Strategic analysis of electronic prescriptions in Iran: a qualitative study

Abstract

Objectives

This study aims to examine the electronic prescription programme in Iran by thoroughly identifying the key strengths, weaknesses, opportunities and threats (SWOT) associated with its implementation and utilisation among healthcare stakeholders.

Design

A thematic analysis was adopted, with data systematically examined through the SWOT analytical framework.

Setting

Hospital, pharmacy, specialised clinic, insurance affiliated clinic in Iran.

Participants

Participants consisted of four groups involved in implementing the electronic prescription programme, including physicians, pharmacists, nurses and hospital administrative employees. Moreover, research participants were selected using a purposive sampling approach and sampling continued until data saturation was reached.

Methods

Semistructured interviews were employed for data collection. The data analysis steps were systematically executed using Braun and Clarke’s six-phase thematic analysis approach. Within the study’s conceptual framework based on SWOT analysis, themes and codes were categorised into positive (strengths, opportunities) and negative (weaknesses, threats) drivers. In addition, the method proposed by Lincoln and Guba was employed to endorse the data credibility.

Results

Overall, data saturation was reached with 25 participants and two major themes and four minor themes. The ‘strengths’ theme comprised patient safety, economic efficiency, information sharing, remote access and drug list accessibility. The ‘weaknesses’ theme encompassed internet and electricity dependency, resistance to implementation, numerous platforms and diverse insurer schemes and frequent changes in insurance company tariffs. The ‘opportunities’ theme consisted of health system networking, clarifying processes, eliminating drug intermediaries, improving health service quality, enhancing data banks, expediting drug monitoring and improving technological infrastructures in the health field. Ultimately, the ‘threats’ theme involved confidential information access and misuse, damaged drug barcodes, incorrect data recording, patient dissatisfaction and government financial burden.

Conclusions

Due to the fact that the challenges and benefits associated with this system vary across countries depending on their technical and non-technical capacities and infrastructures, the findings of the current research can contribute to promoting the system within our country.

STRENGTHS AND LIMITATIONS OF THIS STUDY

• The study is grounded in a strong conceptual framework that draws on the strengths, weaknesses, opportunities and threats analytical approach.

• A rigorous six-phase thematic analysis approach, as outlined by Braun and Clarke, was employed.

• Validation was conducted following Lincoln and Guba’s criteria of trustworthiness.

• The study is inherently susceptible to subjectivity due to the qualitative nature of the research.

• The process engaged diverse stakeholders to ensure inclusion of multiple perspectives; however, opinions of laypeople were not recorded.

Introduction

Health information technology, particularly electronic prescriptions, is regarded as the foundation of advancements in health service quality.¹ According to the definition provided by the Iranian Medical System Organisation, an electronic prescription refers to an ‘electronic document whose all components are individually produced and recorded by an authorized prescriber through authorized systems or software’.² An electronic prescribing system can be a stand-alone system or merged with an electronic health record (EHR) system.³ The primary motivation for launching an electronic prescription system was to mitigate preventable medical errors by creating software to assess drug interactions and other potential issues.³

A review study by Salmon J W demonstrated that the use of electronic prescribing mitigated medication errors to less than one-seventh of their previous level. Moreover, it resulted in cost savings due to improved patient outcomes.⁴ Based on Khammarnia’s study exploring the rate of medical errors in Iran between 2005 and 2019, error rates in the medication process, including prescribing, recording and administration, were reported to be 31%, 27% and 35%, respectively.⁵

A scoping review indicates that e-prescribing offers benefits such as time efficiency, convenience and improved legibility, although barriers like system design and inadequate training persist in primary care settings.⁶ The results of the other review study indicated that improper implementation of electronic prescribing systems may lead to the emergence of new errors that adversely affect operational effectiveness, escalate medication costs and compromise patient safety.⁷ To address these challenges, stakeholders suggest implementing forcing functions, prescription tracking technologies and enhanced training, with overall positive experiences reported.^{6 7}

Physicians and pharmacists believe that changes in workflow, familiarity with technology and time commitment may overshadow the potential advantages of electronic prescribing. Hence, to ensure the success of this system, project administrators must monitor factors that contribute to user satisfaction or dissatisfaction.⁸ In order to extend the adoption of electronic prescriptions among physicians, it is necessary to implement strategies at both the technological and healthcare system levels.^{8 9}

History in Iran

As acknowledged by the Food and Drug Administration, administering an electronic prescription system is a priority for the Iranian Ministry of Health, Treatment and Medical Education. In 2015, a multidisciplinary working group composed of medical informatics experts was formed, and the electronic prescription pilot project was first launched in Yazd province with nine physicians. Gradually, the online prescription issuance plan expanded nationwide. On average, 80% of this plan has been implemented in each province. In 2020, in accordance with clause (a) of Article 74 of the Sixth Development Plan Law, the Ministry of Health was obliged to provide electronic health services. Moreover, all healthcare facilities and associated organisations were mandated to use electronic prescriptions. Additionally, based on Note 17 of the 2020 Budget Law, basic health insurers were obligated to issue electronic prescriptions based on the national ID number, personal information, physician’s medical education number and other required data. As of December 2021, paper prescriptions were no longer accepted. It is worth mentioning that the COVID-19 pandemic was another factor that prompted the Social Security Organisation to eliminate health insurance booklets at that time, giving rise to the recognition of electronic prescriptions as a legal form for prescribing medication. Generally, healthcare centres in Iran use three separate electronic prescribing systems: ‘Electronic Prescription’ and ‘Dinad’ provide services to outpatients covered by the Social Security Organisation and health insurance, and ‘Shafa’ provide services to all inpatients. For individuals not covered by these insurers, physicians resort to paper prescriptions.¹⁰

Undoubtedly, the implementation of e-prescription programme entails both benefits and drawbacks across different levels of the health system. SWOT (strengths, weaknesses, opportunities and threats) framework is an effective tool for strategic planning and management within organisations. This tool enables managers to assess the capabilities and deficiencies of organisational resources, market opportunities and external threats.¹¹ Due to the fact that the challenges and benefits associated with e-prescribing programme implementation can vary significantly across countries based on geographical location and differing technical and non-technical capacities, it is essential to conduct a comprehensive study of this programme, which is relatively new in Iran. This examination should focus on identifying the specific challenges and obstacles that hinder effective implementation, thereby facilitating targeted improvements and reforms.

Employing SWOT analysis serves as an effective method for assessing the various dimensions of the programme. In this context, the present study was designed and implemented to examine the dimensions of the programme within the framework of SWOT analysis. The insights gained from this analysis can provide valuable guidance to policymakers in enhancing the programme’s effectiveness and overall impact.

Methods

Research setting and participants

The current study was conducted in the city of Saqqez, Kurdistan Province, Iran, in 2023, after obtaining ethical approval and ensuring confidentiality. Kurdistan Province is situated in western Iran, bordering Iraq.¹²

The study settings included hospitals, clinics and pharmacies that met two inclusion criteria: long-term implementation of the electronic prescription system (at least 2 years) and being under contract with the Social Security Organisation. These settings were selected using maximum variation purposeful sampling. Locations were chosen that would provide access to diverse stakeholders in terms of organisational role (physicians, pharmacists, nurses and programme-related staff), as well as work experience and level of engagement with the system. The aim of this variation was to obtain information-rich cases from different aspects of the electronic prescription system implementation, from the perspective of a wide range of involved actors.

Participants consisted of four groups involved in implementing the electronic prescription system, including physicians, pharmacists, nurses and hospital administrative employees. Moreover, research participants were selected using a purposive sampling approach, and sampling continued until data saturation was reached.¹³

Patient and public involvement statement

Patients and individuals of the public were not engaged in the design, conduct, reporting or dissemination plans of this research.

Research design

The current research was conducted by using qualitative thematic analysis. Qualitative thematic analysis deals with interpreting and reporting obtained from qualitative data. This method employs a back-and-forth method to identify meaning units, codes, subthemes and the main themes.^14–16

The conceptual framework of the present study is based on the SWOT framework, as illustrated in figure 1. This framework clearly delineates the negative drivers that can potentially harm the system, which include internal weaknesses as well as external threats beyond the internal environment. Conversely, the positive drivers that contribute to the improvement and enhancement of the system encompass internal strengths and external opportunities. This framework facilitates a more comprehensive analysis of the current situation, aiding in the identification of strengths and weaknesses, and lays the groundwork for leveraging opportunities and countering threats (figure 1).¹¹

Figure 1.

Conceptual framework of this study depicting the hypothesised pathways within the SWOT framework. SWOT, strengths, weaknesses, opportunities and threats.

Data collection

Semistructured face-to-face interviews were employed for data collection. The interviews took place at the participants’ workplaces after performing necessary coordination and obtaining participants’ informed consent.

Before conducting the interview by AG, to get appropriate answers, the applied research objectives and key concepts (strategic analysis: SWOT) were explained and clarified to the interviewees.

Each interview lasted approximately 45 min to 1 hour. Participants were free to enter and exit the study at any time. In addition, interviews were audio-recorded with the participants’ informed consent. To ensure participants’ confidentiality and protect their content, a code was assigned to each participant.

Key interview questions

The key questions were developed in accordance with the SWOT framework. The following key questions were used, and several other related questions were also asked within the context of each.

• In your opinion, what are the strengths of the electronic prescribing programme in your region and in Iran?

• In your opinion, what are the weaknesses of the electronic prescribing programme in your region and in Iran?

• In your opinion, what are the opportunities of the electronic prescribing programme in your region and in Iran?

• In your opinion, what are the threats of the electronic prescribing programme in your region and in Iran?

Data analysis

The analysis was conducted based on a conceptual framework developed in alignment with the SWOT approach. This analysis was performed in a recursive manner to ensure that the initial codes were accurately incorporated within the established framework (figure 1). Additionally, the data analysis steps were systematically executed using Braun and Clarke’s six-phase thematic analysis framework, facilitating a comprehensive exploration of the data.¹⁴

The coding process was independently performed by three coders in three phases: open coding (ie, line-by-line extraction of initial labels from the transcripts), axial coding (ie, grouping codes into categories and subcategories and identifying inter-relationships) and selective coding (ie, identifying the core category and constructing the final analytical framework). To assess intercoder reliability, 20% of the data (five interviews) was randomly selected. Cohen’s kappa was calculated for each of the three coder pairs and the average was reported as a reliability index. Disagreements were resolved through negotiation sessions among all three coders, referencing the transcripts and theoretical framework, until full consensus was reached.¹⁷

Interviews were recorded by the researcher AG, and their texts were manually transcribed verbatim by AG. The first phase (familiarisation with the data) was achieved through multiple readings of the transcripts (SS, AG and BS). In the next phase, the text was organised into meaningful concepts, and initial open codes were extracted from the data, encompassing all concepts. Subsequently, after establishing a deep connection between the text and the codes, initial themes and subthemes were extracted. In this process, the researchers, through an iterative method using an induction and deduction process, sought to identify relationships between concepts and codes, extracting themes at both positive and negative factors the organisation (axial coding). Themes and codes were then placed under the SWOT framework of strengths, weaknesses, threats and opportunities (selective coding). Ultimately, the findings were interpreted. The analysis was conducted manually and using Atlas software V.8. The relationship between codes and themes for each section was presented in tables.

Reliability and validity

The method proposed by Lincoln and Guba was employed in this study to provide and endorse the data credibility.

To elevate credibility, the researcher immersed themselves deeply in the data, taking detailed and comprehensive notes of the interviews. Sufficient time (6 months) was allocated for data collection and interpretation. To enhance transferability, thick description was employed, including a detailed account of the research context, participant characteristics (maximum variation sampling), data collection and analysis procedures, and direct interview excerpts. This allows readers to compare their own context with the studied sample and judge the transferability of the findings.

To ensure dependability, participants with a wide range of experiences, ages, genders and academic backgrounds were selected. Sampling continued until data saturation was reached and the most appropriate semantic unit was identified. Additionally, the recorded interviews were listened to multiple times (by SS, AG and BS). A strong rapport was established with the interviewees, and sufficient time was allocated to this stage. After extracting codes and themes, their accuracy was verified by discussing the extracted themes with several research participants. Reflexivity was examined at three levels: personal, interpersonal and methodological. The interviewer, though employed in healthcare, had no direct involvement with the electronic prescription programme, thus holding no preconceptions that could influence the research. Participants were assured of anonymity and confidentiality, which enabled them to express critical opinions freely. Methodologically, an iterative inductive–deductive approach was used alongside Braun and Clarke’s (2006) thematic analysis to ensure coding validity. Intercoder reliability was assessed using both qualitative and quantitative methods. Finally, the codes were reviewed through member checking and their accuracy was confirmed.¹⁸

Results

Data saturation was achieved with a total of 25 participants, including 11 physicians, 5 pharmacists, 4 nurses and 5 hospitals administrative employees. Table 1 presents the characteristics of the research participants.

Table 1.

Demographic characteristics of the participants

Participants	Number	Age range (years)	Employment history range (year)	Place of service
Physician	1	30–40	5–10	Insurance affiliated clinic
Physician	2	40–50	5–10	Insurance affiliated clinic
Physician	3	40–50	5–10	Insurance affiliated clinic
Physician	4	30–40	5–10	Specialised clinic
Physician	5	40–50	5–10	Insurance affiliated clinic
Physician	6	50–60	5–10	Insurance affiliated clinic
Physician	7	40–50	5–10	Insurance affiliated clinic
Physician	8	40–50	10–15	Insurance affiliated clinic
Physician	9	40–50	5–10	Specialised clinic
Physician	10	50–60	5–10	Specialised clinic
Physician	11	40–50	5–10	Insurance affiliated clinic
The Nurse	1	40–50	5–10	Hospital emergency
The Nurse	2	30–40	5–10	Hospital emergency
The Nurse	3	20–30	<5	Hospital emergency
The Nurse	4	50–60	10–15	Hospital emergency
Pharmacist	1	50–60	10–15	Hospital pharmacy
Pharmacist	2	40–50	5–10	Pharmacy
Pharmacist	3	50–60	5–10	Pharmacy
Pharmacist	4	40–50	5–10	Pharmacy
Pharmacist	5	40–50	5–10	Pharmacy
Administrative staff	1	30–40	5–10	Hospital admission
Administrative staff	2	40–50	10–15	Hospital admission
Administrative staff	3	20–30	<5	Hospital admission
Administrative staff	4	30–40	<5	Hospital admission
Administrative staff	5	50–60	5–10	Hospital admission

The analysis of the semantic units yielded two main themes (the positive drivers and the negative drivers), a total of 898 codes, and 58 final codes after removing duplicates.

The findings of the intercoder reliability assessment are reported below. Cohen’s kappa coefficients for the three coder pairs were 0.75 (SS and A.Gh), 0.78 (SS and BS) and 0.84 (A.Gh and BS), with a mean of 0.79, indicating substantial to almost perfect agreement according to Landis and Koch’s benchmarks.¹⁷

The positive drivers

The positive drivers comprise two themes: strengths and opportunities. The codes associated with each theme are presented and explained in the corresponding tables below.

The strengths’ theme

Table 2 presents the strengths theme and frequent codes. Among the most frequently mentioned codes in this study were reduced prescribing errors, reduced misreading of prescriptions, mitigated drug interactions, drug dosage and access to patient history, prevention of potential misuse, information sharing, time saving, preparing medicine in several separate steps, the managing physicians’ appointments for patients, rapid access to patient records and improved pharmacy workflow, which nearly all participants consistently emphasised as important strengths (table 2).

Table 2.

The strengths’ theme and related codes

Common codes	Number of repetitions	Percent
The possibility of preparing medicine in several separate steps	27	8.46
The possibility of managing and registering physicians’ appointments for patients	27	8.46
Reduced misreading of prescriptions	25	7.84
Time saving and accelerated services	25	7.84
Connection with other departments and information sharing	24	7.52
Prevention of potential misuse of health insurance booklets	24	7.52
Control drug interactions, drug dosage	22	6.9
Rapid access to patient records and previous medications	22	6.9
Improved pharmacy workflow	19	5.96
Control the patient’s prescription with more care and obsession by the physician	17	5.33
The possibility of choosing the desired drug by the physician through the system	17	5.33
Avoid prescribing the wrong drug	13	4.08
Eliminating the traditional paperwork process	11	3.45
Reducing the costs of the organisation in terms of paper printing	9	2.82
Preventing drug waste outside of the consumption process	5	1.57
Avoid wasting people’s time in the queue to renew paper notebooks	5	1.57
Creating a patient’s medical record in the shortest possible time	5	1.57
Total	319

Facilitated work processes, drug list accessibility

No. 1 (Physician): “This program can provide physicians with a complete list of all medications available in pharmacies, along with their expiration dates and status. This action gives physicians the freedom to choose the appropriate medication based on their diagnosis, allowing for accurate and convenient prescription writing.”

Time saving and accelerated services

No. 14 (Hospital Admissions): “One of the most significant strengths of this program is its ability to expedite pharmaceutical and therapeutic processes for patients. All information can be stored, encrypted, and backed up on a small hard drive, making it easily portable and accessible at any time. This efficiency can significantly improve the quality of patient care.”

Rapid access to patient records and previous medications, information sharing

No. 23 (Physician): “Previously, finding a specific patient’s record required searching through countless physical files in the archives. This was a time-consuming process that involved administrative steps to retrieve and copy the file.”

Avoid prescribing the wrong drug

No. 2 (Physician): “We have seen a significant reduction in adverse events stemming from pharmacy staff misinterpreting prescriptions and subsequently administering the wrong medication to patients, errors with devastating and irreversible consequences that were previously common.”

The opportunities’ theme

Table 3 presents the opportunities theme and frequent codes. Enhancing health data banks, improving health quality services, expediting drug monitoring, decreasing bureaucracy, developing health information networking, clarifying processes and patient information synthesis were among the most frequently cited codes in this study, and nearly all participants consistently emphasised their importance (table 3).

Table 3.

The opportunities’ theme and related codes

Common codes	Number of repetitions	Percent
Creation of new jobs/need for specialists in the field of programming	26	9.19
Effective management in the treatment process	26	9.19
Enhancing health data banks in the country (health digital/data banks)	25	8.83
Expediting drug monitoring and satisfying the country’s drug needs	25	8.83
Making changes in the management and administrative system/helping decrease bureaucracy in the country	24	8.48
Providing and designing tailored training programmes	24	8.48
Issuance of electronic prescriptions by physicians without the need to sign contracts with insurance companies	23	8.13
Health information networking	22	7.77
Creation of health system automation	22	7.77
Clarifying processes/eliminating drug intermediaries and black market	22	7.77
Patient information synthesis	18	6.36
Considering the problems at the managerial and organisational level	10	3.53
Improving technological infrastructures in the country/government’s obligation and collective commitment to improve that	7	2.47
Clarifying processes/reducing tax evasion	7	2.47
Payment of physicians’ insurance premiums faster due to transparency in the process of this programme	2	0.71
Total	283

Expediting drug monitoring by the organisation

No. 4 (Hospital Admission Employee): “The electronic format of prescriptions has significantly facilitated drug monitoring for the organization. It allows for better control over the dispensation of medications to patients, preventing substantial drug wastage.

No. 9 (Pharmacist): “The implementation and efficiency of this program allow for complete control and management of the hospital’s pharmaceutical and healthcare system.”

Patient information synthesis, health information networking

No. 16 (Nurse): “The implementation of this program has remarkably contributed to the automation of various systems within healthcare facilities. For instance, electronic prescription systems can be employed to manage and schedule physician appointments, pharmacy systems, distribute medications, record medical histories, analyze clinical data, and facilitate numerous other activities.”

Helping decrease bureaucracy in the country

No. 22 (Physician): “All bureaucratic processes have been eliminated, and all patient information is readily accessible in a centralized location. This system also offers significant eco-friendly benefits.”

Clarifying processes, reducing tax evasion

No. 24 (Pharmacist): “The existence of an electronic prescription system provides support to insurers by accurately tracking which drugs have been dispensed to which patients. This is particularly significant given the thriving black market for pharmaceuticals in Iran, where many pharmacies have a tendency to sell subsidized drugs at exorbitant prices on the black market.”

No. 6 (Physician): “Some organizations and influential individuals are resistant to information clarification. For instance, pharmacies may be reluctant to fully implement the program as it reveals their exact drug inventory, hindering the diversion of drugs to the black market or their hoarding.”

Improving infrastructures in the country

No. 1 (Physician): “…. Fortunately, the infrastructure for Internet connectivity provided by service providers is gradually improving, which is a noteworthy development.”

Improving the health data bank (digital data banks)

No. 17 (Nurse): “This significant advancement ensures that a complete record of a patient’s information, medical history, and medication history is readily available.”

Patient information synthesis

No. 14 (Hospital Admissions): “This program enables the detailed analysis of clinical data collected during the treatment process, with each patient having a separate record.”

The negative drivers

The negative drivers comprise two themes: weaknesses and threats. The codes associated with each theme are presented and explained in the corresponding tables below.

The weaknesses’ theme

Common codes identified in the weaknesses theme within the system encompass the programme’s internet and electricity dependency; non-compliance of physicians and medical staff due to past general habits and the associated challenges with equipment usage; and etc. (table 4). Programme’s internet and electricity dependency were identified as one of the most frequently mentioned factors, representing a major weakness of the programme that strongly contributed to negative implementation outcomes and unsatisfaction.

Table 4.

The weaknesses’ theme and related codes

Common codes	Number of repetitions	Percent
Programme’s Internet and electricity dependency	25	15.03
Non-compliance of physicians and medical staff due to past general habits	25	14.45
The possibility of human error in recording patient information	25	14.45
Slow prescription retrieval system	24	13.29
Power outage	24	13.29
Poor platform	23	13.29
Internet problem	22	12.72
Medical staff’s requirement for training/(costly and time-consuming)	22	12.72
Poor infrastructure in medical centres and offices in general	20	11.56
Lack of access to medical services provided if you do not have a national code	20	11.56
Poor support for the provision of the requirements in the electronic prescribing system	20	11.56
Forgetting prescription and national ID codes by the patient	19	10.98
Increased waiting time for drug delivery/patient wandering	18	10.4
Failure to predict the necessary orders and plans at the macro level	18	10.4
Lack of mechanisms to verify the accuracy of data recording	17	9.83
The associated challenges with equipment usage in the private sector	8	4.62
Multiple insurers and multiple platforms (the discrepancies and inconsistencies between the programmes of different insurers)	5	2.89
The necessity for the system’s coordination and compatibility with other existing systems in medical centres	4	2.31
Failure to notify the pharmacy of the patient’s contact number	2	1.16
Total	173

No. 8 [Nurse]: “Unfortunately, Internet outages, reduced speed, and bandwidth limitations can significantly disrupt data recording and hinder healthcare employees’ access to patient information promptly. This issue is particularly prevalent in Iran, where we frequently encounter widespread internet outages or disruptions due to political and security reasons.”

Medical staff’s requirement for training

No. 7 (Nurse): “If such training is inadequate or nonexistent, the risk of human error and inaccurate data recording in patient records increases, which can potentially culminate in misdiagnosis and incorrect medication prescriptions.”

Non-compliance of physicians and medical staff due to past general habits

Resistances are largely attributed to limit computer literacy, unskilled staff and the time-consuming nature of the system for physicians at the initial stage, as well as the lack of insurance coverage for certain medications and services.

No. 24 (Pharmacist): “Inputting numerous prescriptions throughout the day can be exceptionally difficult and time-consuming for physicians.”

Multiple insurers and multiple platforms

No. 24 (Pharmacist): “Another reason can also be the existence of numerous drug insurers that import each drug for a specific company and finding the desired company and registering the drug in that company is really time-consuming and boring.”

The threats theme

Table 5 presents the threats theme and frequent codes. The potential for misuse of patient data was among the most frequently mentioned, with many participants expressing concern about it. Another code that particularly worried pharmacists was damaged drug barcodes, which could occur as a result of repeated power and internet outages (table 5).

Table 5.

The threats’ theme and related codes

Common codes	Number of repetitions	Percent
Access to pharmacies’ financial resources	25	20.33
The potential for misuse of patient data and the healthcare facility and access to confidential information (security, hackers, crimes)	22	17.89
The government financial burden	22	17.89
The potential for misuse of patient data and access to confidential information/access to the patient’s national code	18	14.63
Creating problematic health data bank/incorrect completion of health record information	17	13.82
Frequent changes in insurance company tariffs	11	8.94
Damaged drug barcodes	8	6.5
Total	123

Access to confidential information and the possibility of misuse of patient information

No. 1 (Physician): “Unfortunately, there have been instances where, for example, an individual can use the national ID and password of a physician, carelessly disclosed by the physician, to log into the prescribing system. They can then add or remove medications, access patients’ drug lists, modify patient records, and even access confidential patient information for personal gain, exploitation, or even extortion.”

Security/hackers

No. 3 (Hospital Admissions): “Ensuring adequate security requires a budget and significant investment, which unfortunately has not been prioritized until now. A security breach resulting in the disclosure of hospital data and patient records could culminate in the disclosure of personal information pertaining to both the patient and the healthcare facility.”

Damaged drug barcodes

No. 4 (Hospital Admissions): “Sometimes, while entering the drug barcode, we observe that the drug barcode is damaged because of organization problems and cannot be retrieved. However, due to system malfunctions often caused by Internet connectivity issues or power outages, barcodes are frequently rendered unreadable……”

Discussion

In this study, participants’ perspectives were explored through the SWOT framework, which allowed us to identify both the positive drivers (strengths and opportunities) and the negative drivers (weaknesses and threats). These findings provide a structured basis for discussing the factors that facilitate or hinder the implementation process.

The positive drivers

The theme of strengths

From the perspective of all stakeholders, the most frequent codes explored in this section can be categorised as time-saving and accelerated services, avoid prescribing the wrong drug and prevention of potential misuse of health insurance booklets. Numerous studies have been conducted in this area, and the findings of the current research align with them. Zadeh P E and Bouraghi H also highlighted the key benefits of electronic prescribing, such as mitigated saving healthcare costs and increased prescribing accuracy.^{7 19} In a systematic review, Osmani F reported a relative risk reduction in medication error rates ranging from 13% to 93%, while Zadeh P E reported a reduction of 83%.^{7 20}

The findings of studies conducted by Bouraghi H, Camacho E M, Boonstra A, Oktarlina R Z, Cusack C M and Ammenwerth E revealed that electronic prescribing has been associated with a reduction in medication errors (such as drug name, dosage and treatment duration).^{19 21–25}

In a study, Lanham A E highlighted innovations in electronic prescribing, there is potential to add value and improve prescribing.²⁶ Lina’s research indicated that 81% of respondents found the electronic prescribing system easy to use, more time-efficient and safer.²⁷ The findings of Tiffany’s study, conducted during the COVID-19 pandemic, also demonstrated improvements in the prescribing process, safety and security, and also increased convenience for patients during the pandemic.²⁸

The prescription of medications within the primary care system, particularly in health houses staffed by non-physician personnel, presents significant challenges, including inadequate expertise and high patient volumes, which can contribute to the incidence of medication errors.²⁹ Yazdi F B stated in the scoping review that the adoption of electronic prescribing systems enhances primary healthcare quality by providing access to drug information, reducing human errors and improving patient monitoring and follow-up.⁶

Despite the considerable advantages of electronic prescribing, inadequate implementation of these systems can generate unintended consequences. Evidence suggests that such circumstances may introduce new categories of errors that diminish workflow efficiency, elevate medication costs and compromise patient safety. While the occurrence of certain unintended mistakes in electronic prescribing appears unavoidable, empirical data indicate that approximately 9% of electronic prescriptions contain medication errors.^{7 23 30}

The theme of opportunities

The most frequent themes associated with the opportunities of electronic prescribing in this study include improved health service quality; the potential for sharing patient records across different departments (networking); remote access to patient information.

The opportunities identified in this study align with numerous pieces of evidence worldwide. In this regard, Ashley has introduced opportunities such as the adoption of new technology, strong competition, an improved image of healthcare and increased health service quality.²⁶ Klinis S reported opportunities gained from the use of an information technology system in the health system, including compatibility with existing systems like mobile devices, remote data access, data storage and data synthesis.³¹ Furthermore, findings from a number of review studies indicate that demographic disparities in technology adoption and use constitute critical barriers to the successful implementation of e-prescribing systems. This consequently leads to missed implementation opportunities and ultimately undermines the overall effectiveness of such systems.^{7 9 23}

The negative drivers

The theme of weaknesses

The following frequent codes were identified in the study findings: shortcomings in technical infrastructures; the impossibility or disobedience of electronic prescription registration in the private sector and unskilled staff.

The weaknesses observed in the current study are consistent with numerous findings in the literature. In line with the findings of our study, Moghani N B highlighted that the main challenges in implementing electronic prescribing were unstable internet connections and the complexity of multiple insurance schemes.³¹

Cusack C M’s study findings refer to the levels of physician’s acceptance and resistance.²³ Oktarlina R Z considered compatibility with healthcare centres and healthcare workers as major obstacles.²²

One of the key findings of this study was the lack of staff proficiency in using electronic prescribing systems and the need for targeted training. This aligns with Boonstra’s research, which reported that electronic prescribing increased medication errors and, in some cases, prolonged patient waiting times due to typing mistakes, system failures and forgotten codes.²¹ Tiffany also reported that the most significant weakness was the patients’ and medical staff’s requirement for training.²⁷

Moreover, the lack of access to computer systems by some physicians has culminated in an increase in prescriptions for uninsured drugs.²¹ Finally, Zadeh P E also demonstrated factors contributing to potential errors were categorised into four main groups, including human, technical, interactive and organisational.⁷

As emphasised by other researchers, increasing physicians’ adoption of such systems requires coordinated interventions at both the technological and health system levels. In particular, user-friendly design and supportive organisational policies are essential to facilitate physicians’ acceptance and adaptation in practice.^{9 32} In line with this, Lina’s study demonstrated that the majority of respondents considered their EHR systems specifically effective for prescribing medications (88%).²⁶

The theme of threats

Among the most significant issues in this theme are the following subthemes: access to confidential information and the potential misuse of patient data and legal issues and the government financial burden, etc.

Aligning with the present study findings, Ashley’s study results demonstrated that data breaches caused by cyberattacks, poorly designed platforms, data recording errors and financial burdens were among the system’s threats.²⁵ Klinis S identified concerns related to confidentiality and malpractice, system failures, natural and human-made crises, and technological, systemic and equipment-related crises.³⁰ Rasmi and Caitlin’s findings considered the biggest barriers to be related to high costs.^{22 23}

Tiffany delves into the concepts of insecure systems and the criteria by which a system is deemed insecure.²⁷ Warren highlights significant barriers to implementation, including costs, lack of vendor support, patient privacy concerns, system errors and legal issues.³

Among the benefits of the study, several unique findings can be highlighted, including the clarifying processes, reducing tax evasion, eliminating drug intermediaries, effective monitoring of the country’s drug needs.

Through appropriate policymaking and proper programme implementation, challenges such as damaged drug barcodes due to power outages and internet disruptions, numerous tariffs of insurers and multiple platforms are expected to be prevented. Additionally, implementing such measures may significantly enhance service quality and further strengthen stakeholder trust.

Limitations

One of the main limitations of most qualitative studies is the subjective expression, which may make people’s opinions different in the same situation. A person with an average infrastructure may have the same opinion as others in another place with an excellent infrastructure. To more rigorously examine the successful implementation of such programmes and to clarify their dimensions and effectiveness, future research should employ complementary approaches, including systematic reviews, time-series analyses and randomised controlled trials. These methodologies can generate stronger evidence and broader generalisability, thereby supporting more effective policy and practice.

Another limitation is that people’s views were affected by working conditions. So, it is often dependent on the improvement of technical and electrical facilities. This issue caused the interviewees to refrain from expressing the benefits at the national level.

One of the other limitations of this investigation is that it was conducted in a single province, which may limit the transferability of the findings to other regions. Iran’s geographical, cultural and climatic diversity creates significant variation in socio-economic conditions and technological access. This heterogeneity influences programme implementation, producing different levels of resistance and compliance and leading to context-specific outcomes. Effective implementation requires attention to local infrastructural and cultural factors, supported by regional studies that inform policymakers.

Conclusion

The findings of this study indicated that the strengths of the implementation programme comprised reduced prescribing errors, misreading of prescriptions, mitigated drug interactions, drug dosage, facilitated work processes and time saving, rapid and remote access to patient records and previous medications, and connection with other departments and information sharing, while the weaknesses included shortcomings in technical infrastructures, the programme’s internet and electricity dependency, the impossibility or disobedience of electronic prescription registration in the private sector and unskilled staff and the associated challenges with equipment usage, and the presence of multiple platforms and the diversity of insurer schemes. The most frequent codes identified within the ‘opportunities’ theme involved expediting drug monitoring by the organisation and satisfying the country’s drug needs, improving health information networking, helping decrease bureaucracy, clarifying processes, eliminating drug intermediaries and black market, reducing tax evasion, improving digital health data banks and improving the quality of health services, whereas the most critical findings in the ‘threats’ theme were the government financial burden, access to pharmacies’ financial resources, the potential for misuse of patient data and access to confidential information (security, hackers, crimes).

Overall, despite the presence of internal and external factors that may lead to negative outcomes, the programme yielded notable positive results. By distinguishing between internal and external sources of both challenges and benefits, the analysis provides a balanced understanding of the programme’s current position and informs strategies for sustainable improvement. In the realm of developing and implementing electronic prescription infrastructures, it is imperative to foster constructive interactions among all stakeholders and technology providers to create highly acceptable platforms. Similarly, policymakers must be cognisant of their roles in this domain and take effective measures to establish policies aimed at improving health outcomes.

Data availability statement

Data are available upon reasonable request. All data relevant to the study are included in the article or uploaded as supplementary information. Not applicable.

Ethics statements

Patient consent for publication

Not applicable.

Ethics approval

The present study is a qualitative study. Its non-clinical research. It has been done in compliance with confidentiality and privacy and voluntary participation and withdrawal. Informed consent was obtained from participants verbally and in writing.This research was approved at the Ethics Committee of the Shahid Beheshti University of Medical Sciences (IRAN) with the ethical code IR.SBMU.SME.REC.1402.048.(https://ethics.research.ac.ir/ProposalCertificateEn.php?id=373423&Print=true&NoPrintHeader=true&NoPrintFooter=true&NoPrintPageBorder=true&LetterPrint=true)