Environmental Impact and Provider Satisfaction Associated with ePrescriptions in Otolaryngology: A Quality Improvement Study

Abstract

Importance

ePrescriptions are associated with increased patient satisfaction, decreased provider burden, decreased administrative costs, and a positive impact on planetary health. However, ePrescription uptake by physicians is historically low and acts as a barrier to reaping the benefits therein.

Objective

We aimed to attain 20% overall usage of ePrescriptions in the Department of Otolaryngology-Head and Neck Surgery (OHNS) at the London Health Sciences Centre (LHSC) by December 2023 through systematic implementation of change ideas.

Design

Pre-post intervention design.

Setting

Ambulatory clinics in OHNS at LHSC, an academic hospital.

Participants

Fourteen staff and 15 resident physicians in OHNS; 38 patients in pediatric otolaryngology clinic.

Intervention or Exposure

A root-cause analysis identified potential obstacles to ePrescribing. Change ideas, including educational seminars, surveys, quarterly reporting of ePrescription usage, and public encouragement of top ePrescribers in the department, were implemented and tested using Plan-Do-Study-Act cycles.

Main Outcome Measures

Percent ePrescription usage and carbon footprint savings associated with ePrescriptions were measured. Provider and patient satisfaction surveys were conducted as balancing measures to assess for the perception of increased burden on providers.

Results

During the pre-intervention and post-intervention phases, a total of 400 and 1000 ePrescriptions were prescribed by the department, respectively. There was a statistically-significant increase in the mean proportion of ePrescriptions used before (mean: 9.7%; sd = 7.6) and after (mean: 40.7%; sd = 6.4) the intervention (p < 0.001), which exceeded the goal. SPC charting suggested special cause variation, signifying a statistically-significant improvement. Additionally, a reduction of 125.9 lbs of CO₂ equivalents was associated with ePrescription use. 66.7% of providers rated overall satisfaction with ePrescriptions at 7/10 or higher, and 76.9% indicated that patients either sometimes, usually, or always opted for ePrescriptions when given the choice.

Conclusion and Relevant

Our change ideas increased ePrescription usage in an academic OHNS department and were associated with increased planetary health savings and provider satisfaction.

Graphical Abstract

Key Messages

• 1) Stated change ideas improved ePrescription uptake in an academic ambulatory patient setting.

Introduction

ePrescription systems allow the prescriber to send an electronic version of the prescription directly to the patient’s preferred pharmacy at the point of care. In contrast, printed prescriptions are associated with decreased patient satisfaction, decreased patient access to medications, increased provider burdens, increased administrative costs, and a negative impact on planetary health.^{1 -5} The increasing demand for ePrescription systems reflects their promise of being more beneficial for patients, providers, the health care system, and planetary health.

Benefits of ePrescriptions for Patients

The 2020 Canadian Digital Health Survey reported an increasing patient demand for electronic services. Eighty percent of patients preferred that new prescriptions be sent directly to their pharmacy instead of receiving a paper prescription. ⁶ Furthermore, 65% of patients preferred electronic prescription renewals, while the percentage of patients actively sending electronic requests for prescription renewals grew from 12% to 20% in 2019. ⁶ Finally, 77% of patients reported that implementing electronic prescription renewal services would better help them manage their health. ⁶ In addition, multiple studies have shown that integrating ePrescription systems into practice reduces medication errors by over 50%.^{7 -10} This improvement increases the quality of prescriptions, increases patient safety, and reduces medication processing time.^{7 -10}

Benefits of ePrescriptions for Health Care Providers and Health Care System

Beyond benefits for patients, existing literature suggests that the integration of ePrescription systems is also beneficial for health care providers and the health care system as a whole. For example, studies have found overall time-saving advantages for providers that use computerized prescribing services.^{11 -13} Providers were increasingly able to work from home owing to ePrescription services, which omit the need for printers, fax machines, or scanners. ¹⁴ In addition, with education about ePrescriptions, physicians are receptive to changing prescribing behaviors to more cost-effective ones that still prioritize the health of patients.^{14 -17} Studies in which proper awareness and implementation of ePrescription systems were made had many cost-saving benefits.^{14 -17} One study estimated $140 billion to $240 billion saved over ten years through improved patient outcomes and decreased patient visits. ¹⁸

Benefits of ePrescriptions on Planetary and Climate Health

By 2050, Canada has committed to net-zero emissions and, notably, health care is a major contributor to global greenhouse gas (GHG) emissions.^{19 -22} An estimated 5% of Canada’s total GHG emissions are attributed to the health care sector. ²¹ In keeping with Canada’s commitment to planetary health, conserving resources such as toner ink and paper from printed prescriptions are actionable steps by which the health care sector can contribute. A quality improvement study conducted at the University of Ottawa, Canada, showed that switching from paper to an eFax system in the Department of Urology resulted in savings of $13,000 and a reduction of 12,000 kg in carbon emissions yearly. ²³

Despite the benefits of the ePrescription system, 6 months after initial implementation, ePrescription use in the Department of Otolaryngology-Head and Neck Surgery (OHNS) at London Health Sciences Centre (LHSC) remained low at 1.7%. Given the limitations of printed prescriptions, the robust potential for ePrescription systems in health care, and its low usage among providers in the OHNS department at LHSC, this project aimed to systematically devise quality improvement strategies to increase ePrescription use and to assess its impact on patient and provider satisfaction.

Materials and Methods

This quality improvement project followed the Institute for Healthcare Improvement (IHI) model. ²⁴ We aimed to attain an ePrescription system departmental usage rate of 20% by December 2023. Fourteen of 18 faculty are based at LHSC, and 15 residents rotate between the hospital sites and ambulatory clinics. Institutional data regarding the number of prescriptions being prescribed by faculty and resident physicians through the ePrescription system were provided on a monthly basis from Decision Support Services on a PowerBI Dashboard. These data were used as a primary baseline measure. Secondary measurements, including outcome and balancing measures, were also collected. A root-cause analysis using an Ishikawa fishbone diagram (Appendix 1) was conducted to identify potential causes for the low ePrescription uptake. The root-cause analysis informed change ideas. We implemented change ideas and tested them on a small scale using Plan-Do-Study-Act (PDSA) cycles.

Change Ideas

We implemented 4 primary change ideas, which we hypothesized would increase ePrescription use. These were (1) educating faculty and residents on the availability and benefits of ePrescriptions, (2) reporting relevant ePrescription use metrics on a quarterly basis, (3) publicly celebrating and encouraging the performance of top ePrescribers in the department, and (4) creating patient surveys to increase patient awareness for the existence and benefits of ePrescriptions.

Education about ePrescriptions was primarily through presentations. These presentations highlighted the benefits of ePrescriptions, and relevant literature was also shared with care providers as additional resources. The presentations also provided a step-by-step tutorial on how to prescribe using the ePrescription system on the electronic medical record (EMR) software and addressed common pitfalls. Finally, physicians were made aware of resources and contacts to connect with if they needed additional support with the ePrescription system. Events such as the departmental “Annual Student Research Day” and departmental meetings were used as opportunities to present and increase awareness regarding ePrescriptions.

ePrescription usage metrics were reported on an ongoing basis to faculty and resident physicians during quarterly departmental and patient safety committee rounds. The metrics reported included the percentage of total prescriptions prescribed using the ePrescription system across the whole department and various subspecialties within OHNS. Differences in usage between faculty and residents were also highlighted to induce friendly competition that would help providers keep ePrescriptions in mind during patient encounters. Reporting usage metrics in these ways was intended to remind providers to integrate ePrescriptions into their patient encounters and to inform providers whether their personal strategies for incorporating ePrescriptions improved the overall rate.

Top ePrescribers within the department who had personal ePrescription usage rates of over 50% were publicly encouraged and celebrated. Their performance was highlighted during patient safety committee round presentations to encourage their continued performance and as models for other prescribers looking to emulate their progress.

Finally, patient surveys were utilized to assess how patients felt about ePrescriptions, obstacles they faced using ePrescriptions, and as a means to educate them of the available ePrescription option during their appointments. These surveys were administered to 38 patients in the pediatric ambulatory clinic over a 6 week period.

Primary and Secondary Outcome Measures, and Inclusion and Exclusion Criteria

The primary measure, a process measure, was the proportion of ePrescriptions sent from the OHNS ambulatory clinics, which was reported monthly. Our secondary measures included outcome and balancing measures. Outcome measures included cost savings and planetary health savings (greenhouse gas emissions/carbon footprint savings) associated with the ePrescription system. Finally, balancing measures included the perception of whether there is an increased burden associated with using the ePrescription system by providers and patients. Balancing measures were measured using self-reported surveys distributed to providers and patients.

The inclusion criteria for patients included any patient (pediatric or adult) who received care at LHSC by OHNS during the study period on an outpatient basis. The inclusion criteria for providers included OHNS faculty and residents involved in providing care for pediatric or adult patients on an outpatient basis. There were no exclusion criteria for patients and providers.

Statistical Analysis

Descriptive statistics such as mean, standard deviation, percent, and sample size were used to describe the outcomes of this quality improvement project. The main outcome of the project was reported as the average percentage change in ePrescription usage across department members. The average change in percentage of usage was statistically analyzed using independent sample t-tests. An alpha of 0.05 was used to determine statistical significance. All statistical analyses were completed using SAS Software (version 9.4; SAS Inc, Cary, NC). Statistical process control (SPC) charting was used to assess for special cause variation and, therefore, a shift in the center line. SPC charts were created and analyzed using QI Macros version 2022.07.

Ethical Considerations

This project did not require ethics oversight by the Western University Health Sciences Research Ethics Board (HSREB) due to its status as a quality improvement project (REB# 122420).

Results

Post-Intervention ePrescription Use in OHNS

ePrescription system use throughout the study period is outlined in Figure 1. The pre-intervention phase of the study was January 2022–April 2023. Change ideas were implemented in April 2023. During the pre-intervention phase, average usage was 9.7% (SD: 7.6, n = 16). The post-intervention phase was from May 2023 to March 2024. The average usage rate for the department in the post-intervention phase was 40.7% (SD: 6.4, n = 11), which represents a statistically-significant improvement from baseline (p < 0.001). The department’s data were subsequently stratified and analyzed by specific subspecialty clinics within otolaryngology including Pediatric, Head and Neck, and Otology/Neurotology. The pre-intervention average usage in Pediatric ENT was 15.6% (SD: 10.5) and increased to 61.2% (SD: 9.6) in the post-intervention phase. The pre-intervention average usage in Head and Neck was 5.4% (SD: 8.1) and increased to 40.0% (SD: 8.8) in the post-intervention phase. Finally, pre-intervention average usage in Otology/Neurotology was 2.2% (SD: 4.1) and increased to 9.9% (SD: 8.4) in the post-intervention phase. All increases in average ePrescription usage following interventions represented statistically-significant improvements from baseline (p < 0.001, p < 0.001, and p = 0.015, respectively). The most prescribed medications in Pediatric, Head and Neck and Otology/Neurotology were ciprodex and ciclesonide, pantoprazole and amox-clav, and ciprodex, respectively.

Figure 1.

Statistical process control charts, which show special cause variation after the implementation of the change ideas (arrow), which signifies a statistically-significant improvement in all graphs. (A) The proportion of ePrescriptions sent from ambulatory clinics in OHNS over the study period across the entire department. (B) The proportion of ePrescriptions sent from ambulatory clinics in Pediatric OHNS over the study period. (C) The proportion of ePrescriptions sent from ambulatory clinics in Head and Neck OHNS over the study period. (D) The proportion of ePrescriptions sent from ambulatory clinics in Otology/Neurotology OHNS over the study period. The blue arrow represents the onset of change idea implementation.

Post-Intervention Cost and Planetary Health Savings Associated with ePrescription Use

To assess the beneficial impact of ePrescriptions on planetary health, we converted the paper used for printed prescriptions into estimated CO₂ released into the atmosphere using an online CO₂ calculator. ²⁵ Our project assumed that each prescription utilized one piece of paper. However, we recognize that most prescriptions in our department range from 1 to 4 pages each. Our project included only the contributions of printed paper and omitted planetary health contributions from other sources, such as toner ink and patients driving to pick up prescriptions. In the absence of ePrescription use, we estimated 586.5 lbs of CO₂ released into the environment over the entire study period. However, owing to a proportion of prescriptions being ePrescribed over the study period, we estimate about 460.6 lbs of CO₂ actually released into the environment. We also assessed the financial cost incurred by the department from printed prescriptions with and without ePrescriptions. Assuming a single paper used per printed prescription and omitting other factors contributing to the cost, we estimated $206.30 would have been incurred by the department for printed prescriptions over the entire study period without ePrescription use. In reality, we estimate a $162.04 cost actually incurred owing to a proportion of prescriptions being ePrescribed over the entire study period.

Provider and Patient Survey Considerations

Provider surveys were conducted to assess the attitudes toward ePrescriptions and how providers felt ePrescriptions affected their practices and patients. Relevant results of these assessments are outlined in Figure 2. Overall, 66.7% of respondents rated their satisfaction with the ePrescriptions system at 7/10 or higher. Of respondents, 76.9% reported that patients either sometimes, usually, or always opted for ePrescriptions when given a choice. Eighty percent of respondents felt that ePrescriptions had no impact on their overall stress levels. Sixty percent of respondents felt ePrescriptions did not affect their job satisfaction and 33.3% felt that ePrescriptions effectively increased their job satisfaction. Over half (53.3%) of providers felt that ePrescriptions did not change their administrative loads, and 40.0% felt decreased administrative loads. There were no significant differences in preferred methods of prescribing following interventions.

Figure 2.

(A) The provider overall satisfaction ratings with the ePrescription system (0 = low satisfaction; 10 = high satisfaction). (B) The provider reporting of how often patients opt for ePrescription options. (C) The preferred method of prescribing for providers before and after interventions.

Finally, a narrative analysis of the free-responses given by providers indicated that the most cited factor that deterred providers from using ePrescriptions was the difficulty of finding the patient pharmacy in the online charting system. Notably, the least cited reason by providers was provider convenience with printed prescriptions. The most cited change that would make providers more likely to freely adopt ePrescriptions into their practices was a system that would prepopulate the patient’s preferred pharmacy prior to the encounter. The least cited change was increased access to computers. Results of surveys given to 38 patients to assess patient attitudes toward ePrescriptions revealed that 57.9% of patients preferred to have their prescriptions sent directly to their pharmacies and 60.5% felt that ePrescriptions were filled faster.

Discussion

This project aimed to increase the awareness among physicians and patients regarding the availability and benefits of ePrescriptions. Following the implementation of our change ideas, ePrescription system use improved from 9.7% to 40.7%. Our results indicate that the strategies used in our project were successful in improving ePrescription system use in OHNS beyond our target of 20% overall use while maintaining a positive impact on physician satisfaction. Our project is also the first, to our knowledge, to quantify and contrast the carbon footprint associated with ePrescription system use versus traditional printed prescription use in otolaryngology. It provides easy to implement strategies that can be adopted to increase ePrescription system use in a variety of ambulatory clinic settings.

Anecdotally, we noted that many faculty and resident care providers were aware of the existence of ePrescriptions but were unaware of how to ePrescribe and of the benefits of ePrescribing for themselves as well as their patients. Therefore, we believe that the simple presentations centered around teaching providers how to ePrescribe was the most impactful change idea. This pattern of adequate awareness of ePrescription availability, yet a lack of knowledge of how and why to ePrescribe among providers, is consistent with the existing literature and highlights the need for more comprehensive training and support.^{26 -30} In a systematic review conducted by Farre et al. (2019), personal factors, including a lack of support and training during the implementation of ePrescription systems were found to be predictive of significant implementation delays and de-implementation among physicians. ³¹ This phenomenon is not restricted to OHNS as previous studies have also found that a lack of familiarity with ePrescribing technology is a major barrier to ePrescription adoption in other specialties.^{32 -34}

The current literature concerning planetary health primarily focuses on telehealth, of which ePrescriptions are a part, and its potential to combat climate change through reduced need for patients to drive to their appointments.^{35 -37} One study estimated 128 metric tons of CO₂ conserved over 11,590 specialist referrals completed on a virtual basis at an academic care center. ³⁶ This conservation was primarily attributed to the ability of telehealth visits to circumvent the need for the patient to drive directly to a physician. ³⁶ Although our study did not account for the greenhouse gasses emitted from patients traveling to their pharmacies, we concur that ePrescriptions also have the potential to reduce greenhouse gas emissions by circumventing the need for the patient to make multiple trips to their pharmacy. Instead, our data newly enrich the existing literature with the potential for CO₂ reduction from paper conservation alone by ePrescriptions. Our data, which estimate 125.9 lbs of CO₂ reduced over the study period, can be extrapolated to estimate a significant reduction in CO₂ across all OHNS clinics across Canada owing just to paper conservation. We did not account for the digital carbon footprint generated by the electronic medical record or prescription system.

The majority of providers had a positive experience while using ePrescriptions, reflecting their ease of use and potential to enhance patient encounters. Notably, however, providers consistently reported that the most critical barrier to incorporating ePrescriptions into their practices was the difficulty associated with finding a patient pharmacy during the encounter itself. This standard reporting likely reflects reduced flow of the clinic and extra time it may take to find the patient’s pharmacy. In addition, an overwhelming majority of respondents reported that pre-populating the patient’s pharmacy at an early stage during the patient’s visit may assist with improving clinic flow and increase the likelihood of providers incorporating ePrescriptions into their practices. Finally, other studies have found that federal incentive programs, practice types, and a physician’s beliefs about the limitations and benefits of ePrescriptions affect the likelihood of ePrescription adoption.^{38 -40} Taken together, the likelihood of ePrescription adoption is multifactorial, and future implementation strategies should consider these multiple factors when implementing ePrescriptions. To our knowledge, patients did not report any issues with receiving their ePrescriptions or the ePrescription system specifically.

Based on our findings, we suggest three additional changes that we believe would optimize ePrescription use in OHNS. Firstly, we propose a comprehensive training program to educate providers on the benefits of ePrescriptions and how to ePrescribe. These targeted programs would act as a resource that providers can access to troubleshoot any issues that they may face when ePrescribing and better support their transition to ePrescribing. Secondly, we propose changes to EMR systems that allow the clerk at registration to pre-populate the patient’s preferred pharmacy. Thirdly, we propose creating posters that urge patients to ask providers for ePrescriptions whenever possible. These posters would be placed in clinic waiting rooms and would also include information that would educate patients on how they can benefit from ePrescriptions.

We acknowledge the limitations of our study. Firstly, the data in our study were gathered from ambulatory clinic settings in OHNS. Therefore, the generalizability of our data to other clinical settings is currently unknown. Furthermore, our study focused on improving ePrescription use within an academic center. Therefore, whether or not these strategies can effectively improve use in community hospitals is currently unknown and is left to future studies to elucidate. We suspect that it may be more difficult to implement ePrescriptions systems in rural community hospitals owing to the lack of infrastructure that supports connecting pharmacies and hospitals to one another virtually. However, we believe this barrier further highlights the need for advocacy surrounding support for ePrescription implementation on a systemic level.

The impact of our change ideas is sustainable. In July 2024, ePrescription use was 53.0% across all 3 ambulatory OHNS clinics. We continue with quarterly data reporting and celebration of top ePrescribers at our quarterly patient safety and quality improvement rounds. The next steps include implementation for outpatient surgery, with a plan to trial in the pediatric minor procedure room.

Conclusion

In conclusion, our project aimed to develop systematic strategies to improve the use of the ePrescription system in OHNS. Through education, quarterly reporting of metrics, and celebration of high ePrescription users, a statistically-significant improvement in ePrescription use was achieved. This was accomplished while maintaining provider and patient satisfaction associated with ePrescriptions, which also resulted in planetary health savings.