Physicians ’ Perceptions of Electronic Prescribing with Electronic Medical Records in Kuwaiti Primary Healthcare Centres

Objectives: This study aimed to evaluate physicians’ perceptions of electronic prescribing in Kuwaiti primary healthcare centres. Methods: This cross-sectional study was conducted between June and August 2017 among 368 physicians from 25 primary healthcare centres in Kuwait. Data were collected from the participants using a selfreported questionnaire, including sociodemographic characteristics, previous experience with computers and awareness, knowledge and use of e-prescribing systems and their functional features. In addition, perceptions of the benefits and levels of satisfaction associated with e-prescribing were explored. Results: A total of 306 physicians completed the survey (response rate: 83%). The majority had positive perceptions regarding the use of e-prescribing, particularly in terms of time-savings (86%), healthcare quality (84%), productivity (80%) and clinical workflow and efficiency (83%). However, many respondents indicated that e-prescribing systems required additional improvements in terms of functionality. Conclusion: Most physicians in primary healthcare centres in Kuwait recognised the importance of e-prescribing to improve the quality of patient care, streamline workflow, increase productivity and reduce medical errors. However, there is a need to improve the design and infrastructure of e-prescribing systems, which may aid in the adoption of such systems in Kuwait.


P
rescribing medicines is an important part of public healthcare services; as such, systems that optimise the prescription process are essential. 1Electronic prescribing is defined as a computerbased method of creating, transferring, sorting and documenting prescriptions electronically. 2A successful e-prescribing system functions as an interoperational platform between physicians and pharmacies to facilitate the exchange of treatment information. 3E-prescribing systems often form part of a larger electronic medical record (EMR) system allowing physicians access to a broad range of patient information, including medical histories and details of diagnoses and treatment, in addition to prescription information. 4][10] The successful adoption of e-prescribing systems has been reported in many regions worldwide, including the USA, UK, European Union and Canada. 10,112][13][14][15] Furthermore, there may be concerns regarding differences in healthcare policies and the enforcement of local privacy and data protection laws. 16According to Sicotte et al., preferred style of information acquisition, successful integration of e-prescribing into day-to-day practice and previous computer experience all contribute to a better understanding of technology and can positively influence the usage and adoption of e-prescribing systems. 17n Kuwait, healthcare services are offered at the primary, secondary and tertiary level via health centres, regional general hospitals and specialty hospitals.There are a total of 97 primary healthcare centres located throughout the country. 18Each residential area has at least one primary healthcare centre, with some centres also incorporating specialised clinics catering to patients with diabetes, dermatological and ophthalmological problems and those requiring antenatal care, among others.Although these centres operate on an independent basis, they are overseen by the Central Directorate of Primary Healthcare in the Kuwaiti Ministry of Health (MOH). 18,19n 2000, a national health information EMR system was developed by the MOH and subsequently implemented in all primary healthcare centres in 2001.The EMR system was specifically designed to support end-users (i.e.physicians, nurses and pharmacists) by providing access to a complete and accurate database of relevant patient information. 20This study aimed to evaluate physicians' perceptions of e-prescribing in Kuwaiti primary healthcare centres.

Methods
This cross-sectional study was conducted between June and August 2017 in 25 primary healthcare centres in Kuwait.The required sample size for the study was based on a finite population of 1,685 physicians.As a conservative estimate, it was assumed that 50% of users would be satisfied with the current e-prescribing system.Taking into account a 4.6% error, the number of participants was calculated to be 350 at a 95% confidence level.Adjusting for a 5% non-response rate, a total of 368 Kuwaiti physicians were selected by a two-stage stratified random sampling method, considering the proportional allocation of the total population in the study area.In the first stage, a total of 25 primary healthcare centres were randomly selected, comprising five centres from each of the five main regions of Kuwait (Ahmadi, Asmimah, Farwaniya, Hawalli and Jahra).Subsequently, during the second stage, physicians from each of the selected centres were randomly chosen and invited to participate in the survey.
A two-part English-language questionnaire was developed to elicit information from the participants.The first section focused on sociodemographic factors and computer experience (13 items), while the second consisted of 48 items to determine the physicians' perceptions of e-prescribing in four categories: knowledge (four items), functionality (18 items), benefits (18 items) and satisfaction (eight items).All of the questions were closed-ended and were scored on a three-point Likert scale, with one indicating disagreement with the item, two neither agreement nor disagreement and three agreement.A pilot study of 10 physicians who were not included in the final study pre-tested the questionnaire to ensure the clarity and relevance of the items.The questionnaires were physically distributed to the selected physicians during their work shifts and collected one week later by the same researcher.
Data were analysed using the Statistical Package for the Social Sciences (SPSS), Version 24.0 (IBM Corp., Armonk, New York, USA).Responses for each item in the second section of the questionnaire were averaged over the total number of items in the category.As the scores for each dimension were not normally distributed, the results were expressed as minimums, maximums, medians and interquartile ranges (IQRs), with an overall unweighted or weighted score.Mann-Whitney U, Kruskal-Wallis and Spearman's rank correlation tests were used to calculate associations at a 5% significance level.
The study was approved by the Standing Committee for the Coordination of Medical & Health Research at the Kuwaiti MOH (#537/2017).All participants were informed of the study's purpose, the anonymity of their data and that participation was voluntary in nature.Written consent was obtained from all participants prior to their inclusion in the study.

Results
A total of 306 participants took part in the survey (response rate: 83%).Most respondents were female (59%), 30-39 years old (49%), married (84%), had a postgraduate degree (58%) and had worked for between 6-11 years (40%).The majority (71%) had received their medical education outside of Kuwait and 61% had taken computer courses during medical school.More than half (56%) reported having average computer literacy.Awareness of e-prescribing systems was high (94%), with 94% indicating that they understood how to use the system.The vast majority (95%) were currently using an e-prescribing system, with between 1-17 years of previous experience (median: 7 years; IQR: 5-11 years).The number of daily prescriptions was between 15-54 prescriptions (median: 42 prescriptions; IQR: 36-47 prescriptions) [Table 1].The overall weighted median score for the knowledge dimension of the questionnaire was 3, while the median score for functionality was 2.3.Median weighted scores for the benefits and satisfaction dimensions were 2.7 and 2.5, respectively [Table 2].
Generally, the majority of physicians had positive perceptions regarding the concept of e-prescribing, reporting that the EMR system was easy to use (85%), efficient (88%) and provided easy access to prescriptions services (81%).Notable benefits of e-prescribing were time-savings (86%), increased healthcare quality (84%), productivity (80%) and clinical workflow and efficiency (83%).However, many of the respondents indicated that e-prescribing systems should have better functionality,

Disagree
Neither Agree

Satisfaction
The EMR e-prescribing system is useful for my job 7 (2) 13 ( 4) 286 (93) The EMR e-prescribing system makes my job easier 9 (3) 18 ( 6) 279 (91) The EMR e-prescribing system is not time-consuming 46 (15) 48 ( 16) 212 (69) The EMR e-prescribing system improves the speed and efficiency of processing orders 12 (4) 41 ( 13) 253 ( 83) The EMR e-prescribing system maintains data accuracy 10 (3) 39 ( 13) 257 ( 84) The EMR e-prescribing system makes my job much more difficult 214 (70) 45 ( 15) 47 ( 15)  for instance regarding the ability to add electronic signatures (57%), receive medication interaction alerts (53%) and perform dosing calculations (47%).Respondents also highlighted the need for technical support (58%) [Table 3].Tables 4 and 5 show the relationship between the overall median scores in each of the questionnaire dimensions and selected sociodemographic characteristics.The median functionality score of physicians who had received medical education abroad was significantly higher than that of those who had been educated in Kuwait (2.4 versus 2.2; P = 0.015).Physicians who had received computer courses at medical school had a significantly higher median benefits score compared to those who did not (2.8 versus 2.7; P = 0.026).Median functionality scores were also significantly higher among physicians who were aware of e-prescription systems (2.4 versus 2.1; P = 0.039) and who understood how to use them (2.4 versus 2; P = 0.008).Median scores for the satisfaction and knowledge dimensions varied according to use of e-prescribing systems; users had significantly higher satisfaction (2.5 versus 2.4; P = 0.039) and knowledge (3 versus 2.8; P = 0.017) scores compared to nonusers.All four dimensions of the questionnaire were significantly related with each other (P ≤0.001), with Spearman's rank correlation coefficients ranging from 0.177-0.350[Table 6].

Discussion
The current study assessed perceptions of e-prescribing among physicians in primary healthcare centres in Kuwait.As physicians are the primary end-users of such systems, they are in the best position to identify factors that affect successful adoption and implementation of the system. 21The majority of physicians in the present study had positive perceptions of e-prescribing, particularly with regards to time-savings, ease of use, accessibility and increased healthcare quality, productivity and efficiency.In particular, most physicians anticipated that e-prescribing would result in improvements in prescription accuracy, data confidentiality and patient satisfaction and help to reduce prescription errors.
The findings of the present study are in line with those of previous research.In a study in Singapore, Tan et al. reported that most doctors were satisfied with specific functions of e-prescribing systems such as the ability to review prescription histories, receive drug interaction alerts and create prescriptions and e-prescription processing and system speed. 22A Swedish study noted that physicians were satisfied with the clear display of patient information on such systems. 23Thomas et al. found that physicians using an ambulatory e-prescribing system in the USA were optimistic about improved workflow, efficiency, cost-savings and patient communication. 245,26 Despite mostly positive perceptions, more than half of the physicians in the current study indicated that e-prescribing systems should have better functionality, such as the ability to add electronic signatures, receive medication interaction alerts and perform dosing calculations.Cohen et al. highlighted a desire for e-prescribing technology to incorporate electronic signatures among physicians in South Africa, while Savage et al. revealed similar issues regarding allergy and interaction alerts and dosing calculations among staff at a district general hospital in the UK. 27,28In addition, a major area of concern in the present study was ensuring adequate technical support in the workplace for system maintenance and to overcome technical problems.These results are consistent with the findings of other studies regarding the need for greater technical and organisational support for the successful implementation and maintenance of e-prescribing systems. 1,3Jawhari et al. also emphasised the need for on-site technical support. 29he main limitation of the current study was that the sample was not representative of all primary healthcare physicians in Kuwait; furthermore, as the questionnaire data were self-reported, the findings may be subject to bias.

Conclusion
This study found that physicians' perceptions of e-prescribing systems in Kuwaiti primary healthcare centres were mostly positive, particularly with regards to improvements in time-savings, efficiency, quality of patient care and safety.These results support the continued adoption and use of e-prescribing systems in Kuwait.However, several deficiencies were identified regarding the functionality of e-prescribing systems and the lack of technical support and maintenance.Improvements in these areas may maximise the effective adoption and use of such systems.
Physicians' Perceptions of Electronic Prescribing with Electronic Medical Records in Kuwaiti Primary Healthcare Centres e478 | SQU Medical Journal, November 2018, Volume 18, Issue 4

Table 1 :
Sociodemographic characteristics of physicians in primary healthcare centres in Kuwait (N = 306)

Table 2 :
Dimension scores for a survey assessing perceptions of electronic prescribing systems among physicians in primary healthcare centres in Kuwait (N = 306) Bashair A. Almutairi, Henry W. W. Potts and Saadoun F. Al-Azmi Clinical and Basic Research | e479

Table 3 :
Perceptions of electronic prescribing systems among physicians in primary healthcare centres in Kuwait (N = 306)

Table 4 :
Physicians' Perceptions of Electronic Prescribing with Electronic Medical Records in Kuwaiti Primary Healthcare Centres Dimension scores for a survey assessing perceptions of electronic prescribing systems among physicians in primary healthcare centres in Kuwait according to sociodemographic characteristics (N = 306) EMR = electronic medical record.e480 | SQU Medical Journal, November 2018, Volume 18, Issue 4

Table 5 :
Relationship between sociodemographic variables and dimension scores for a survey assessing perceptions of electronic prescribing systems among physicians in primary healthcare centres in Kuwait (N = 306)

Table 6 :
Spearman's rank correlations between dimensions in a survey assessing perceptions of electronic prescribing systems among physicians in primary healthcare centres in Kuwait (N = 306)