Background
Electronic Patient Record (EPR) systems are being introduced in acute NHS Trusts as part of the National Programme for Information Technology.1 Once implemented, EPR systems are known to affect the work lives of staff within healthcare organisations, however this is a relatively under explored area. Consequently, we carried out a qualitative study to explore the effects of EPR on hospital pharmacy personnel. This paper focuses on the electronic prescribing aspects of the system.

Method
A multiple case study approach was used, with research carried out at four acute NHS hospital Trusts in England at varying stages of developing and implementing their EPR systems. Data were collected through one-to-one interviews, focus groups, observation in the role of participant as observer, and documentary analysis. Study participants were hospital pharmacy personnel with ward or dispensary based duties. Data were analysed using a constant comparison approach, which took account of a priori and emerging themes.

Results
Within the Trusts studied, a mixture of paper and electronic prescribing systems were in use. In both types of prescribing system, pharmacists were able to modify prescribed therapies. Paper-based prescribing systems were found to be well developed to support communication and coordination of medicines supply and clinical pharmacy activities, via the prescription chart itself, and through use of documentation, usually developed in-house. The electronic prescribing systems supported these activities to varying degrees. Where the system failed to 'fit' with working practices and communication channels, users held negative views about the system. In some instances specific related risks were identified in the prescribing process. For example, lack of clarity within an electronic system as to the stage at which the pharmacy had reached in the processing of a discharge prescription could lead to delays, duplication of work, and archiving of incorrect information in the patient's medical record.

Discussion
Within the literature, problems with 'fit' have been associated with system failures. 'Fit' can include, for example, the matching of technology and information needs with work flow, clinicians' levels of expertise, values and professional norms, communication patterns and organisational culture.2 In this study, poor fit with working practices had implications for both systems acceptance by users and safety. The electronic and paper systems studied, however, enabled pharmacists to modify prescription entries. Consequently, both system types fitted with the aspirations of pharmacists for an expanded clinical role and influence on prescribing. EPRs have been said to contain a representation of the activities of the healthcare professionals using them.3 These particular systems therefore formalise this aspect pharmacists' role in prescribing, and might be a tool to prompt further debate as to the roles of professional groups in hospital prescribing processes in the future.

References

1. Department of Health. Delivering 21st Century IT Support for the NHS. National Strategic Programme. 1-26. 2002.
2. Kaplan B. Evaluating informatics applications - some alternative approaches: theory, social interactionism, and a call for methodological pluralism. Int.J.Med.Inf. 2001;64:39-56.
3. Goorman E,.Berg M. Modelling nursing activities: electronic patient records and their discontents. Nursing Inquiry 2000;7:3-9.