also compromise patient safety. A poorly designed e-prescribing system could introduce unexpected medication errors [30], and failure to identify these could lead to patient safety hazards. Therefore, a properly designed e-prescribing system with adequate technical support is important to the uptake of e-prescribing in TCM practice. Patient confidentiality protection was rated the least favourable positive feature of e-prescriptions in this study. It has been suggested that some patients may refuse to disclose full health information if they have concerns about the security of e-prescribing systems [28]. Patient data leakage and loss may be caused by poor system design or human error. Suppliers and users of e-prescribing systems will need make every effort to ensure patient confidentiality. Access to and use of prescription data is a sensitive issue. Approximately 73% of respondents stated that prescription data could be provided to third parties for university research purpose. However, only 14% of the respondents agreed it was appropriate to provide data for research conducted by commercial organisations. This indicates the different views held by TCM students towards data sharing in academic institutes and commercial organisations. Approximately two-thirds of respondents selected signing a confidentiality agreement as a condition for data provision.
Well-planned data sharing policies has the potential to encourage medical research. E-prescribing data has already been used in research in conventional medicine [31,32]. A study was conducted in Europe that connected and extracted anonymous medical data from EHR databases in four European countries [32]. The research group then used prescription data to study the association between non-steroidal anti-inflammatory drugs (NSAIDs) and upper gastrointestinal bleeding (UGIB). It is technically possible to integrate e-prescribing data from different TCM clinics for research [18]. However, appropriate data security and patient privacy policies will need to be implemented [33]. Besides data sharing among TCM professionals, the use of EHR could also promote interprofessional collaboration by allowing information exchange between Chinese and Western medicine professionals [34]. The results of this study could provide support for developing EHR sharing policy between health professionals [35]. It is worth noting that some students stated that maintaining traditional practice was a reason for not using e-prescriptions, and this may reflect the importance of cultural values in TCM [36]. Although a TCM practitioner may agree that e-prescribing has benefits over handwritten prescribing, traditional TCM cultural values may prevail to the exclusion of e-prescribing. In this study, difficulties in learning to use an e-prescribing system and the need to change the current way of working were not rated as major negative features. The results may be different if TCM practitioners were the focus of this study. Further survey studies on the views of TCM practitioners are needed to confirm this supposition. Such studies will also be useful for a comparison between the attitudes of students and practitioners, and to obtain a better understanding of e-prescribing use in TCM. Studies have investigated the attitudes of healthcare providers towards health information technology in conventional medicine [15,37], but few studies have explored electronic prescribing in a TCM context. Students in this study were recruited as they are potential future TCM practitioners. Understanding their attitudes and perceptions towards e-prescriptions is crucial to identifying the facilitators and barriers to uptake of this approach. Strengths and weakness The study’s strength lies in the high response rate, which was achieved as the survey was conducted during lectures. All students who attended the selected lectures completed the questionnaires. One limitation is that not all study levels were included. Some student groups were on clinical placement during the study period. Since the concept of e-prescribing was not delivered directly to students as a taught component, students who had not commenced their clinical placement were likely to complete the questionnaire based on their perception rather than experience of using e-prescribing. In contrast, students who had formal clinical placement experience (university-arranged clerkship and internship) or informal clinical experience (part-time work or summer placement) were more likely to be exposed to e-prescribing and respond to questions based on their
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experience. There is potential for selection bias as those students may have a better understanding of e-prescribing, and their views may differ widely from those who have no clinical experience. Further studies are needed to ascertain the perceptions of student interns who may have relatively more clinical experience. Inclusion of more students with clinical experience will allow informative comparison between two student groups, that is, those who had used e-prescribing and those who had not. Conclusion Traditional Chinese medicine students in Hong Kong were generally supportive to the uptake of e-prescribing with 86.5% of survey respondents indicating that they want to use e-prescriptions after qualifying as TCM practitioners. However, there are notable concerns and potential barriers to the uptake of e-prescribing. These include the possibility of disruption to the patient-healthcare provider relationship and concerns surrounding patient confidentiality. Conflict of interest Mr. Warrington Wen Qiang Hsu’s position was partly funded by HerbMiners Informatics Limited. References [1] Kannry J. Effect of e-prescribing systems on patient safety. Mt Sinai J Med 2011;78(6):827–33. [2] Jamoom E, Beatty P, Bercovitz A, Woodwell D, Palso K, Rechtsteiner E. Physician adoption of electronic health record systems: United States, 2011; NCHS Data Brief, no 98; 2012. p. 1–8. [3] Hsiao CJ, Hing E. Use and characteristics of electronic health record systems among office-based physician practices: United States, 2001–2012; NCHS data brief, no 111; 2012. p. 1–8. [4] Patel V, Jamoom E, Hsiao CJ, Furukawa MF, Buntin M. Variation in electronic health record adoption and readiness for meaningful use: 2008–2011. J Gen Intern Med 2013;28(7):957–64. [5] Rani FA, Byrne P, Cranswick N, Murray ML, Wong IC. Mortality in children and adolescents prescribed antipsychotic medication a retrospective cohort study using the UK general practice research database. Drug Saf 2011;34(9):773–81. [6] Ackers R, Besag FM, Hughes E, Squier W, Murray ML, Wong IC. Mortality rates and causes of death in children with epilepsy prescribed antiepileptic drugs: a retrospective cohort study using the UK general practice research database. Drug Saf 2011;34(5):403–13. [7] McCarthy S, Cranswick N, Potts L, Taylor E, Wong IC. Mortality associated with attention-deficit hyperactivity disorder (ADHD) drug treatment: a retrospective cohort study of children, adolescents and young adults using the general practice research database. Drug Saf 2009;32(11): 1089–96. [8] Wong IC, Murray ML. The potential of UK clinical databases in enhancing paediatric medication research. Br J Clin Pharmacol 2005;59(6): 750–5. [9] Ammenwerth E, Schnell-Inderst P, Machan C, Siebert U. The effect of electronic prescribing on medication errors and adverse drug events: a systematic review. J Am Med Inform Assoc 2008;15(5):585– 600. [10] Jani YH, Barber N, Wong IC. Paediatric dosing errors before and after electronic prescribing. Qual Saf Health Care 2010;19(4):337–40.
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