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Abstract
Background The state of digitalisation in the healthcare sector in Switzerland is lagging, even as the national electronic health record (EHR) is being gradually implemented. Little is known about the implementation of electronic prescribing systems, their auxiliary features or drug datasets in Swiss hospitals.
The aim of this study was to understand which electronic systems are implemented to support doctors in Swiss hospitals during the medication prescribing process.
Methods The survey was sent in spring 2021 to the chief pharmacists of the main Swiss hospitals. The survey focused on the introduction of the EHR, the clinical information system (CIS) and its prescribing module, as well as drug information data and clinical decision support systems (CDSS).
Results The response rate was 98% (58/59 hospitals). Almost half of the hospitals (47%) were connected to the national EHR, almost all hospitals (86%) used a CIS and a vast majority of the hospitals (84%) had implemented electronic prescribing systems in their CIS. 10 years ago, around 63% of hospitals used a CIS and 40% were equipped with an electronic prescribing system. Today, CDSS of any kind were implemented in 50% of the hospitals, predominantly for drug-drug interactions. Drug master data were maintained in most hospitals (76%) via an automated interface, but mostly supplemented manually. Clinical drug information data were maintained in 74% of hospitals. In 67% of hospitals, datasets were imported via an automated interface.
Conclusions The digitalisation of the medical prescribing process in Swiss hospitals has progressed over the last decade. Drug prescriptions via electronic prescribing systems were introduced in most hospitals. However, this survey suggests that the current use of CDSS is far from exhausted, and that clinical drug information data could be maintained more efficiently. Optimising electronic support for healthcare professionals during the prescribing process still has considerable potential.
- Medical Informatics
- MEDICATION SYSTEMS, HOSPITAL
- PHARMACY SERVICE, HOSPITAL
- Safety
- CLINICAL MEDICINE
- Quality of Health Care
Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
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- Medical Informatics
- MEDICATION SYSTEMS, HOSPITAL
- PHARMACY SERVICE, HOSPITAL
- Safety
- CLINICAL MEDICINE
- Quality of Health Care
WHAT IS ALREADY KNOWN ON THIS TOPIC
Ten years ago, around 63% of Swiss hospitals used a clinical information system, while 40% had implemented an electronic prescribing system. The digitalisation of the Swiss healthcare system is progressing slowly and is performing weakly in international comparison.
WHAT THIS STUDY ADDS
There is currently little information available about the number and types of electronic systems and clinical drug information in Swiss hospitals. This study provides an overview of the electronic systems and data supporting the electronic prescribing process. It also illustrates the effort required to digitalise the hospital system in a federalist healthcare system.
HOW THIS STUDY MIGHT AFFECT RESEARCH, PRACTICE OR POLICY
Implementing standardised clinical drug data and decision support systems will optimise the digitalisation and safety of the electronic prescribing process.
Collaboration among hospitals and other care providers may enhance the quality of clinical drug data, save time and costs and, ultimately, improve patient safety. Knowing the current status of digitalisation of drug prescribing in Swiss hospitals may motivate stakeholders to close the gap.
Introduction
In international comparison, Switzerland’s healthcare system performs well overall.1 It is therefore astonishing that the state of digitalisation in the healthcare sector is lagging in comparison with other countries and other industries.2 According to the Digital Health Index of the Bertelsmann Foundation, Switzerland ranks with 41 points (mean 59, maximum 100) on the fourth last place among the 17 countries studied.3 The analysis included 13 EU countries, Australia, Canada, Israel and Switzerland. The first overall ranks are occupied by Estonia (82 points), Canada (75), Denmark (73), Israel (72) and Spain (71). Successful countries share a triad of effective strategies, political leadership and a firmly anchored institution to coordinate the digitalisation process. In this way, the leading nations are already further advanced than Switzerland in various areas. Prescriptions, for example, are already transmitted digitally as a matter of course, and patients’ most important health data are stored in digital files. Furthermore, patients can view their examination results, medication plans or vaccination data online, and they decide who can have access to their data.3
In Switzerland, higher-level cooperation among stakeholders is difficult due to complicated political constellations and the strong federalism that also shapes the healthcare system.3 The fragmented system across the cantons with little national leadership becomes a challenge for various players. For example, the introduction of the Swiss electronic health record (EHR) was originally scheduled for April 2020.4 Even as of the beginning of 2022, the infrastructures for the comprehensive use of file exchange via the various decentralised platforms were not comprehensively available; a stepwise introduction is foreseen.4 5 Therefore, only few patients have been able to open an EHR until now. Even if any questions for healthcare providers were answered during the past two years,5 6 more usability regarding authorisation, alignment with clinical processes and diagnosis, and medication lists are demanded as essential patient information within the EHR.7
In this challenging environment, hospitals, among other healthcare providers, are making their own attempt to digitalise these various processes, both at the interfaces between the outpatient setting and the hospital and within the hospital itself. One of the most important and complex processes concerns medication. This includes drug therapy decisions, medical prescribing process, drug preparation and administration and drug therapy monitoring in the clinical setting, but also logistic and administrative aspects. The prescribing process can be supported by an electronic tool, which may include clinical decision support systems (CDSS) to provide healthcare professionals with support or specific alerts. Furthermore, an electronic prescribing system usually contains information such as drug master data (eg, product names, active ingredients, amounts, concentrations), and when more expertise is provided, clinical drug information is included in these systems.
Today, we know little about the digitalisation of the prescribing process in Swiss hospitals in general and even less about their related features, the use of CDSS and the maintenance of different drug datasets. The focus of this study was to find out which electronic systems are implemented to support doctors in Swiss hospitals during the medication prescribing process and what progress has been made in this area in the last decade.
Methods
The cross-sectional survey focused on the introduction of the EHR, the clinical information system (CIS) and its prescribing module and interfaces as well as the possibilities relating to CDSS and drug master data. The online tool Findmind (www.findmind.ch) was used for data collection. Participants were all chief pharmacists who were members of the Swiss Association of Public Health Administration and Hospital Pharmacists (GSASA). The link to the online questionnaire was sent to the participants via email with up to two personal reminders. Data were collected from March to May 2021.
The questionnaire (online supplemental material 1) was developed by five members of the working group ‘information systems’ of the GSASA. Questions were derived by reusing part of the former questionnaire (2011)8 and by panel discussions of the five members of the working group. Whenever appropriate, an answer selection was provided and/or multiple responses were possible. The possibility of giving a personal response was provided in case the selection was not sufficient. Depending on the response, participants were proposed additional follow-up questions, so that irrelevant questions were skipped (eg, hospitals without a CIS were not asked about CIS manufacturers). Responding to the relevant questions was a requirement to submit the survey, therefore there were no missing data. Participants were able to make use of an additional comment field for many of the questions. This study was reported in accordance with the Checklist for Reporting of Survey Studies (CROSS).9
Supplemental material
Results
The response rate was 98% after the second reminder, 58 out of 59 chief pharmacists completed the questionnaire. Most participants were from general hospitals (n=49, 84%) and nine from specialised hospitals (psychiatry, children, trauma, ophthalmic and rehabilitation). In total, the institutions comprised hospitals with >25 000 beds, of which 21 069 were acute and 4083 were long-term beds corresponding to almost total coverage. The number of inpatient beds of all Swiss acute care hospitals (as of 2020) was given as 22 678.10 A summary of the survey results is also provided as a table in online supplemental material 2.
Supplemental material
Electronic health record
Half of the respondents (n=27, 47%) stated that the hospital was connected to parent organisations of the EHR, 17 (29%) were planning to do so, and 14 (24%) were not yet planning to connect. Out of the 28 (48%) institutions with an EHR, 20 (34%) were connected to xsana, five (9%) to Cara, two (3%) each to Abilis AG and eHealth Aargau and three (5%) to other decentralised platforms (eSANITA, Mon Dossier Santé, Stammgemeinschaften Schweiz AG).
Clinical information systems
Almost all hospitals (n=50, 86%) had implemented a CIS, while in three hospitals only a patient data monitoring system (PDMS) was in place, and five institutions did not implement a CIS until now. Of the 50 hospitals with a CIS, seven did not implement it over the whole organisation. According to the survey in 2011, only 19 of 30 hospitals (63%) had introduced a CIS, but fewer hospitals were surveyed.8
Figure 1 shows the distribution of the various CIS in Swiss hospitals. Fifteen different CIS were in use, with two CIS (KISM from CISTEC and CGM Clinical from CompuGroup Medical) covering almost half of all hospitals. Compared with the answers 10 years ago, the number of hospitals with CIS from KISIM increased from three to 13, the number of hospitals with the CIS from CGM (formerly known as Phoenix, now CGM Clinical) increased from eight to 11, and Soarian (from Cerner) was not even in use (it is today in four hospitals). Twelve hospitals stated that a change of their CIS was planned, and another five were currently evaluating a possible change. The reasons for a change were diverse (eg, user dissatisfaction, CIS being taken out of trade, etc).
Clinical information system (CIS) in Swiss hospitals (n=49) by different providers. Among ‘other CIS’ different CIS are summarised which are used by one hospital each: Cariatides (GIP Symaris), DPI (Geneva University Hospitals), EPIC (EPIC), Meona (Meona), Polypoint (Polypoint), power Medstat (Sinap), GECO (EntE Ospedaliero Cantonale).
Of the hospitals surveyed, 49 (84%) had an intensive care unit and/or an anaesthesia department, 33 (57%) of which had a PDMS. The question on whether the PDMS and the CIS were connected by an interface was answered positively by 13 hospitals and negatively by 19 hospitals, while 11 answered that they did not know.
Electronic prescribing systems
Forty-nine (84%) hospitals with a CIS had implemented an electronic prescribing module. This means that almost all hospitals working with a CIS also had an electronic prescribing system implemented. Most institutions worked with the prescribing module provided by the CIS itself (n=42, 86%); however, in seven institutions another electronic prescribing system was used. In 2011, only 40% (n=12/30) of the hospitals were equipped with an electronic prescribing system.8
In a further question on the electronic prescribing module, it was ascertained whether the users prescribed via the active substance and/or the commercial product. Almost all systems (n=47/49, 96%) allowed the prescription by the commercial product, eight (16%) also provided a prescription by the active ingredient and two (4%) prescribed only by active ingredient.
Another topic of interest was which competencies were given to pharmacists and nurses in the electronic prescription tools. In 17 (35%) of the 49 hospitals using an electronic prescribing system only doctors were allowed to prescribe drugs; however, in 32 institutions certain rights were given to pharmacists or nurses. In 24 of these 32 institutions, internal guidelines regulated the corresponding competencies. Nurses were allowed to prescribe new drugs without any approval by a doctor in nine hospitals and pharmacists were allowed in three. In 20 hospitals, nurses were permitted to prescribe new drugs after doctor consultation, while pharmacists had the same permission in 11 hospitals. No rights concerning new prescriptions were given to nurses in three of these 32 hospitals with defined rights (eg, after doctor consultation) and to pharmacists in 15 hospitals. Changes of drug prescriptions were made in four hospitals by nurses and in six by pharmacists without approval by the doctor. Concerning any documentation in patient records, 26 (53%) out of 49 Swiss hospitals with an electronic prescribing system did not give pharmacists such permissions.
Clinical decision support systems
CDSS had been implemented in 29 (59%) of 49 hospitals with electronic prescribing systems and were planned in 10 others. Drug-drug interaction tools (n=21) were the most commonly used CDSS, followed by duplicate medication alerts (n=14) (table 1). Among CDSS, specific alerts (eg, aminoglycoside in patients with renal insufficiency or specific overdoses) were also provided in 12 hospitals. Alerts were directed to doctors (n=7), pharmacists (n=6) or nurses (n=1). The development of specific alerts usually took place in an interprofessional team. For eight alerts, the CIS manufacturers together with pharmacists or doctors were involved.
Implemented clinical decision support systems (CDSS) in Swiss hospitals, N=77
Drug information data
As a basis for electronic prescribing, the availability of structured drug information data is crucial. Prescribing systems should provide drug master data (eg, lists of active ingredients or products) and clinical drug information (eg, dose adjustments in renal failure, drug divisibility) that may support doctors during the prescribing process. Overall, 50 (86%) of the 58 hospitals surveyed stated that they maintained drug master data or structured clinical drug information; in hospitals with electronic prescribing systems, the proportion (n=46/49, 94%) was even higher. In 44 (76%) hospitals, drug master data were obtained via an automated interface (eg, a webservice). However, 38 (66%) hospitals indicated that they additionally maintained their own drug master data. Three hospitals answered that they maintained their drug master data entirely manually. Concerning clinical drug information, 44 (76%) hospitals maintained data on this. In 40 (69%) hospitals, clinical drug information was imported via an automated interface; in 39 (67%) hospitals, data via interface were supplemented manually and in four (7%) hospitals these data were completely manually maintained. The maintenance of clinical drug information was mainly done in the CIS, and to a smaller extent in third-party systems. Figure 2 shows how many hospitals maintained specific clinical drug information. Clinical drug information was maintained by pharmacists in 68%, by doctors in 18% and otherwise by medical informatics specialists (6%) or other professionals (8%).
Swiss hospitals (n=58) maintaining specific structured clinical drug information
Discussion
In this survey, nearly all relevant Swiss hospitals provided a comprehensive insight into their current state of digitalisation of the medical prescribing process. About half of the hospitals were already connected to the EHR, which allows secure exchange of relevant documents among healthcare providers after patient permission. Even if only unstructured medication information is currently available in the EHR, the structured medication card document (a list of the current medication) will follow in future. The mapping of the medication process in the EHR is the ultimate goal, but because of the complexity and the clarification of the interoperability between the different platforms, it remains a huge challenge.5
One of the conditions for the subsequent exchange of medication data across the individual healthcare providers is the implementation of a CIS with an electronic prescribing tool in the hospitals. Comparing the data of this study with a survey performed 10 years ago,8 the proportion of hospitals with a CIS increased from 63% (19/30 hospitals) to 86% (50/58 hospitals). Another survey of 26 participating Swiss hospitals performed in early 20202 found a rate of 72% of hospitals with implemented CIS. This matches the findings in this survey, which suggest a positive trend in CIS implementation. The fact that the proportion of hospitals with an electronic prescribing tool has even increased from 40% (12/30 hospitals)8 to 84% (49/58 hospitals) within 10 years is encouraging.
A study by Hartel et al 11 showed that the introduction of electronic prescribing systems made handwritten prescriptions and possible misinterpretations due to incompleteness, illegibility and wrong transcription impossible. Furthermore, electronic prescribing can be assisted with drug master data and structured clinical drug information. Although the majority of Swiss hospitals used drug master datasets by an automated interface, two-thirds of the hospitals added further data manually; for example, for imported or compounded products. The consequences of such supplemented data must be carefully considered throughout the entire medication process. For example, manually added products may not be used in the drug-drug interaction check and will result in a false sense of security. Since two-thirds of the surveyed Swiss hospitals maintained their own clinical drug data, the question arises whether multi-hospital projects could lead to resource savings and possibly also to better data quality. Moreover, since the commercial dataset only focuses on labelled data, the availability of off-label data is limited despite being highly relevant for the daily clinical practice. The GSASA has addressed these issues and implemented a first dataset on divisibility and crushing of drugs,12 including off-label data. Another important topic concerns data on preparation and administration of parenteral drugs that are often missing in the package insert. However, despite the success of the first clinical drug information dataset, acquiring funding for collection of new data and even maintenance of existing datasets is a challenge for the small professional society. However, financing by the Swiss government was achieved by a legislative adaptation for paediatric dosing data, which resulted in the database SwissPedDose.13 Global initiatives concerning standardisation of drug data are expected to provide healthcare providers in the future with structured and interoperable data. ISO IDMP (Identification of Medicinal Products) standards are implemented step by step by the European Medicines Agency.14 Consequently, authorisation holders must enter the summary of product characteristics in a structured form.
Even though progress regarding the digitalisation of the medical prescribing process in Switzerland is clearly evident over the past 10 years, the use of digital solutions seems to be far from exhausted. CDSS in particular can reduce medication errors and improve patient safety.15–18 Today, only 36% (n=21/58) of all surveyed hospitals check medications routinely using a drug-drug interaction tool during the prescribing process. According to an inventory of CDSS in 2011, 16% (n=12/73) of surveyed Swiss hospitals had implemented a drug-drug interaction tool.19 Today, 64% (n=37/58) of Swiss hospitals still prescribe without such an automated alert. Whether these hospitals check the medication list in separate, from the prescribing process disconnected drug-drug interaction tool or whether the potential drug-drug interactions simply are not checked lays beyond the authors’ knowledge. Not checking medication for drug-drug interactions would no longer meet today’s standards and would compromise patient safety. Further CDSS (eg, dose adjustment in renal insufficiency, medication appropriateness in case of pregnancy or lactation, dose checks for paediatric patients) are used only in a minority of hospitals. Of course, there are challenges to overcome during implementation of CDSS into the drug prescribing process. Fragmented workflows, inappropriate alerts, impact of user skill, poor data quality, lack of interoperability and financial challenges are among the main pitfalls of CDSS.20
Comparison with other countries concerning the state of digitalisation of the drug prescribing process is difficult since data are sparse or not up to date. It is pertinent that two of today’s leading EU countries concerning digitalisation in healthcare, Denmark and Estonia, already used the electronic prescribing process routinely in 2013.21 In the US, a survey conducted by the American Society of Health-System Pharmacists in 2016 found that 99% of hospitals used EHR and electronic prescribing systems.22 Furthermore, it was estimated that in 2017 41% of US hospitals with an EHR also had an CDSS, while 40% had advanced CDSS capability.20 Endorsement by the government and financial incentives seem to be essential for implementation of EHR, electronic prescribing systems and CDSS.20 Furthermore, national institutions are mostly mandated to promote technical and semantic interoperability in the most advanced countries.3 In Switzerland, funding by the government is limited to the implementation of the EHR platforms. Investments for implementation of electronic systems in hospitals, pharmacies and doctors’ practises is at full expense of the healthcare providers. No reimbursement system for the use of medical applications for patients or professionals is foreseen as yet. Germany, which is ranked sixteenth, behind even Switzerland, on the country comparison3 is trying to catch up with a huge financing boost based on the Hospital Future Act.23 The government will provide €3 billion until the end of 2023 to stimulate digitalisation of hospitals. Other trends like telemedicine, artificial intelligence, wearable medical devices and use of big data can further accelerate the digital evolution. However, without a direct political strategy on digitalisation in the healthcare sector, the gap between digitally progressive and digitally underdeveloped countries may grow even further.
Limitations
Although all Swiss university and cantonal hospitals could have been included in the survey, about 50 smaller hospitals were not sent the questionnaire because they are not members of the GSASA or are supervised by other hospital pharmacies. Furthermore, a certain degree of imprecision and inconsistency of answers is generally to be expected in a survey. However, most questions were factual questions that left no room for the participants' subjective interpretation. Nevertheless, answers were not checked for correctness.
The questionnaire was answered from the perspective of the leading pharmacist. Involvement of other hospital departments like IT or administration was dependent on the judgement of each participant.
Abstract translation
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.Abstract translation
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.Abstract translation
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.Data availability statement
All data relevant to the study are included in the article or uploaded as supplementary information.
Ethics statements
Patient consent for publication
Supplementary materials
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Supplementary Data
This web only file has been produced by the BMJ Publishing Group from an electronic file supplied by the author(s) and has not been edited for content.
Footnotes
EAHP Statement 1: Introductory Statements and Governance. EAHP Statement 5: Patient Safety and Quality Assurance.
Twitter @PVonbach
Contributors Project Lead: PV. Survey design and development: PV, ML, BWS, PV, EHT. Data collection and analysis: PV, ML, BWS, PV, EHT. Writing (original draft): PV, LH. Writing (review and editing): PV, ML, BWS, PV, LH, EHT.
Funding The authors have not declared a specific grant for this research from any funding agency in the public, commercial or not-for-profit sectors.
Competing interests PV and LH are employees of the PEDeus AG, a spin-off company founded by the University Children’s Hospital Zurich with the purpose to develop paediatric clinical decision support systems. EHT was a member of the Galenica (connected to drug master data of HCI Solutions) advisory board during the planning and evaluation of this survey. The views expressed in this article reflect the personal views of the authors. ML, BWS and PV have no conflicts of interest to declare concerning this survey.
Provenance and peer review Not commissioned; externally peer reviewed.
Supplemental material This content has been supplied by the author(s). It has not been vetted by BMJ Publishing Group Limited (BMJ) and may not have been peer-reviewed. Any opinions or recommendations discussed are solely those of the author(s) and are not endorsed by BMJ. BMJ disclaims all liability and responsibility arising from any reliance placed on the content. Where the content includes any translated material, BMJ does not warrant the accuracy and reliability of the translations (including but not limited to local regulations, clinical guidelines, terminology, drug names and drug dosages), and is not responsible for any error and/or omissions arising from translation and adaptation or otherwise.