Electronic prescriptions and disruptions to the jurisdiction of community pharmacists

Abstract

The practice of community pharmacists is being challenged by the appearance of electronic prescription (e-Rx) technology. This article examines the disruptions caused by e-Rx technology to the jurisdiction of community pharmacists based on a model developed from work by Abbott (1988). The main disruptions to professional activities were investigated by qualitative methods in a series of interviews with pharmacists and physicians separated in two groups: practitioners who tested a typical e-Rx technology and stakeholders involved in the implementation of this large-scale e-Rx project in Quebec, Canada. The findings suggest that the technology may disrupt the jurisdiction of community pharmacists, mainly by changing the distribution of information among physicians and community pharmacists. More specifically, the technology represents both a threat to community pharmacists – by supporting the dominant position held by physicians if it gives them access to information held exclusively by pharmacists – and an opportunity – by redistributing information to the pharmacists’ benefit, allowing them to improve the quality of their inferences about medication. However, it would appear that the opportunities offered by the technology generate concerns and tensions, both between physicians and pharmacists and between the pharmacists themselves. This phenomenon may well work against the implementation and use of available tools.

Introduction

Electronic prescription (e-Rx) technologies promise to improve the quality of drug utilization, particularly in outpatient settings, where patients use many drugs for long periods of time (Eslami, Abu-Hanna, & de Keizer, 2007). The term “e-Rx technologies” covers a range of functions, but it basically refers to the use of a computer-based tool to prescribe medication and electronically transfer the prescription to pharmacists (Wang et al., 2005). The technology makes it possible to combine the act of prescribing with a decision support tool, which proposes drug choices and consults the data in the patient record to alert the professional to any potential problems (interactions, allergies, etc.). In addition, the creation of a communication network allows caregivers to share clinical data such as the patient’s drug history. In recent years, the stakeholders managing health systems in many countries have invested considerable effort trying to attain more widespread use of these tools among health professionals. Despite these investments, e-Rx technologies are still not widely used in primary care, with the exception of some European countries such as Sweden, the Netherlands and the United Kingdom. For example, in the USA in 2009, only 12%–18% of all prescriptions written were sent electronically (Surescript, 2010).

In order to better understand the link between the introduction of an information technology (IT) and its use in practice settings, it is important to examine not only the technical challenges raised during implementation but also all the disruptions generated by the technology. The technology’s potential to disturb work and users’ roles exceeds deterministic forecasts, particularly in health, where professionals are constantly negotiating in order to stabilize the barriers between their respective jurisdictions. The sociological literature underscores how negotiating professional roles and respective territories represent a major challenge (Strauss, Schatzman, Ehrlich, Bucher, & Sabshin, 1963). The research in health has mainly examined physicians, due to their traditionally dominant status (Freidson, 1970, Nancarrow and Borthwick, 2005). This status may be tested or threatened through the efforts of other health workers (Charles-Jones et al., 2003, Hartley, 2002) such as nurses (Salhani & Coulter, 2009) and pharmacists (Weiss & Sutton, 2009) as they seek to expand their respective jurisdictions. Some researchers have examined how IT can disturb work and the jurisdiction of physicians (Berg, 1998, Heath et al., 2003, Mclaughlin and Webster, 1998), but very few studies have shed light on other professional groups. In medical informatics, some studies have examined the influence of IT on collaboration and coordination between physicians and other professionals, mainly in hospital settings (Aarts et al., 2007, Ash et al., 2007, Beuscart-Zephir et al., 2005). Few investigators have examined ambulatory care, where organizational boundaries are more vague and the contacts between professionals are less intense. In ambulatory settings, studies on e-Rx have mainly dealt with physicians’ perceptions of the technology, with the goal of achieving better implementations and more widespread use (Crosson et al., 2008, Hellstrom et al., 2009, Wang et al., 2009, Weingart et al., 2009). Overall, few researchers have investigated the effects of e-Rx on the work of community pharmacists (Astrand et al., 2009, Warholak and Rupp, 2009). Our study seeks to develop a better understanding of how an e-Rx technology disrupts the jurisdiction of community pharmacists by examining disruptions to the work of the physicians and pharmacists who are likely to use it. This issue is quite important, since community pharmacists try to consolidate their legitimacy as specialists in the use of medication by claiming new rights, such as the right to prescribe medication and adjust dosages in a treatment already underway (Emmerton et al., 2005, McKnight and Thomason, 2009). This study examines this unstable environment and attempts to identify the role that e-Rx may play in the transformations currently underway in community pharmacy.