Adoption of national electronic prescribing services in primary care in Europe - policy lessons for Ireland

peer-reviewedA growing body of evidence over the past twenty years suggests that electronic prescribing (ePrescribing) can bring a host of benefits to the health sector, and some policy makers now view ePrescribing as a desirable national service that can improve the safety, quality and efficiency of healthcare. Consequently, national ePrescribing and electronic health record (EHR) projects have been launched in many countries in recent years, but success is elusive as ePrescribing in primary care is still unavailable in over 90% of countries worldwide. Progress has been limited to a small number of countries, with a significant cluster in Europe. Why is the adoption of ePrescribing and EHRs slow and uneven? What are the factors that influence the development and adoption of ePrescribing? What are the building blocks for a national ePrescribing service? What are the lessons from the leading countries? What are the policy lessons for countries where national ePrescribing services are not yet developed? This research addresses these questions. Qualitative methods were used, including a comparative analysis of case studies in thirty one European countries and interviews with national ePrescribing experts in the leading countries. A cross-domain comparison was undertaken with a leading eGovernment service in Ireland - the Revenue On-Line Service (ROS) – and interviews were held with national Revenue experts. The context, content and process framework from Pettigrew and Whipp’s model of strategic change and Roger’s diffusion of innovations model provide the conceptual frameworks for analysis and comparison. The research found that ePrescribing services in primary care are now available on a national basis in eleven countries in different regions of Europe. A model for national ePrescribing is emerging over time, which includes local EHR integration, interoperability between prescribers and pharmacists through a national ePrescription database, and a trend towards on-line patient access to medication data using the Internet. In many other European countries ePrescribing and in particular the electronic transmission of prescriptions (ETP) is underdeveloped due to a range of organisational, legal, technical or other barriers. In these countries, the absence of a developed national ETP service is the greatest barrier to adoption. The adoption patterns of recent years suggest that a technical-legal ePrescribing divide exists in Europe between the leading and the following countries. The comparative analysis discovered that a strong inner context is the cornerstone of success in the leading countries and ROS. A strong inner context can shape the outer context, develop quality content and create a supportive process for adoption and diffusion. The findings suggest that this can be achieved through a complex process of continuous stakeholder management. Building blocks were also identified in the outer context in the legal and technological areas, where the national health model in operation emerged as the key contextual factor. The quality of the content was found to be a key adoption factor, including the interoperability, security and usability of ePrescribing systems and ETP services. The key critical success factor for the adoption of ePrescribing and ROS was found to be stakeholder management in the adoption process over a long period. Supporting factors included social marketing strategies, incremental implementation methods, quality user support and the judicious management of consent, incentives and mandates. The overall approach used by the leading countries emerges as a balance of central control and direction from the inner context, coupled with widespread permanent stakeholder management across the domain including the outer context and the private sector, leading to a complex process of development and adoption over a long period. This equates to a combination of the traditional top-down and bottom-up approaches, which Coiera has described as middle-out. The findings in this research may contribute to policy in this area, Irish policy in particular