Perception of physicians towards electronic prescription system and associated factors at resource limited setting 2021: Cross sectional study.

INTRODUCTION: The healthcare industry is increasingly concerned about medical errors, which are the leading cause of death worldwide and also compromise patient safety. This medical error is even more serious in developing countries where healthcare is not supported by technology. Because of the traditional paper-based prescription system, Ethiopia has an overall medication prescribing error rate of 58.07% that could be avoided if an electronic prescription system was in place. Therefore, this study aims to assess physicians' perceptions towards electronic prescription implementation.
METHODS: From February 1 to April 5, 2021, an institution-based cross-sectional study was conducted among physicians working in public hospitals in the Amhara region. 384 physicians were selected using a simple random sampling method. The data was collected using a self-administered questionnaire and analysed using SPSS, version 21. To assess factors associated with perception among physicians, a binary and multivariable logistic regression analysis were performed. A P.05 value, at a 95% confidence interval, was considered statistically significant. The validity of the questionnaire was determined based on expert opinion, as well as its reliability was determined by calculating the value of Cronbach alpha (α = .78).
RESULTS: In this study, 231 (76.5%) of study participants had a positive perception of electronic prescription. Around 70.8% had more than 5 years of computer usage experience. Nearly 90% of participants claimed that their prescriptions were legible; however, 89% believe that paper-based prescriptions are prone to error. According to multivariable logistic regression analysis, technical skill [AOR] 4.7, 95% confidence interval [CI] (1.27-17.41), good internet access (AOR 2.82, % CI 1.75-4.54), and perceived usefulness of e-prescription system (AOR 3.31, 95% CI 1.01-12.12) were significantly associated with perception.
CONCLUSIONS: The majority of respondents have a positive perception of electronic prescription. The most notable factors associated with physician perception were organizational factors, internet access, perceived usefulness of the system, and technical skill.

Introduction

The health care industry has become increasingly concerned about patient safety, which corresponds to societal trends [1]. Medication safety is one of the most important concerning issues in global health policy [2]. Medical error is a common encounter and represents an important public health problem posing a serious threat to patient safety. A medical error is an error occurred in the prescribing, dispensing, or administration of a drug [3]. It is an avoidable negative impact of medical care, regardless of whether it is a visible or detrimental to the patient [4]. According to a study released in 2016, medical error is the third leading cause of death in the United States, following Cardio disease and cancer [5]. Researchers examined studies that analysed medical death rate data from 2000 to 2008 and extrapolated that over 250,000 deaths per year were caused by a medical error, which contribute to 9.5% of all deaths in the United States of America each year [5].

Across the globe, medication errors are the leading causes of avoidable patient harm in the health care system [4]. In African health care, setting medication errors are common health problems [6].

According to a systematic review and meta-analysis study conducted in Ethiopia, the overall medication error rate was found to be 57.6%, with the magnitude of medication administration and prescription error being 58.4% [7].

A study conducted in the northeast part of Ethiopia (Dessie referral hospital) found an overall medication prescribing error rate of 58.07%, with incomplete prescriptions and dosing errors being the most common error types that could be avoided if an electronic prescription (e-prescription) system was in place [8]. Paper-based prescriptions have long been the preferred method of communication for physicians making medication therapy decisions and pharmacists dispensing medications. It is also recognized as a valuable resource for patients in terms of how to use the medicine to achieve the greatest benefit [9]. However, literature revealed that e-prescription is more reliable when it comes to patient safety than the traditional paper-based prescription method [10].

The use of an e-prescriptions has the potential to improve the quality of patient care at the pharmacy [1]. Indeed, a study shows a significant improvements associated with an e-prescription system implementation, including a 86% decrease in serious medication errors, and an increase in Medicare formulary adherence from 14% to 88% [11]. e-Prescription is an alternative to many years old paper-based prescriptions. Electronic prescribing and dispensing processes of drugs whether in medical practice, follow up or research has become an integral part of pharmacy informatics [12]. Despite the fact that the e-Prescription system is an essential tool for the healthcare industry, e-Prescription adoption and utilization remain low in developing countries [13]. Many healthcare organizations around the world have implemented electronic information systems to improve the process of recording information, but only a few have succeeded [14].

The percentages of failure to achieve the desired benefits from the implementation of an electronic information system are alarmingly higher. Globally, more than half of electronic information system projects, including e-Prescription, failed before they reached their goals [15]. Numerous reasons are given for low electronic system adoption such as resistance by the users, the opposition of transition from paper-based to the electronic system, technical competency of the frontline users, and ease of use of a given electronic system, lack of organizational readiness, and security and confidentiality issue [15-19].

One of the major contributing factors in the successful implementation of e-Prescription is health care professionals’ technical competency [17, 19]. In addition to the physician competency to use e-prescription error, free e-prescription requires regular technical assistance [17, 19, 20].

The infrastructure of a given health care organization and the culture of the society in which the organization operates govern the readiness of the professional to implement e-prescription [21]. In addition to this, the overall readiness of healthcare organizations to implement e-prescription is affected by individual-related factors [22]. According to the Technology Acceptance model ease of use of a given information system influences users’ perception and outcomes [17, 23]. The other factor that governs the perception of the physician to use an e-Prescription systems is the security concern of electronic systems. Electronically transmitted data could be attacked and be used for other criminal purposes such as inappropriate prescribing of controlled substances or high-cost medications [24]. Despite the fact that most e-prescribing systems have measures in place to secure access, they are vulnerable to hacking.

As successful adoption of electronic prescription system or any electronic health information system is a change process it needs many behavioural modifications in the work environment for physicians [25].

Perception assessment, as a comprehensive measure to provide a proper image of existing conditions and the preparedness of healthcare organizations to change, is also a way to identify potential causes of failure in innovation [26]. This study, therefore, aims to assess the perception of physicians towards electronic prescription system implementation and associated factors at public hospitals in East and West Gojjam zones North Ethiopia.

Method

Study design and setting

This was a cross-sectional, questionnaire-based study done to assess physicians’ perception towards implementation of an electronic prescription system and associated factors at public health hospitals in East and West Gojjam zones north Ethiopia 300km from Addis Ababa. The sample size was computed as 384 which was 80% of the total physicians in the study setting during the data collection period. Using single population proportion formula taking 50% at 95% confidence level assuming a 5% margin of error. Where;

n = estimated sample size

p = single population proportion (50%).

Zα/2 = is value of standard normal distribution (Z-statistic) at the 95% confidence level (α = 0.05) which is 1.96,

d = is the margin of error 5% (0.05)

There are 17 hospitals in the west and east Gojjam zones and all the 17 hospitals were taken and then proportional allocation was made for each hospital in order to assure representativeness of the sample. Finally simple random sampling method was used. 384 participants were recruited using the lottery method (each member of the population was assigned a unique number and the number was written on separate paper/card/ with the same size, the card mixed in the basket well and sample drown) and formed the sample. The survey consisted of 35 questions encompassing the following domains: 1. sociodemographic characteristics, 2. Current prescription status, 3. Current computer usage status 4. Physicians’ technical skill, 5. Perceived usefulness, and 7. Organizational factors.

A self-administered questionnaire was adapted from the previous studies [17, 27]. To ensure the validity of the questionnaire, an expert panel (10 doctors having at least 5 years’ experience in general practice or primary care research) with different specializations were invited to review the tool and revise it and from pilot study reliability was calculated result was α = 0.78.

Before the actual data collection, pilot testing of the questionnaire was conducted among 20 physicians at Debre tabor hospital to check internal consistency within the questioners. Then necessary correction was done based on the pre-test finding.

Two-days training was given by the principal investigator for (five data collectors) on the objective of the study and data collection procedures. Data were collected from February 5 to March 30, 2021, using a self-administered questionnaire, one data collector was assigned for each hospital and the supervisor facilitated the data collection process. The principal investigator and supervisors did daily supportive supervision on data collectors. Data backup activities, like storing data at different places and putting data in different formats (hard and soft copies) were performed to prevent data loss.

Study variables and operational definitions

Dependent variable

The dependent variable was perception of physicians towards electronic medical prescription system.

Independent variables

The independent variables were sociodemographic factors (age, sex, profession, educational status, experience), system-related factors (perceived usefulness, perceived ease of use), organizational factors (infrastructure), and behavioural factors (knowledge, technical skill, previous IT experience).

Operational definitions

In this study, “physician” includes general practitioners, residents, dentists, specialists, and subspecialists.

Data processing and analysis

Data was entered using Epi-info version 7 and analysed using Statistical Package for Social Science (SPSS) version 20. Descriptive analyses were computed for the dependent variable in the study to determine the Perceptions of Physician to implement electronic e-Prescription. Adjusted odds ratios were used to measure the association of dependent and independent variables, 95% confidence intervals, and P-value was calculated to evaluate statistical significance. A value of P < .05, corresponding to a 95% CI, was considered statistically significant. Binary logistic regression was done and variables with p-value < = 0.2 were taken and multivariable logistic regression analyses were carried out to assess the effect of selected variables on perception to implement e-prescription. Standardized coefficient and 95% confidence intervals were calculated for each of the independent variables in simple binary regression models with the perception of physicians to use electronic prescription as the dependent variable.

Ethical consideration

In conducting the study, ethical clearance was obtained from the Debre Markos university ethical review board with the ethical approval number of HSC/R/C/Ser/Co/227/12/13. Additional permissions to access participants were also obtained from each hospital administrator. In addition, written informed consent was gained from all participants, participation in the study was voluntary, and no incentive was provided for the participants.

Result

Socio-demographic characteristics of participants

A total of 302 response was received (Out of 384 distributed questionnaire 302 valid response was received) with a response rate of 78.6%. About one-third 225(74.5%) of the respondents being male. The mean age was 28+_3.6SD years with the majority of the age group were 25–34. About 231(76.5%) of the physicians had a positive perception towards electronic prescription system Table 1.

Table 1

Sociodemographic characteristics of participants (n = 302).

VARIABLE	CATEGORY	FREQUENCY (#)	PERCENTAGE (%)
GENDER	Male	225	74.5
	Female	77	25.5
AGE	< = 30	165	54.7
	>30	137	45.3
EDUCATIONAL STATUS	General practitioner	240	79.5
	Resident	39	12.9
	Specialist	23	7.6
DEPARTMENT	Internal medicine	105	34.7
	Pediatrics	54	17.9
	Surgery	59	19.5
	Gynaecologist	56	18.5
	Dermatology	14	4.6
	Other	14	4.6
WORK EXPERIENCE	1–3 Years	192	63.6
	3–6 Years	87	28.8
	>6 Years	23	7.6

Around 70.8% had computer usage experience for more than 5 years, 23.7% for 1–5 years and, the rest less than one year. As shown in Table 2, 97.3% were comfortable with the use of computers, and only 52% had used computers at the hospital. Of the 70.5% (181) who have heard of e-Prescriptions only 14% (37) had hands-on exposure in generating it Table 2.

Table 2

Response of physician on current computer usage status (N = 302).

Question	Responses (%)
	Yes	No
I am comfortable with computer use	293 (97.3%)	9(2.7)
I use computer for personal purpose	297 (98.7%)	5(1.3)
I use computer at home	276 (91.3%)	26(8.7)
I use computer at hospital	155 (51.3%)	147(48.7)
I have good knowledge of computer usage	295 (97.7%)	7(2.3)

About 90% of the participant claimed that their prescriptions to be legible and 76% liked paper prescriptions, on the other hand, 89% perceive that paper-based prescription is prone to error Fig 1.

Fig 1

Current prescription profile of participants (N = 301).

The mean perceived usefulness and technical skill of physicians were 4±0.4, 3.9±0.45, respectively. As shown in Table 3 below, the majority of the participants perceive that using the e-Prescription system will decrease the cost of healthcare (71.2%) and 91% of the study participants think e-prescription would promote the use of data for research.

Table 3

Perception of physicians towards perceived usefulness of electronic prescription system (N = 302).

Variable	Disagree (1+2)	Neutral (3)	Agree (4+5)
Using an electronic prescription system will decrease the cost of healthcare	7.9%	20.9%	71.2
Using an electronic prescription system promote the use of data for research	2%	7%	91%
The electronic prescription system will provide an alert when the patient receives medication	3.3%	16.7%	80%
The electronic prescription system will improve alert about the drug	0	6.3%	93.7
The electronic prescription system will save time and reduce error	3%	18.2%	78.8%
The electronic prescription system will be safe	3.3%	18.2%	78.5%

Table 4 depicts the perceived readiness of the institution to implement e-prescription. Even though the majority of the participants agreed to accept e-prescription once it was adopted in the institution, 40% felt that the hospital firm cannot afford to get all physician’s computers. There was a compelling demand for infrastructure development and massive training in the Institution. Only 36.8% of the participants felt that the patient will be ready to adopt the e-prescription system.

Table 4

Perceived readiness of organization to implement e-prescription (N = 302).

Variable	Disagree(1+2)	Neutral(3)	Agree(4+5)
I think the hospital firm can afford to improve the internet network	19.5%	29.5%	51%
I think the internet network in the hospital is good	45.4%	16.2%	38.4%
I think the hospital firm can afford to get all physicians computer	40.1%	36.1%	23.8%
The hospital firm Can manage and be consistent with the system over a long time	22.2%	28.1%	49.7%
I think the hospital firm would be ready to adopt the new system based on the infrastructural facilities	25%	45%	30%
I think the patient will be ready to adopt the new system	15.8%	47.4%	36.8%

Factors associated with perceptions physicians towards electronic prescription

A total of 5 variables were selected as potential predictors for perception after bivariable logistic regression and entered into multivariable logistic regression. Variables included in multivariable logistic regression were the technical skill of physicians, internet access in the organization, gender, work experience and, perceived usefulness of the e-Prescription. The multivariable analysis of logistic regression pointed out the technical skill of the physicians, availability of internet access, perceived usefulness of the e-Prescription, and organizational factors as significant variables which were positively related to perception of physicians towards e-Prescription Table 5.

Table 5

Bivariable and multivariable logistic regression analysis of factors with perception among physicians at public health hospitals in Amhara region Northwest Ethiopia 2021(N = 302).

Variable	Perception, n (%)		Crude ORa (95% CI)	P value	AORb (95% CI)	P value
	Positive	Negative
Current computer usage
Yes	269 (89)	19 (.062)	3.86 (1–15.02)	.052	2.06 (0.51–8.31)
No	11 (0.04)	3 (.01)	1		1
Internet access
Yes	163 (54)	2 (.66)	13.846 (3.174–2.25)	.000	2.82 (1.75–4.50)	< .001
No	117 (38.7)	20 (6.6)	1		1
Technical skill
Yes	268 (88.7)	12 (3.9)	8.37 (2.8–25.21)		4.7 (1.27–17.41)	.002
No	16(5.3)	6 (2)	1		1
Perceived usefulness
Yes	265 (87.7)	16(5.3)	6.62 (2.3–19.3)		3.31 (1.01–12.12)	.041
No	15 (5)	6 (2)	1		1
Organizational factor
Yes	157(52)	7(0.23)	2.75(1.09–6.9)	.032	1.8(.66–5.07)
No	122(40.4)	15(5)	1	1

aOR: odds ratio.

bAOR: adjusted odds ratio.

Discussion

This study was conducted to assess physicians’ perceptions towards e-Prescription systems in the context of resource-limited hospitals. Insights were provided into the future successful implementation of the e-Prescription system since the perception of the user greatly affects it. The study was done among the prescribing doctors at public health hospitals, which have a high workload with a physician to population ratio of.0769/1000 [28]. The study revealed that almost all 89% perceive that paper-based prescription is prone to error and 84% of the respondents encountered refill demand due to the absence of data verification and validation in paper-based prescription.

The mean perceived usefulness and technical skill of physicians were 4±0.4, 3.9±0.45, respectively this result is slightly higher than the result 3.5 and 3.4 obtained in the prior study conducted in India [20]. This could be attributable to the time difference between the current study and the previous study, which was conducted five years earlier (2016). Physicians’ perceptions about e-prescription were found to be influenced by factors such as internet availability, perceived usefulness, technical skill, and previous computer-related training. In this study, more than two-third 76.5% (95% CI 71.5–81) of the study participants had a positive perception towards e-Prescription. This result is consistent with that of a study done in Jordan (74.7%) [27].

Different studies conducted on technology acceptance in different domains have suggested that Perceived usefulness is the main determinant factor for new technology acceptance and utilization [29-31]. The finding of the current study was consistent with these studies. The current study revealed that the perceived usefulness of the e-prescription system is positively associated with the positive perception of physicians 3.31(95% CI 1.01–12.12). The odds of physicians who thought the e-prescription system as useful to have positive perception is 3.31 times more likely than their counterparts. The possible reason for this could be that, as the user thought the system would be useful more likely to have a positive perception.

According to this study, physicians who were working in an institution with internet access (WiFi) were 2.82 times more likely to develop positive perceptions than those who had no internet access (AOR 2.82, 95% CI 1.75–4.50).

The majority of authors who conducted a study on electronic information systems acknowledge that users’ perception is more likely to be affected by their computer skills [17, 20, 31, 32]. The result of this study is consistent with those findings, this study revealed that physicians who had good technical skills were 4.7 times more likely to have a positive perception towards implementation of e-prescription than those who had poor technical skills (AOR 4.7, 95% CI 1.2717.41]).

This study summarizes the perceptions of front-line prescribers (physicians) as a pre-implementation assessment. Implementation of new information system greatly affected by Perception of front-line system users, as pre-implementation study the result suggests that implementation of e-Prescription would be successful within physicians’ perception perspective. Even though the study population corresponds to a usual proportion of prescribers in the institution a larger sample size would have yielded better results, further more if included perception of pharmacists and patients would have provided better insights.

Conclusion

The findings of this study showed that the positive perception of physicians towards e-Prescription was 76.5%. Good internet access, perceived usefulness of the e-prescription system, and the technical skill of the physicians were the most notable factors that were associated with a positive perception.

According to this study finding, the perception of the user has a significant impact on the successful implementation of an e-prescription system. To be successful in e-prescription system implementation, health care organizations should improve the computer technical skill of physicians’ providing training on digital device usage, and improve internet connectivity. As a limitation, the study was a cross-sectional which has inherited limitation of a cross-section study. In addition to this the sample size of the study was a little bit smaller. Furthermore, there might also be a possibility of bias towards young physicians. In addition to this the sample size of the study was a little bit smaller.

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5 Aug 2021

PONE-D-21-14066

Perception of physicians towards electronic prescription system and associated factors at resource limited setting 2021: Cross sectional study

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Reviewer #1: This paper talks about the Perception of physicians towards electronic prescription system and associated factors at resource limited setting 2021 using cross sectional study design. The idea of this manuscript was okay but the execution of the study wasn’t. The abstract is vague and condensed with extra information such as the method part. There is a lack of support from previous studies in introduction and discussion. It wasn’t clear how would the authors did the reliability test on such a yes/no type of questions! It seems they do the study in a hurry. The type of questions were driving the answer toward “yes” answer and seems there is a bias. Enormous amount of English mistakes grammatically and misspelling.

Reviewer #2: The adoption of e-prescription platforms is increasing worldwide and is already considered standard and mandatory in many countries. The usefulness and benefits of electronic prescriptions are well described, but the viability of its implementation, notably in less resourceful countries, still needs to be evaluated.

The authors conducted a well-designed questionnaire-based inquiry in an underserved area to evaluate the local physicians' perception of computer use and preparedness for e-prescription platforms implementation. However, there are some aspects of the manuscript that need critical, major, and minor revisions, concerning mainly scientific standards and methods description:

Critical (authors must provide data/modifications):

1) There is no mention of ethical committee approval and informed consent provided by subjects.

2) Data is not fully available (please upload to approved platforms and provide the links).

3) Methods should describe how the investigators sent/filled the questionnaires (web-based, paper, or other)

Major revision: (modifications needed for publication)

1) The questionnaire should be annexed as applied in its full version (translated from Amharic if needed).

2) With the complete questionnaire annexed, the description in the "methods" section can be rewritten with a more general description.

3) There are many types of e-prescription platforms. The authors need to describe what type of e-prescription is being asked about, such as:

- printed form with physical signature,

- printed form with verifiable digital code,

- electronic form sent directly to the hospital network pharmacy or central prescription portal,

- full electronic version (PDF) available for patients/physicians in web portals or send by e-mail,

- weblink or code sent by SMS/text platforms,

- need for verified digital signatures or public key certificates

Minor revisions:

- Grammar and writing style review

- Tables style review

Reviewer #3: The English language quality is generally good, but a small number of corrections are still needed.

The sample size computation is written in a somewhat confused manner and the software used for computation is not stated (it should be). Besides, a 10% non-response rate is overly optimistic. Moreover, it is my understanding that although the sample size was computed using a simple random sampling, whereas the sampling process was stratified. Conventionally scientists use 80% power (to detect a difference), rather an 80% sample. We have also doubts about the lottery system, because that would imply that the researcher already knows the name of all potential participants; if so, the authors should first explain how did they obtain the names (or other identification means) of all participants, so as to select 384.

The description of the questionnaire could probably be better replaced with a full copy of it annexed to the paper, and only a summary being described in the main text.

Apparently the study is underpowered, because the authors only recruited 302 respondents (despite the computed sample size of 384). Moreover, as mentioned above, the non-response rate was over 21% and not 10%.

“The mean age was 28+_3.6SD years with the majority of the age group were 25-34”. We tend to be skeptical of the representativity of the sample and of the correctness of the sampling process, because there seems to be a strong bias towards young doctors (as confirmed by the work experience of less than 4 years for almost 64% of the sample). It is very unlikely that the hospitals involved are working with 64% of their staff having less than 4 years of experience and only less than 8% having more than 6 years of experience. The authors should acknowledge this bias as a strong limitation, and avoid extrapolation to other settings or ages, for which the sample has little representativity.

Table 4: adjusted odds ratios values are reported, but there is no information on the models developed (only one? Several?) or the variables included in (each of) the models. Besides, p values should be reported even in the case they are larger than 0.05, and 0.000 should be replaced with p<0.001.

We are afraid that the interpretation of the 4.7 OR (“4.7 times more likely to have a positive perception…”) is erroneous and should be corrected (see this paper for an explanation of why: https://www.ncbi.nlm.nih.gov/pmc/articles/PMC5253299/)

Reviewer #4: Minor comments:

1. Please review manuscript carefully for grammatical errors and typos such as:

a. In abstract, 4th sentence should start as this study (and not Thus is study...)

b. In abstract, results first sentence: 76.5% should be outside bracket

c. Under methods section (Study design and settings), second sentence describing sample size, is 384 80% of total physician population? Current sentence indicates that 384 is 80% of total population in the region. Please correct.

2. Define medical error in introduction and include the most common medical errors observed in your region.

3. Even though perceived usefulness of electronic prescription was assessed, the questionnaire does not include a question regarding prior awareness of the physician about electronic prescription, how it works and its benefits. This is crucial question that needs to be used to understand any biases associated with their results.

4. the manuscript does not discuss potential pitfalls/shortcomings of the study. Please include this information.

Reviewer #5: PONE-D-21-14066

Perception of physicians towards electronic prescription system and associated factors at resource limited setting 2021: Cross sectional study

Reviewer’s Comment

General Comments:

Throughout the manuscript, there are numerous grammatical faults. It is strongly recommended that the work be edited by a native English speaker or a company that provides editing services.

Key words: The authors must ensure that the keywords are MeSH words and that they are in alphabetical order.

Introduction:

According to the findings of this study, 89 percent of participants believe that paper-based prescriptions are prone to errors, however the literature mentioned [6] reveals that paper-based prescriptions have been a favored communication method for many years for physicians.

Isn't it true that if a paper-based prescription is prone to drug errors, it shouldn't be preferred?

Several references have been provided discussing paper-based versus electronic prescriptions, but despite several studies conducted on the topic in various regions of the world, there is not a single source about physicians' perceptions of electronic prescriptions.

Methods:

Incorporating a formula for calculating sample size would be more useful.

A total of 17 referral hospitals were chosen, with each receiving a proportional allotment. What was the foundation for the proportional allocation and how was it done?

“Do you have legible handwriting?” was asked as a yes or no question to assess current prescription practice. I believe that observing written prescriptions rather than asking questions is a better way to evaluate this assertion.

Technical skill was assessed using questions like: do you think using a computer for an

electronic prescription would make your work more effective and accurate?, are you good at

operating a computer system?, Are you fast in responding to training on a new device? Are you

really motivated to pick up the new electronic prescription system (1. Strongly disagree, 2.

Disagree 3. Neutral 4. Agree 5. . Strongly agree). How might these types of questions be used to measure technical skills? For determining attitude or perception, likert scale questions are utilized.

More information on the expert panel (10 doctors), such as their qualifications, departments, and so on, should be included.

What necessary correction were done in questionnaire based on the pre-test finding?

Who gave two-days training for five data collectors) on the objective of the study and data

collection procedures? Who were the data collectors? How were their levels of education, experience, and other factors matched to ensure that the data they collected was uniform?

Please specify the number and date of the ethical approval.

Results:

Table 5 might be presented in a more appealing manner.

Discussion:

In light of the outcomes of this study, this area demands greater critique and clarity.

Conclusions:

Availability of data and materials: It is recommended that they be made available in the journal's repository.

References:

Check the journal's requirements for references and their citations in the article.

Reviewer #6: Comments to authors

1- This sentence in the abstract need to be revised Grammarly “ This medical error is even more serious in developing countries that lack a technologically supported healthcare system”

2- Please rewrite this sentence and organize it “ In Ethiopia because of the traditional paper-based

prescription system the overall medication prescribing error rate of 58.07%, in which incomplete

prescriptions and dosing errors were the most prevalent error types which could be prevented if there were an electronic prescription system”

3- I gave 2 examples of grammars errors I suggest to check all manuscript language to make the language more academic. There are several grammars errors the manuscript need to be checked Grammarly.

4- “ A study released in 2016 found that medical error is the third leading cause of death in the United States, after heart disease and cancer.” Please add reference after this sentence

5- “ the medical death rate” this phrase is not accurate I suggest called it medical errors related death rate

6- “ Medication errors are the leading causes of avoidable patient harm in the health care system across the world” add reference

7- “ the overall medication error in Ethiopia was found to be 57.6%” this sentence is not clear 57.6% from total prescriptions? Or from total medical errors or ….

8- “ Indeed, studies show significant improvements associated with e-prescription implementation, including an 86% decrease in serious medication errors, and an increase in Medicare formulary adherence from 14% to 88% [8].” Authors started with studies show… but only one reference was added

9- In study design and settings section, there are many unneeded details that can be shown in the questioner directly, I suggest to reduce the details about the survey and just refer the reader to the questionnaire in the supplementary files. Just summarize the domains of the survey

10- “ ethical clearance was obtained from the Debre Markos university ethical review board.” I suggest adding the number of ethical approval letter

11- In table 5, the p value of (Current computer usage) is not written

12- “ The study was done amongst the prescribing doctors at public health hospitals which has a high workload with physicians to population ratio of .0769/1000” I suggest change amongst to among. Additionally, I don’t know the meaning of numbers followed the sentence.

13- “ The finding of the current study was consistent with this studies” this sentence in discussion has grammar mistakes

Reviewer #7: This study aims to assess physician’s perception towards electronic prescription system implementation in Ethiopia. This study administered questionnaires to 384 physicians from several hospitals in certain regions in Ethiopia to gauge their perception of electronic prescription systems.

This work covers an interesting topic. Below I have a few minor comments

Minor comments

1. In the Introduction section, it is stated that “A study released in 2016 found that medical error is the third leading cause of death in the United States, after heart disease and cancer”. However, no citation is given.

2. In the future, I think it will be interesting to include some space in these questionnaires where physicians and others responding to the questionnaires can write (in their own words) some of their perception to electronic prescription systems. With this, the researchers conducting the study can check to see if there are any common themes and if these themes vary or are similar to some of the questions being asked in the questionnaire

Reviewer #8: The manuscript is well written with sound idea and presentation. All parts of manuscript are mentioned. Methodology is well explained with sample size and states applied. The questionnaire is not given separately, it must be given in the paper. Discussion is not enough for this paper. Discuss it with more references.

Reviewer #9: I thank the authors for the interesting manuscript and my comments are listed below

the title is clear with no edits needed

the abstract is has some grammar mistakes

the introduction has many comparative studies that needs to be moved to the discussion

suggest to be consistent when using decimals in %, in intro remove decimals

the intro is too long with un-necessary details

References need to be combined using reference management tool e.g. (10), (11), (12) to (10-12)

Methods

lots of grammar mistakes

sampling is confusing need to be clarified

what do you mean by reliability was it calculated after the pilot, you said that the expert physicians only reviewed it

was the survey paper base?

was the survey in English?

Results

total sample 302, was not mentioned in the abstract

why was the cut-off point in age was 30 years?

tables need more organization

I don't understand why the Likert scale in tables were combined? 1+2 and 4+5

the regression table could be presented in a different way, the current way is confusing

Reviewer #10: I think this manuscript has a merit but there are many comments that must be addressed. ‎

I have found some errors that should not be present at this level, for example there are 2 ‎references in bibliography but were missed in the next. ‎

The authors must read again the Author’ guidelines and fill all the requirements. ‎

The authors must proofread their work by an English language professional.‎

My specific comments are included in the PDF file.‎

Reviewer #11: The author carried out a cross sectional study on Perception of physicians towards electronic prescription system and associated factors at resource limited setting 2021. However the author needs to resolve the queries raised during review it.

1. A lot of grammatical errors present through out the manuscript. Author needs to check it by a native English speaker.

2. Why does the author select the physicians with age below 35? Need to clarify it.

3. Why the female participants were in a ratio of 25% of total participants (302).

4. What were the strength and limitations of this study must incorporate in conclusion section.

5. Author should include reference no. of ethical permission.

Reviewer #12: The submitted manuscript requires following rectifications in addition to language repeat:

1) The title may be revised "Instead of resource limited setting some proper wording may be placed.

2) In introduction first define the medical error, and then switch to the medication error.

3) Authors should also explain properly statistical out put.

4) While putting the p-value use zero before decimal and values after the decimal should be synchronous.

5) Place all the abbreviations in foot notes of the tables.

Reviewer #13: 1.0. The data presented may support the conclusion but there is much to desire and replicating this study would be a challenge

2.0 I have challenges with how the analyses were done and results were presented.

3.0 Did not see how some means were calculated

4.0. The presentation of some aspect especially the methodology found a huge cap there

Reviewer #14: The study topic itself is interesting from a health systems research perspective. However, several factors limit the enthusiasm for this manuscript. Firstly, the survey questions seem to elicit cross-sectional responses regarding uptake of and perceptions about e-prescribing and EHR use. The questions themselves do not appear to have been sufficiently tested. For e.g. ~90% respondents answered Yes to the statement "Paper prescription is prone to error" and about 70% responded that they like paper prescriptions while 79% responded that electronic prescriptions would reduce errors and save times. All three of these statements contradict each other. It is unclear to this reviewer what the general attitudes of this survey sample are and how accurately do they reflect upon behaviors. There is little mention of current trends in e-prescribing and the availability of systems at the various study sites. This needs to be clearly explained. Organizational factors such as administrative assistance technical help etc. are not addressed. The logistic regression seems inappropriate since the outcome variable is not measurable (perception). It is unclear how perception, the outcome variable was scored as 0/1/for the logistic regression on a 5-point Likert scale. The authors seem of to overreach in their analyses by stating that internet access had a positive perception. This statement doesn't mean much if the access is inconsistent. However, it is unclear since internet access and systemic factors are not well-described. The study has significant gaps in methodology and survey design and analysis.

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Reviewer #1: No

Reviewer #2: No

Reviewer #3: No

Reviewer #4: Yes: sandeep artham

Reviewer #5: Yes: Mukhtar Ansari

Reviewer #6: Yes: Abdullah Salah Alanazi

Reviewer #7: No

Reviewer #8: No

Reviewer #9: No

Reviewer #10: Yes: Salem Abukres

Reviewer #11: Yes: AHM Khurshid Alam

Reviewer #12: No

Reviewer #13: No

Reviewer #14: No

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2 Oct 2021

Here is a point-by-point response to the reviewers’ comments and concerns.

Comments from reviewer 1

Comment 1: It wasn’t clear how the authors would did the reliability test on such a yes/no type of questions!

Response: Thank for pointing out such comments, but most of the question in the study were Likert scale type, beside this reliability/validity test can be done for Yes or No type questions.

Comments from Reviewer 2

Critical comments by reviewer 2

Comment 1: There is no mention of ethical committee approval and informed consent provided by subjects.

Response: Thanks for the comment but we have already included this point under Ethical consideration section of the manuscript at page 8.

Comment 2: Data is not fully available (please upload to approved platforms and provide the links)

Response: We will provide all the data needed

Comment: Methods should describe how the investigators sent/filled the questionnaires (web-based, paper, or other)

Response: As it was already stated in method section page 7 the data was collected using self-administered questionnaire(data collector provided paper printed questionnaire for participants)

Major comments by reviewer 2

Comment 1: The questionnaire should be annexed as applied in its full version (translated from Amharic if needed)

Response: we have provided the questionnaire under annex section page but we the questionnaire wasn’t translated to in Amharic we used the English questionnaire as it is.

Comment 2: With the complete questionnaire annexed, the description in the "methods" section can be rewritten with a more general description.

Response: thanks for reminding us to revise this section we made the revision and highlighted the change.

Comment 3: There are many types of e-prescription platforms. The authors need to describe what type of e-prescription is being asked about

Response: Thank you for raising such important question, the type e-Prescription method asked about is an electronic form sent directly to the hospital network pharmacy.

Comments from Reviewer 3

Comment 1: Sample size calculation is not clear

Response: Thanks for the question again, to clarify the issue we used single population proportion formula to calculate the sample size. We took 50% because there was no previous study conducted in the study area.

Sample size (n) =((〖Z α⁄2)〗^2 x p(1-P))/d^2 , (n) =((〖1.96)〗^2 x 0.5(1-0.5))/〖(0.05)〗^2 = 384.2

Where;

n=estimated sample size

p=single population proportion (50%).

Zα/2 =is value of standard normal distribution (Z-statistic) at the 95% confidence level (α=0.05) which is 1.96,

d=is the margin of error 5% (0.05)

Comment 2: The authors should first explain how they obtained the names of all participants, so as to select 384.

Response: After the sample size was determined proportional allocation was made for each hospital and the names of the physicians was collected from HRIS office simple random sampling was made

Comment 3………authors only recruited 302 respondents (despite the computed sample size of 384). Moreover, as mentioned above, the non-response rate was over 21%andnot10%.

Response: Your point here is valid and acceptable, we agree that the statement in the result section which state” A total of 302 physicians were included” is a little bit confusing.

Here we mean that a total of 302 valid response were received from participant (Total of 367 response were received but 52 of the response were incomplete and the other 13 contains some personal identification like name of the physician so we discarded 65 responses), in addition to this there were 17 questionnaires which were not returned back. But we distributed 384 questionnaires

Comment 4…there seems to be a strong bias towards young doctors, the authors should acknowledge this bias as a strong limitation

Response: This is an important issue and we accept your point to some extent and we acknowledge the bias under limitation section in the revised manuscript. But there was undeniable reason behind this, as stated in the previous manuscript the study was done in two zones namely East Gojjam and west Gojjam which has 17 public hospitals (1 referral hospital, 2 General hospitals and 14 primary hospitals). So most of the study participants were from primary hospitals, and the minimum physician professional requirement of primary hospital in Ethiopia is general practitioner. That was the case.

Comment 5: adjusted odds ratios values are reported, but there is no information on the models developed (only one? Several?)..

Response: Thank for pointing out such critical point, we have mentioned that we done binary logistic regression and multivariable logistic regression but it lacks detail so we have included the detail under data processing and analysis section line 6 to 10.

Comments from Reviewer 4

Comment 1: Define medical error in introduction and include the most common medical errors observed in your region.

Response: Thank for suggesting this important point, we incorporated your suggestion in the introduction section line 5-7.

Comment 2: Even though perceived usefulness of electronic prescription was assessed, the questionnaire……

Response: Your point is valid but we have already collected the data, at this time we can’t include your suggestion. Beside this we have used perceived usefulness questionnaire from Technology acceptance model which doesn’t include previous experience questions.

Comments from Reviewer 5

Comment 1: According to the findings of this study, 89 percent of participants believe that paper-based prescriptions are prone to errors, however the literature mentioned [6] …………. Isn't it true that if a paper-based prescription is prone to drug errors, it shouldn't be preferred

Response: we agree that this needs clarification, the point here is before advancement of information communication technology physicians used to prescribe drug using paper printed forms which is prone to different errors. The article 6 in the manuscript shows the history drug prescription before the invention of e-Prescription. The article did not compare the paper based prescription method with e-prescription.

Comment 2: Incorporating a formula for calculating sample size would be more useful.

Response: Thank you this valuable suggestion we have incorporated sample size calculation formula in the revised manuscript in the method section line 8-16.

Comment 3: A total of 17 referral hospitals were chosen, with each receiving a proportional allotment. What was the foundation for the proportional allocation and how was it done?

Response: As you already mentioned there are 17 hospitals (1 referral hospital, 2 general hospitals and 14 primary hospitals). In order ensure the representativeness of the sample we used proportional allocation for each hospitals.

In order to show how proportional allocation done we provide an example below

One of these hospital is Debre Markos hospital which has 132 physicians, there are a total of 465 physicians and the sample size for this study is 384. So using proportional allocation

(Total number of physcian in Debre markos hospital(132)*Total sample needed(384))/(Total number of physcians in 17 hospitals (465))= 109 participants were selected from Debre Markos referral hospital.

This formula was used to allocate sample size for all other hospitals.

Comment 4: “Do you have legible handwriting?” was asked as a yes or no question to assess current prescription practice. I believe that observing written prescriptions rather than asking questions is a better way to evaluate this assertion.

Response: Yes it would be more appropriate if we observe rather than asking them, but as stated in the manuscript we used self-administered questionnaire to collect the data. That’s why we couldn’t observe their hand writing.

Comment 5: More information on the expert panel (10 doctors), such as their qualifications, departments, and so on, should be included.

Response : Thank you for this suggestion, based on your comment we have revised the document and your suggestion is included under the method section

Comment 6: What necessary correction were done in questionnaire based on the pre-test finding?

Who gave two-days training for five data collectors) on the objective of the study and data

collection procedures? Who were the data collectors? How were their levels of education, experience, and other factors matched to ensure that the data they collected was uniform?

Response: corrections like grammatical errors, order of the questions, were corrected.

The training were provided principal investigator, data collectors were Bsc health informatics professionals with two years of working experience.

Comment 7: Please specify the number and date of the ethical approval.

Response: This is incorporated in the revised manuscript.

Comment 8: It is recommended that data and material made available in the journal's repository.

Response: We will upload the data with revised document.

Comments from Reviewer 6

Comment 1: A study released in 2016 found that medical error is the third leading cause of death in the United States, after heart disease and cancer.”

Response: Thank you for reminding us we missed this reference, based on your comment the reference is added.

Comment 2: Medication errors are the leading causes of avoidable patient harm in the health care system across the world” add reference

Response: Thank you for reminding us we missed this reference, based on your comment the reference is added.

Comment 3: “ the overall medication error in Ethiopia was found to be 57.6%” this sentence is not clear 57.6% from total prescriptions? Or from total medical errors or ….

Response: 57.6% represents the total medical errors including drug administration and prescription.

Comment 4: “Indeed, studies show significant improvements associated with e-prescription implementation, including an 86% decrease in serious medication errors, and an increase in Medicare formulary adherence from 14% to 88% [8].” Authors started with studies show… but only one reference was added

Response: Thanks for the suggestion. It was editorial error and it changed to study.

Comment 5: In study design and settings section, there are many unneeded details that can be shown in the questioner directly, I suggest to reduce the details about the survey and just refer the reader to the questionnaire in the supplementary files. Just summarize the domains of the survey

Response: Based on your suggestion the questions were removed in summarised under Appendix section.

Comment 7: In table 5, the p value of (Current computer usage) is not written

Response: Of course it is not written. We left it black because current computer prescription was not a significant variable based on multivariable logistic regression. Its p value was >.05.

Comments from Reviewer 7

Comment 1: In the Introduction section, it is stated that “A study released in 2016 found that medical error is the third leading cause of death in the United States, after heart disease and cancer”. However, no citation is given.

Response: Response: Thank you for reminding us we missed this reference, based on your comment the reference is added.

Comments from Reviewer 9

Comment 1: what do you mean by reliability was it calculated after the pilot, you said that the expert physicians only reviewed it.

Response: Experts of physicians with different speciality reviewed the tool or the questionnaire before data collection. Beside that we have conducted pilot study outside of 17 hospitals, and reliability test were performed, it was found to be 0.78.

Comment 2: was the survey paper base? was the survey in English?

Response: Of course it was paper based and the questionnaire was in English language.

Comment 3: total sample 302, was not mentioned in the abstract

Response: Your point here is valid and acceptable, we agree that the statement in the result section which state” A total of 302 physicians were included” is a little bit confusing.

Here we mean that a total of 302 valid response were received from participant (Total of 367 response were received but 52 of the response were incomplete and the other 13 contains some personal identification like name of the physician so we discarded 65 responses), in addition to this there were 17 questionnaires which were not returned back. But we distributed 384 questionnaires. But the total sample was 384.

Comments from reviewer 11

Comment 1: Why does the author select the physicians with age below 35? Need to clarify it

Response: Thanks for asking as for the clarification, as we have already stated in manuscript under result section the majority of the age group were 25-34, but it doesn’t meant that all the participants are under the age of 35. There were participants with age of above 35. The majority of the age group were 25-34 because most of the study participants were from primary hospitals, and the minimum physician professional requirement of primary hospital in Ethiopia is general practitioner which is fresh graduate that tend to be younger.

Comment 2: Why the female participants were in a ratio of 25% of total participants (302).

Response: As you have said there are only 25% female participants. This the output of the data collected.

Comment 3: What were the strength and limitations of this study must incorporate in conclusion section.

Response: Thank you for the suggestion. We have incorporated your suggestion under “limitation of the study” section.

Comments from Reviewer 12

Comment 1: In introduction first define the medical error, and then switch to the medication error.

Response: Thank you for reminding us such an important point missed in the previous document, we incorporated the definition of Medical error under introduction section line 5 to 7.

Comment: While putting the p-value use zero before decimal and values after the decimal should be synchronous.

Response: That was an error and it corrected.

Comments from Reviewer 13

Comment 1: I have challenges with how the analyses were done and results were presented.

Response: Thank you for taking you time to review our paper. But your point here is too general, under method section we have stated how the analysis were performed, the software used and the model fitted. Please make sure that you raised specific that needs clarification so that we can address your comment.

Comment 2: Did not see how some means were calculated

Response: We will look forward for your specific question on which mean calculation need clarification, otherwise it is difficult to address this question.

Comment 3: The presentation of some aspect especially the methodology found a huge cap there

Response: Thank you, we have made some revision on the methodology section. But if you still have additional issue on the revision we look forward to give clarification for your comments.

Response for general comment from reviewer 14

…….90% respondents answered Yes to the statement "Paper prescription is prone to error" and about 70% responded that they like paper prescriptions while 79% responded that electronic prescriptions would reduce errors and save times. All three of these statements contradict each other

Response: Thank you raising such an important comment, we agree that the statement may contradict but the question are different someone may like paper prescription because it is easy and He/She has used it many years. In addition to this they may have no skill and ability to use e-Prescription. Due to these reason they like traditional paper based prescription, but doesn’t mean that this paper based prescription is not prone to error. They like it but they acknowledge its limitation.

The third question is under perceived usefulness of e-Prescription section that shouldn’t compared with the others.

The logistic regression seems inappropriate since the outcome variable is not measurable (perception). It is unclear how perception, the outcome variable was scored as 0/1/for the logistic regression on a 5-point Likert scale.

Response: Even though the original questionnaire was 5-point Likert scale we have transformed the data in to two category which 0 and 1 negative and positive respectively. Based this result logistic regression was performed.

…… stating that internet access had a positive perception. This statement doesn't mean much if the access is inconsistent. However, it is unclear since internet access and systemic factors are not well-described

Response Here we compared perception of physicians working at hospitals those have internet connection and those has no internet connection. Based on this the result revealed that physicians in organization with internet connection to develop positive perception. We haven’t considered other factors.

Submitted filename: Response to Reviewers.docx

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7 Dec 2021

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1 Jan 2022

Thank you for giving as the opportunity to submit a revised draft of my manuscript titled “Perception of physicians towards electronic prescription system and associated factors at resource limited setting” we appreciate the time and effort that you and the reviewers have dedicated to provide valuable feedback on the manuscript. We are grateful to the reviewers for their insightful comments on our paper. We have been able to incorporate changes to reflect most of the suggestions provided by the reviewers. We have highlighted the changes within the manuscript.

Here is a point-by-point response to the reviewers’ comments and concerns.

Comments from reviewer 1

Comment 1: The manuscript needs extensive English editing

Response: Thank for pointing out such a valuable comment, we have edited the manuscript accordingly.

Comments from Reviewer 3

Comment 1: They should have sent the questionnaires to 450-500 questionnaires in order to get a valid sample size of at least 384. As such, the inappropriate sample size should be acknowledged as one of the limitations of this study.

Response: Thanks for the comment based on your comment we have included this limitation under conclusion section of the manuscript line 10-11.

comments by reviewer 5

Comment 1: Keywords are still not in alphabetical order

Response: we arranged the key words in alphabetical order.

Comment 2: I am still not convinced with accessing current prescription practice through the question "do you have legible handwriting?

Response: Your point here is valid, but as we have mentioned in the method section, we used validated tools from the previous study conducted in India.

Comment 3: Proportional allocation of physician/hospital need to elaborate in the manuscript as well.

Response: Thank you for raising such important issue that we have missed; we have incorporated this in the method section of the revised document.

Comment 4: Ethical approval number and date need to be specified in the manuscript.

Response: we have included this revision under ethical consideration section.

In addition to the above revisions all grammatical and language usage style comment raised by the reviewers were addressed accordingly.

Submitted filename: Point by point response to the reviewer.docx

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5 Jan 2022

Perception of physicians towards electronic prescription system and associated factors at resource limited setting 2021: Cross sectional study

PONE-D-21-14066R2

Dear Dr. Hailiye,

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Dylan A Mordaunt, MB ChB, MPH, MHLM, FRACP, FAIDH

Academic Editor

PLOS ONE

Additional Editor Comments (optional):

Thank you for your resubmission. This now meets the criteria for publication.

Reviewers' comments:

10 Mar 2022

PONE-D-21-14066R2

Perception of physicians towards electronic prescription system and associated factors at resource limited setting 2021: Cross sectional study

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Dr. Dylan A Mordaunt

Academic Editor

PLOS ONE