Attitude Towards Electronic-Prescription and Associated Factors Among Physicians at University of Gondar Referral Hospital: Institution Based Cross-Sectional Study

Background: Electronic prescription is described by the United States Centers for Medicare and Medicaid Services as the broadcast utilizing electronic medium, of prescription or prescriptionrelated information between prescriber, distributor, pharmacy benefit manager, or health plan, either openly or through an agent, including an electronic prescribing system. the aim of this study was designed to assess attitudes towards electronic prescription and associated factors among physicians at the University of Gondar referral hospital 2021. Gondar, Ethiopia. Methods: Hospital-based Cross-sectional study was used among (n=152) physicians who have involved with a response rate of 88.8%. Data were collected using structured self-administered questionnaires from August 1 to September 1/2021. The collected data were entered into Epiinfo Version 7.2 and exported to SPSS version 23 software for analysis. Descriptive statistics using frequency and other summary statistics were using present socio-demographic and clinical characteristics of participants. Bivariate and multivariable logistic regression was employed to identify factors associated with dependent variables. Odds ratio (OR), with 95% CI and p value< 0.05 were computed to determine the level of significance. Results: Based on the operational definition the overall score of attitudes to an electronic prescription of physicians from the University of Gondar referral hospital was 76.8% [95% CI: 66.7-84.2]. Among the applicant variables for multivariable analysis two variables like age of the respondents [AOR: 2.48 (95% CL:1.055-5.830], and the monthly salary of the respondents [AOR: 8.29(95%CL: 3.002-22.89] had to have a significant association with electronicprescription. Conclusion and recommendation: The overall score of attitudes to the electronic prescription of physicians from the University of Gondar referral hospital was good. Age and a monthly salary of the respondents were significantly associated with an electronic prescription from the working organization university of Gondar referral hospital, and health care policymakers and hospital managers need to develop and institutionalize evidence-based widespread preparation of stakeholders especially prescribers and communications development earlier than its acceptance to build it doing well and victorious.


Background of the study
For several years, the written prescription has been the technique excellent for physicians to communicate decisions on drug treatment, and pharmacists to dispense medicine, while at the same time being a source for the patient about how to use the medication to increase its benefit. currently, the medical prescription is at the transitional stage between paper and electronic state. When adopting an old-style process to the new electronic period, unique opportunities and challenges are offered to the involved performers like prescribers, patients, pharmacists, and also health care and EHR-system providers, and other stockholders (1). The traditional way of communication was by Prescription which is a written order by the doctor to the pharmacist. It has a status of a legal document. Re dispensing with repeated use of the same prescription is illegal.
Electronic prescribing is defined by the US Centers for Medicare and Medicaid Services (CMS) as the transmission using electronic media, of prescription or prescription-related information between prescriber, dispenser, pharmacy benefit manager, or health plan, either directly or through an intermediary, including an e-prescribing network (2).
Electronic prescribing is the advancement of a traditional technique to technological advancement. It is an integral component of the health information technology (HIT) system, an inter-operational platform, joining communication gaps among doctors, patients, nurses & pharmacists. It has the potential to augment the safety of pharmacological treatment to reduce the morbidity associated with medication errors by reducing illegible handwriting, providing alerts by drug-drug interaction and drug allergy. The time spends handling the prescription renewal requests was considerably reduced. Electronic prescribing for controlled substances curbs the abuse and diversion of prescription drugs. This is by substantially reducing prescription fraud associated with paper prescriptions like falsifying prescriptions, prescription pad theft, and forgery. (3) E-prescription is a tool for prescribers to electronically send an accurate, error-free, and understandable prescription directly to a pharmacy from the point of care. It allows the patient to improve safety through electronically checking patient allergies contraindication etc security and accuracy of his prescriptions, saving his time during handling prescription renewals by making it electronically with his pharmacy(4).
Mistakes with e-prescribing are seen to be on the rise soon after its implementation. It could be attributed to technology factors like poor user interface design like auto-populate features and dropdown menus, end-user factors like poor knowledge of the e-prescribing platforms or unintentionally entering improper information, and environmental factors such as lack of time or poor location of the computer(3).
gap between physicians perceived value of e-prescribing and their intent adopt this practice. (8) Their reluctance to embrace the changeover from paper to computerized systems was based in large part on the perception that e-prescribing is time efficient. E-prescribing system has the potential to greatly reduce adverse pharmaceutical effects driving from transcription, drug-drug interaction, allergies and dosage errors, to name a few indeed studies show significant improvements associated with e-prescribing implementation, including an 86% in decrease serious medication errors and increase in Medicare formulary adherence from 14% to 88%. (8)Despite this evidence, however, providers have been slow to adopt e-prescribing technology due mainly to cost and regulatory constraints in the health industry.
Therefore, this study is designed to assess the perceptions of health care professionals towards e prescriptions, to identify possible barriers and to provide recommendation based on the results obtained. This may be helpful to know the current status of physician attitude and perceptions and to take action for the improvement.

Study Setting
The study was conducted in University of Gondar referral hospital, which is found in Gondar town, Amara region of North West Ethiopia far from Addis Ababa and Bahirdar 772km and 168km respectively. UoG comprehensive specialized hospital has 1049 health professionals and 653 beds were available. Patients are referred from primary health unit to this hospital that provides specialized healthcare services. UoG referral hospital currently offers a wide spectrum of services both preventive and curative as well as serving as a primary, district and tertiary hospital. Some of the services offered by the hospital are surgical, pharmaceutical, medicinal, social work, laboratory, dental, occupational therapy and intensive care services to mention but a few. It has a staff complement of 1915 distributed across different departments.
There are about 450 nurses and 171 physicians including 67 GP.

Study Design and Period
An institutional based cross-sectional study was conducted to assess the Attitude of eprescription among physicians at UoG referral hospital. The study was conduct from August 1/2013 to September 1/2014 E/C.

Source Population
All Physicians working in University of Gondar referral Hospital were taken as source population.

Study Population
The study subjects were all physicians working in university of Gondar referral hospital for six (6) months and above during the study period.

Inclusion Criteria
All physicians who are working at university of Gondar referral hospital were included in the study.

Exclusion Criteria
Study participants who are seriously ill and absent from work during the data collection period were excluded from this study.

sample size determination
The desired sample size is calculated using single population proportion formula.

Formula:
However, because of the absence of previous similar studies in Ethiopia for p-values well as small number of study population we have, all physicians working in UOGCSH were participated in the study.

Sampling technique and procedure
The study participants were selected by using census method which is the method of statistical enumeration where all members of the study population are studied. Based on the above assumption for our study the participants were all physicians working in university of Gondar referral hospital.
 Electronic prescription: defined as a technology applies on drug prescription either online or offline used to computer, tablet, and hand phone systems used to prescribing by physicians (15).

Data collection tools and techniques
Quantitative data was collected using self-administered questionnaire, Socio-demographic, behavioral, technical and organizational variables was included in the questionnaire.
Questionnaire was prepared in English this is because the study participants is well educated and they can easily understand English and if the questioner translated in to local language (Amharic) it was create some difficulty to understand.

Data quality control
Data collection were supervised for correct implementation of procedures by supervisors and the investigator. Completeness and consistency of the questionnaire was also be checked at the end of data collection.

Data analysis and processing
After the data collection, the response was code and enter in to computer by using EPI-info data version 7 statistical packages, and 10% of the response were randomly selected and checked for the consistency of the data entry. SPSS version 20 also was used for data analysis. Frequency and Percentage were calculated to all variables which are related to objective of the study, and Bivariate and multivariable logistic regression was employed to identify factors associated with dependent variables. Odds ratio (OR), with 95% CI and p value< 0.05 were computed to determine the level of significance.

Data Dissemination Plan
A copy of the report will be given to UoG referral hospital, CHMS Department of Health informatics and other concerned bodies. It is also expected that the result of this study will be disseminated to the public through media. Additionally, the result may be presented on scientific conferences and published in scientific journals.

Ethical Consideration
Ethical clearance was obtained from institutional review board (IRB) of the University of Gondar. A written letter of permission from the research coordination committee were submitted to UGCSH Administration to grant permission for conducting the study. The study participants were provided with clear information about the purpose of the study and asked if they are willing to participate in the study. Data was collected after receiving verbal consent from those who are willing to participate in the study. Anonymity of the respondents was preserved and their information were kept secret and were not be disclosed to anyone except for the purpose of the study.   were reported as unsatisfied (Table2).    The current study tried to assess the magnitude of e-prescription among physicians and the overall score attitudes of physicians on e-prescription from the organization in the study area was The study analyzed e-prescription from the physicians' view in the public sector at University of Oulu user experience, acceptance of technology, success in implementing and using information system with the help of five themes forming a framework (information quality, service quality, system quality, perceived ease-of-use, perceived usefulness and intention to use) (12).

RESULT Socio demographic characteristics of respondents
A survey was conducted in four hospitals in Nigeria to determine the economic, technical and organizational feasibility of adopting e-prescribing included 42 medical practitioners -doctors, pharmacists, pharmacy technicians and assistants -working at the hospitals at the time of the survey so, respondents felt that implementation of an EP system is economically feasible (p=0.031) and organizationally feasible (p=0.032). (13) The current study revealed that higher numbers of physicians were dissatisfied than the above study. The possibility of dissatisfaction would be due to lack of computer at their office and home, absence of internet accesses at office as well as at their home, lack of training related to eprescription those who perform better.
Factors like monthly salary of the respondents were significantly associated 8.29 times with physicians to adapt e-prescription. The findings of the current study are inversely related with above study that in Nigeria to determine the economic, technical and organizational feasibility of adopting e-prescribing so, respondents felt that implementation of an EP system is economically feasible (p=0.031) and organizationally feasible (p=0.032). (13) The possible difference may be due to inadequate funding by the government does not provide for the health sector to acquire the necessary resources and training to enhance the skills of physicians in health care industry.
Generally, the magnitude of attitudes of physicians on e-prescription from the current study is higher and influenced with factor like monthly salary, and age of respondents.

Limitation of the study
The current study has some limitations such as related kinds of literature and as data were collected based on self-reported information, the possibility of recording errors and recall biases.

Conclusion
the overall score attitudes of physicians on e-prescription from the organization in the study area was good in the university of Gondar referral hospital. variables for multivariable analysis variables like age and the monthly salary of the respondents had to have a significant association with e-prescription. monthly salary of the respondents was significantly associated with eprescription of monthly salary less than 9,056.00 of the respondents from the University of Gondar referral hospital compared with those who had monthly salary more than 11,305.00 with attitudes ready to adapt e-prescription of the respondents from the working organization.

Recommendations
Recommendations were given for the responsible bodies based on the findings of the research and conclusions. The followings are the appropriate recommendations for different responsible bodies.

To Hospital Administrators
Recommendations were given for the responsible bodies based on the findings of the research and conclusions.

To Researchers
 Since there was no adequate research done in Ethiopia on this topic the findings of the research are expected to be used by another researcher who wants to conduct similar research.