The vast majority of PHCPs (94.7%) is prescribing medications daily and 44.2% of them are registering more than 20 electronic prescriptions per day (Fig. 1). In addition, 76.8% of SMDs prescribe daily, with 38.4% of them stating that they prescribe < 5 e-prescriptions per day and 31.7% of them 6–9 prescriptions per day (Fig. 1). 94.2% of pharmacists execute prescriptions daily, while they almost unanimously (91.2%) stated that the percentage of prescriptions processed through an e-prescribing system on a daily basis is greater than 75%.

Number of e-prescriptions per day administered by PHCPs and SMDs

The UI provided by the Greek national e-prescription system operated by IDIKA is used by 58.9% of PHCPs with the rest of the participants using third party applications (which still use the IDIKA system’s back-end via the respective Application Programming Interface - API). The vast majority of SMDs use the UI provided by IDIKA (91.5%), while among pharmacists, the IDIKA system holds second place along with a third party application.

Regarding the open-ended question “How has e-prescribing affected your work?“, the answers collected showed a positive connotation while an equal number of answers revealed a negative impact on the work of individuals. It was observed that even though PHCPs and SMDs recognize the positive effects of e-prescribing they also identify problems and malfunctions of the systems. Both groups noted that the procedure is easier, it allows to follow the patients’ medical history (via the patients’ electronic health record, EHR) and increases the time available to interact with the patient. Notably, at the same time, under the negative aspects, they mentioned that in case of system malfunction they are unable to proceed with the prescription, with the delay causing stress and reducing the interaction time with the patient. For 88.3% of pharmacists, e-prescribing has had a positive effect on their work routine. Open-ended answers gathered, note that it has increased prescription processing speed and efficiency. Furthermore, ease of use and avoiding errors are pointed out.

Additionally, participants were asked to comment on a set of sentences regarding e-prescription. All three groups agreed that e-prescription reduces the risk of errors (67.5% primary care physicians, 64.6% SMDs and 88.3% pharmacists answered “Agree” or “Strongly Agree”, Fig. 2A). Participants perceived that e-prescription offers potential for improved management of patients’ overall medication (71.3% PHCPs, 70.8% SMDs and 66.4% pharmacists answered “Agree” or “Strongly Agree”, Fig. 2B). Moreover, responses showed that participants believe in some extent that multiple drug therapy can be monitored through e-prescription [55.1% PHCPs, 49.1% and 41.6% pharmacists answered “Strongly Disagree” or “Disagree”, (Figure C) (this statement was provided as a reverse-polarity question)]. However, pharmacists’ highest percentage (33.6%) was collected for the answer “Moderately Agree/Disagree” regarding the statement “E-prescription does not facilitate the monitoring of multiple drug therapy”. Regarding the monitoring of side effects and drug to drug interactions, approximately half of the participants in each group responded that this is not promoted and facilitated by e-prescription [51.1% PHCPs, 48.7% SMDs, 48.2% pharmacist answered with “Agree” or “Strongly Agree” (Fig. 2D) and 43.4% % PHCPs, 45.8% SMDs, 46.7% pharmacist answered with “Disagree” or “Strongly Disagree” correspondingly (Fig. 2E) (the statement was provided as a reverse-polarity question)]. However, it is also noted that 27.1% PHCPs, 21.3% SMDs and 26.3% of the pharmacists responded with “Moderate Agree/Disagree” with the statement “E-prescription does not promote the monitoring of side effects” (Fig. 2D). This answer gathered even higher percentages for the statement “E-prescription facilitates the monitoring of drug to drug interactions” (31% PHCPs, 28.7% SMDs and 29.2% of the pharmacists) (Fig. 2E).

Line charts depicting participants’ answers per group on e-prescribing

Detailed examination of the impact that e-prescription has on different phases of prescription, followed. Thirteen phases related to prescribing were presented (Table A, Supplementary Material) and participants were asked to comment on whether they thought e-prescriptions had affected each of them. The highest percentages of “Strongly agree” and “Agree” responses (in total > 70%) were given by all three groups for the sentences: [e-Prescription has facilitated] Recipe registration (compared to handwritten prescriptions), Recipe information check, Monitoring of intervals of execution of the prescription from the moment of prescribing. In addition, > 80% of pharmacists responded “Strongly agree” and “Agree” at the following: [e-Prescription has facilitated] Checking and completing the participation rate (cost sharing rate), Transfer prescription data to the pharmacy data system.

Afterwards, participants were given a series of questions specifically assessing the national e-prescription UI.

Regarding the national e-prescription system, pharmacists’ answers appeared to be the most undivided, with 81% finding it not difficult to use (Fig. 3A), 70% perceiving the system as clear and comprehensible (Fig. 3B) and 80.3% responding that it is easy to learn (Fig. 3C).

Within the PHCPs and the SMDs groups, answers were more varied (Fig. 3A-3C). In detail, PHCPs answers were divided when asked to respond to the statement “The national e-prescription system is difficult to use” (13.6% “Strongly Disagree”, 27.3% “Disagree”, 24.2% Moderately Agree/Disagree”, 19.7% “Agree” and 15.2% “Strongly Agree”) (Fig. 3A). For SMDs, while 50% responded with “Strongly Disagree” or “Disagree”, 24.2% answered with “Moderately Agree/Disagree” to the same statement (Fig. 2A). Moreover, when asked to respond to the statement “The national e-prescription system is clear and comprehensive”, although answers vary within groups it is noted that the responses from PHCPs and SMDs exhibit similarities (Fig. 3B). Additionally, in Fig. 3C, it can be observed that even though 53% PHCPs and 59.1% SMDs perceive the system as easy to learn, 29.5% and 29.3% answered with “Moderately Agree/Disagree”.

The national e-prescription system currently is the main data provider to the patients’ national EHR, as it provides the dispensed prescriptions along with the associated diagnosis. Participants’ answers reflect the importance of having access to this information, with 72% of the PHCPs and 71.3% of the SMDs finding it necessary to link the e-prescription system to patient’s EHR and medical history (Fig. 3D).

Regarding the implementation of the integrated Therapeutic Prescription Protocols (TPPs), the answers of the doctors are divided, and no clear tendency can be detected as to whether they consider them to promote good clinical practice (Fig. 4). Furthermore, this lack of a trend could be also observed in the next questions, as 40% of the participants perceive the TPPs as easy to learn, while 50% of the participants in the next question note that the TPPs are not easy to use.

Participants’ answers regarding the IDIKA system given in line charts

Participants’ answers regarding TPPs implemented in the IDIKA system

Even though 80% of all three groups considered the system to be secure, the rest of the participants were asked to identify which issues they consider problematic. Participants mainly commented on the ease of access by third parties knowing the patient’s social security number (AMKA), thus being able to access patient’s medical history. In addition, access to the system is feasible, as passwords are inevitably known among employees. For this, they propose the introduction and regular update of a security question.

When asked for the participants’ opinion regarding clarity of the official regulations on e-prescribing, approximately 60% of all HCPs replied that they are clear. The rest of the participants identified as issues the lack of information (some were even unaware of the existence of regulations), along with ambiguities in directives and missing explanations.

The benefits listed by physicians in the open-ended questions include error prevention, gained control and transparency of the prescribing process. Monitoring the overall treatment of the patient and access to the medical history were also mentioned as main benefits. Answers often referred to the ease and speed of the prescribing process using an e-prescription system compared to handwritten prescriptions. Physicians prescribing using a platform other than IDIKA unanimously answered that the respective system used is faster and easier, the renewal of the prescriptions is uncomplicated while they consider the use of the TPPs as facile. The most common answer given by the participating pharmacists is the safety offered by e-prescription, due to the reduction of errors when executing a prescription (errors mentioned varying from illegible handwritten prescriptions to giving the wrong medication to the patient). Also, the speed and time saving through the system are recognized. Reference was made on how over-prescribing and fake prescriptions are avoided, while emphasis was given again to the patient’s medical history. Pharmacists also mentioned the convenience e-prescription offers in terms of administrative matters like checking patient’s participation rates and drug prices.

Participants identified the lack of reference to patients’ allergies (45%), the incorrect pharmaceutical form of the medication (ml, mg, tabs, etc.) (32.6%), as well as the lack of reporting on adverse drug reactions (31%) as more often accounted problems creating uncertainties. Other obstacles seem to be the wrong total amount of medicine in the package, the lack of dosage information or the vague or incorrect dosing instructions and the lack of useful information as for example the patients weight. Pharmacists ranked the unclear or incorrect dosing instructions as the most important issue (64.2%), the lack of reference to patient’s allergies (38.7%) and the lack of reporting adverse drug reactions (34.3%). The list of potential gaps / identified issues can be found in Table 2 along with participants’ collected answers.

Twenty possible improvements of the e-prescription system were presented to the participants and they were asked to select at least three they considered important. Table 3 shows the four selected improvements from each group that gathered the highest percentages. All three groups perceived as crucial the “Link/Connection with patients’ EHR, Medical History, Diagnoses, Comorbidities, Allergies”. For the group of pharmacists and SMDs the second preferably suggested improvement is information on drug interactions. For PHCPs, “Integration of TPPs allowing flexible interaction” is in second place (fourth in preference for SMDs), followed by “Easy / simple drug selection” and “Reduced actions (e.g., mouse clicks)”. The third preferred improvement for pharmacists is the “Communication between the prescribing clinician and the pharmacy for the availability of a specific drug” and next is the “Warning for prescribing high doses (not in accordance with the drug’s SPC)”. The third selected improvement for the SMDs and pharmacists was the “Easy / simple drug selection”. It is noted that for SMDs, further improvements (Q11 – option to save favorites, Q20 – issuing reports, e.g., list of medicines prescribed to a patient, 12, 15) gathered a percentage higher than 40%.

Additionally, in the open-ended questions, most participants pointed out technical problems such as delays, frequent connection interruptions, slow response speed. Extended references were made regarding the integrated TPPs. The participants seek more flexibility in management and the overall interaction with the TPPs. Specific features were identified that could improve the TPPs’ usability, for example, the ”prescription repetition” function in the context of e.g., a refill request, as this is not possible prior to the completion of a TPP currently followed by a patient.

They also noted the difficulty of copying recipes and the lack of “memory” so that it is necessary to fill in again information about e.g., dosage. They consider the connection/link to the patient’s medical record necessary, while the option to upload laboratory results was also mentioned as a desirable feature. A significant number of pharmacist respondents identified problems related to drug dosing and urged for better ways to record dosage, while they often reported discrepancies between the prescribed medication amount and the proposed dosage regimen. Pharmacists also suggested the existence of restrictions for doctors when prescribing. As the main area that requires development, they identified the control of drug-to-drug interactions to avoid possible side effects. They considered it necessary to have access to the patient’s pharmacotherapy history. This exists currently at the pharmacy level but there is a need to expand the implementation to the patient level. Promoting intangible prescription, many reported the annulment of the use of paper and self-adhesive barcodes (used for auditing aspects). In addition, they noted the lack of improvements, in the form of regular updates made, to enhance the available systems and their functionalities.