them (71%, 522/739), promoted faster dispensing (58%, 425/ Tora Hammar et al.

101
739) and gave them a better overview of their medications
(59%, 433/739). Almost half (46%, 340/739) agreed that
elec-tronic storing of prescriptions contributed to a better
conver-sation with the pharmacist. To all of these
statements, a large proportion (19–29%) of the respondents
answered with ‘I do not know’ (Figure 6).
The vast majority of the respondents (86%, 633/739)
were positive towards electronic storing of prescriptions.
There was a relationship between attitudes towards elec-
tronic storing of prescriptions and respondents experience of
storing prescriptions (P  0.01). Of the respondents who
only had paper prescriptions about one third (35%, 16/46)
were positive, compared to almost all (96%, 434/450) of
respondents who stored all their prescriptions electronically
(Figure 7).
80
70
60
%onde
Resp
Attitudes towards mail-order prescriptions
Among respondents who had ordered prescription drugs via
the pharmacy home page, the majority agreed that order-ing
via the pharmacy home page was safe (86%, 18/21), created
benefits for them (95%, 20/21), was time-saving (90%,
19/21), was easy (86%, 18/21) and that the informa-tion they
received about their prescription drugs via the home page
was good (67%, 14/21). Among respondents who had
ordered prescription drugs via the pharmacy customer
service on telephone, the majority agreed it was safe (63%,
20/32), created benefits for them (59%, 19/32), was time-
saving (63%, 20/32), was easy (59%, 19/32) and that the
information they received regarding their prescription drugs
via telephone was good (56%, 18/32).
80

nts

50 70
40 % 60
30
onde
Resp

nts

50
20
40
10
30
0
1 Very 2 3 4 5 6 Very Don’t 20
Bad Good know
10
Figure 5 How the respondents with different experiences of storing 0
prescriptions regard e-prescriptions all in all, on a six-point Likert-type 1 Very 2 3 4 5 6 Very Don’t
rating scale. Missing answers are not reported in the figure. ( ) Store Bad Good know
all prescriptions electronically; ( ) Store some prescriptions
electronically; ( ) Only have paper prescriptions; ( ) Have not Figure 7 How the respondents with different experiences of storing
received any iterated prescriptions. prescriptions regard the possibility to store prescriptions electronically,
on a six-point Likert-type rating scale. Missing answers are not reported
in the figure. ( ) Store all prescriptions electronically; ( ) Store some
prescriptions electronically; ( ) Only have paper prescriptions; ( )
Have not received any iterated prescriptions.

Figure 6 The respondents’ degree of agreement with five positive statements regarding electronic storing of prescriptions on a six-point Likert-type
rating scale. Missing answers are not reported in the figure. ( ) 1 Not agree at all; ( ) 2; ( ) 3; ( ) Don’t know; ( ) 4; ( ) 5; ( )6
Completely agree.
102 Journal of Pharmaceutical Health Services Research
In the entire study population (739), only 10–16% agreed
on the same positive statements about ordering via the phar-
macy home page, or ordering prescription drugs via the
phar-macy customer service on telephone. The vast majority
of the study population (79–86%) answered with ‘do not
know’, or did not answer at all.
Received information about e-prescriptions
and electronic storing of prescriptions
The majority (62%, 456/739) of the respondents regarded the
information about e-prescribing they received from prescrib-ers
as good, but 21% (158/739) of the respondents regarded this
information as bad. A majority (58%, 430/739) perceived the
information they received from the pharmacist the first time
they were informed about electronic storing of prescrip-tions as
good, and 18% (136/739) perceived it as bad.
Suggested improvements
The most common suggestion (n = 27) for improvement was to
extend the information given about the services. The sought for
information included information about how to use the services,
and the safety in using them. The suggestions on how to spread
the information included information via media, the pharmacy
home page, brochures and information from pharmacist or
prescriber. One of the most common sug-gestions for
improvement was improved availability of cus-tomer service (n
= 10), for example longer phone hours and shorter waiting times
to get through to the telephone operator. Two of the most
common comments were that the respon-dents had limited
experience with the services (n = 26) and that they do not have a
computer (n = 10).
In total, 136 respondents (18%, 136/739) answered in free
text; however, 24 answers were unrelated to the question and
were excluded, for example comments about waiting times,
personnel or stock holding at their local pharmacy and clari-
fying information about their answers to others parts of the
questionnaire. The remaining 112 answers included 143 com-
ments or suggestions, giving 1.28 comments or suggestions per
free-text answer. See Table 2 for the most common free-text
answers, and improvements suggested by the patients.
Discussion
We found that Swedish patients generally had a positive atti-
tude towards e-prescriptions as well as electronic storing of
prescriptions. A majority affirmed that e-prescriptions and
electronic storing of prescriptions was safe, created benefits and
promoted faster dispensing. The results also revealed age
differences in attitudes towards e-prescriptions, with the age
group 25–39 years having the most positive attitudes and the
age group over 75 having the least positive attitudes. An even
stronger correlation was shown between the respondents’
experience of storing prescriptions in the Online Prescription
Repository and their attitudes towards both e-prescriptions and
electronic storing of prescriptions, where more experi-enced
patients generally were more satisfied.
The study also indicates that Swedish patients still have
limited experience related to specific mail-order related ser-
vices such as ordering prescription drugs via pharmacy home
2011; 2: 97–105
Table 2 Suggestions for improvements and comments about e-
prescriptions, electronic storing of prescriptions and services related to
mail-order prescriptions
n Percentage*
Suggestions
Extended information regarding the services 27 18.9
Improved availability (e.g. extended phone 10 7.0
hours)
Make it easier to keep track of electronically 7 4.9
stored prescriptions
Confirmation of prescribed medications from 7 4.9
doctor
Improved history of e-prescriptions 4 2.8
Increase reliability of technique 4 2.8
Clarify freedom of choice between electronic 2 1.4
storing and paper prescriptions
Comments
Have limited experience with services 26 18.2
Satisfied 15 10.5
Have no computer 10 7.0
Prefer the traditional paper prescriptions 6 4.2
Worse integrity 3 2.1
Other comments or suggestions 22 15.4
Total 143 100
*Percentage of the total amount of suggestions or comments regarding
the topic (n = 143).
page or via customer service on telephone. This was obvious
since only a minor part of the respondents could answer the
questions concerning these specific services. However, the
respondents who possessed these experiences mostly
answered that it was safe, created benefits for them, was
time-saving, was easy and that the information they received
regarding their prescriptions was good.
The study population was randomly selected from indi-
viduals storing prescriptions in the Online Prescription
Repository, which corresponds to about 65% of the Swedish
population. Since not all Swedish patients necessarily have
prescriptions stored electronically this prevents the study
population from being representative for all Swedish patients.
This method was chosen to include a study population with at
least 4 months experience of electronic storing of prescrip-tions.
However, a significant proportion of the respondents reported
that they did not have any prescriptions stored electronically,
which can have several reasons; respondents not recalling
having prescriptions stored electronically or not understanding
what electronic storing of prescriptions is, respondents not
realizing that an e-prescription has been transmitted from doctor
or respondents who have ceased electronic storing after our
selection process. In addition, we cannot rule out that someone
other than the individual to whom the questionnaire was
addressed, may have answered the questionnaire. The number of
questionnaires analysed was relatively large, increasing the
reliability of the results. However, the non-response of 48%
results in a risk of biased results. We tried to minimize the risk
of our results being biased towards more computer friendly
respondents by using a postal questionnaire instead of a web-
based questionnaire.
The most common suggestion for improvement of e-
prescriptions, electronic storing of prescriptions and mail-
Survey of e-prescribing in Sweden
order prescriptions, was extended information about the dif-
ferent services. Several respondents commented about not
having a computer, which might reflect a misunderstanding
or lack of information. To receive an e-prescription or to
store prescriptions electronically there is no need for the
patient to personally have a computer or experience using
computers. Some individuals might reject and instinctively
oppose the word ‘electronic’, and think of it as something
complicated. In the questionnaire, a significant proportion of
the respondents answered with ‘I don’t know’, mainly for
questions about specific mail-order services. These findings
further support the need for extended information and
education to patients about the available services.
When e-prescribing and electronic storing of prescriptions
gradually have been implemented in numerous outpatient and
inpatient ward and hospital settings and all Swedish pharma-cies
during the last decade the participation has not been an active
choice for patients. The patients have in most cases passively
accepted when prescribers have electronically trans-mitted an e-
prescription instead of giving them a handwritten prescription.
Furthermore, nowadays the vast majority of prescriptions in
Sweden are automatically transmitted to the Online Prescription
Repository. The patients can then opt out if they do not want to
have their prescriptions stored electroni-cally. This
implementation model has probably caused the use and
acceptance of e-prescriptions and electronic storing of
prescriptions to pass a critical mass faster than an opt-in model.
However, it might result in less-informed patients compared to
an implementation model where the patients make an active
choice in each prescription situation. The use of specific mail-
order prescription services (i.e. use of pharmacy home page or
customer services via telephone) is, in contrast, active choices
which may explain the slower adoption and limited experience
with these services.
To further increase the acceptance and satisfaction with e-
prescribing services more information and education to
patients is important, as satisfied patients are more likely to
comply with treatment and take an active role in their own
health care.[29,30] In addition, prescribers should always
clearly state to patients when they give them an e-
prescription to avoid unintentional nonadherence.
The respondents’ most common comment to the free-text
question was limited experience with the services. A study of
perceptions among geriatric patients regarding e-prescriptions
support our findings of a correlation between experience and
attitude.[40] However, from our study we cannot draw any
conclusion about the causality in this relationship; that is, if
more experience in fact results in a more positive attitude, or if
it is a negative attitude to begin with that leads to a decreased
likelihood for patients to try e-prescribing services.
Previous studies have concluded that both prescribers and
pharmacists in Sweden are satisfied with e-prescribing, and
consider it to be safe and time-saving.[3,12,13,41] In addition,
several studies from different countries support that pres-cribers
and pharmacists have a positive attitude towards e-
prescribing.[4,13,16,18,20,26,42,43] The results from these attitude
studies concerning e-prescribing have some support in other
types of study.[5,6,17,19] However, there are also studies showing
conflicting results, for example e-prescribing as more time-
consuming compared to handwriting, e-prescribing resulting
Tora Hammar et al. 103
in more errors compared to handwritten prescriptions and e-
prescribing systems facilitate medication error risks.[44–46]
Fewer studies have been directed towards patient attitudes.
Lapane et al. studied geriatric patients’ perceptions regarding e-
prescriptions and concluded that patients may require more
education to appreciate the value of e-prescribing.[40] In a recent
study, Duffy et al. demonstrated high patient and pro-vider
satisfaction after the implementation of e-prescribing.[43]
Montelius et al. showed that Swedish patients appreciate having
access to their prescriptions online.[33]
The present study shows that the Swedish patients have
similar opinion as Swedish physicians and pharmacists
regarding e-prescribing, as the majority of patients seem to
be satisfied with e-prescribing. Since the e-prescribing
process in Sweden is accepted and appreciated by the vast
majority of users, the implementation of e-prescribing in
Sweden can be considered as successful. However, different
studies of the Swedish e-prescribing system have also
revealed weaknesses with e-prescribing, implying an
ongoing need for improvement.[2,3,12,13,47]
Further research and studies of the Swedish e-prescribing
processes are warranted, aiming to follow the evolution,
quality of processes and attitudes by patients, pharmacists
and prescribers.
Conclusions
Our nationwide survey showed that a majority of Swedish
patients had positive attitudes towards e-prescriptions and
electronic storing of prescriptions, but that there was a minor
part having a negative attitude. Our results also indicated
that patients with more experience of e-prescribing had a
more positive attitude compared to those with less
experience. In addition this study revealed differences in
attitudes between age groups.
Several studies have shown that prescribers and pharma-cists
value e-prescribing and perceive advantages with the new
technology compared with the traditional handwritten pre-
scriptions. This study adds information that not only the pro-
fessionals, but patients as well, are satisfied with e-prescribing.
In conclusion, this study showed that the implementation
of e-prescribing in Sweden has passed its critical mass and
has become accepted and appreciated by the vast majority of
patients. Even though the implementation as a whole can be
regarded as very successful there is still need for improve-
ments, especially concerning information and education to
users.
Declarations
Conflict of interest
During the study, three of the authors (SN, BÅ, TR) have
been employed by the National Corporation of Swedish
Pharmacies (Apoteket AB).
Acknowledgements and funding
We thank the National Corporation of Swedish Pharmacies
(Apoteket AB), eHealth Institute, County Council of Kalmar,
Regional Council of Kalmar, Municipality of Kalmar and the
Linnaeus University who together have supported this study.
104 Journal of Pharmaceutical Health Services Research 2011; 2: 97–105