The pharmacy sector is not immune to pervasive digitalization. Innovations, such as robots, have disrupted the pharmacy practice . One major element affecting this sector is the electronic prescription, or ePrescription, which can be defined as “the use of computing devices to enter, modify, review, and output or communicate drug prescriptions” . Electronic prescribing is argued to have potential to streamline and improve medicine dispensing [3,4,5]. The potential benefits include a decrease in medication errors [6, 7] and efficient identification of adverse effects .
ePrescriptions have been widely adopted in Finland . Another significant change in the Finnish community pharmacy sector is the introduction of the direct dispensing model – a model that streamlines the prescription-only (PO) customer service process with the support of new technology. In this article, we examine what these changes mean for Finnish pharmacies and discuss the impact from a sociotechnical perspective.
ePrescription and the direct dispensing model
The Finnish pharmacy sector has undergone significant changes in recent years. Electronic prescription has been widely adopted in Finland since 2010, and it became the sole prescription method in 2017 [9,10,11]. The use of electronic prescription and the related centrally governed databases are mandated by law in Finland . The Finnish Patient Data Repository (KanTa) is a centralized database containing personal healthcare records with a separate partition for medicine prescriptions .
The Finnish KanTa is a wide ecosystem digitally integrating Finnish healthcare service providers and pharmacies through a centralized data source containing records for each Finnish citizen . It is considered a pivotal integration mechanism within the medicine supply chain. Physicians can, e.g., investigate previous prescriptions ordered by any healthcare service provider while prescribing. Pharmacists access the database to fetch prescriptions when dispensing the medicine, and the prescription can be dispensed in any pharmacy, in contrast to implementation in some countries, where the prescription is transmitted only to a selected pharmacy.
The benefits of this complete digitalization of the medicine prescribing process include avoidance of overlapping medication , a clear overview of the total patient medication , and uniform medicine information between health care units and pharmacies . According to Aanestad et al. , ePrescription systems have the potential to improve control of medicine expenses and related performance management. This type of wide-scale centralized ePrescription solution is a rarity worldwide, and even in Europe .
ePrescriptions were a key trigger of the transformation of the pharmacy dispensing process; the pharmacists collect, handle and finally sign off on the dispensed medicine in the centralized online ePrescription service without first copying the content of the prescription to the pharmacy IT system [19, 20]. This means that medicine dispensing had to transform in all pharmacies from a workflow that we call the “traditional dispensing model” to a model that we call the “direct dispensing model”.
Several differences exist between the workflows of these two dispensing models. The main difference – from the customer point of view – is that in the direct dispensing model, the customer is served in an uninterrupted episode by a single pharmacist handling prescriptions through an IT system, while in the traditional dispensing model, there are several pharmacists and technical workers involved in the workflow. The two delivery models are depicted in Fig. 1.
The direct dispensing may be divided into two different models, the older one with paper prescriptions and the present one with ePrescriptions. In the older model, the paper prescriptions are copied into the pharmacy IT system, which collects the data of the dispensed prescriptions, maintains documentation and includes tools for reimbursement calculation. The work is done in face-to-face interaction with the customer, by one pharmacist. For the sake of clarity, we will refer to these three different models as mode 1, mode 2 and mode 3, as follows:
Mode 1: Traditional dispensing model with paper prescriptions;
Mode 2: Direct dispensing model with paper prescriptions;
Mode 3: Direct dispensing model with ePrescriptions.
Where electronic prescription is used, the pharmacist is supported by a view of all the prescriptions of the customer. Finding the right prescription may be time-consuming when the customer has multiple prescriptions and prescription data from a long time period. As the prescriptions are already in electronic form, a pharmacist does not have to copy the data to the pharmacy IT system. The critical and most value adding phases in the process regarding quality are the professional checking of the prescription content and the implementation of the reimbursement rules. After that, the medicine can be collected and dispensed.
In the traditional dispensing model, the originality of the prescription must be evaluated, and this task is not needed in the case of electronic prescription. Additionally, copying the prescription content to the pharmacy IT system is mandatory. In the traditional dispensing model, the customer session was often broken into many service episodes, which engaged several employees including pharmacy technicians.
The sociotechnical model
The sociotechnical system approach examines information systems from the point of view of both social and technical subsystems . It focuses especially on the interaction between these subsystems. According to Berg et al.  p. 297, the sociotechnical approach seeks to “increase our understanding of how information systems or novel electronic communication techniques are developed, introduced and become a part of social practice”.
Relating to the pharmacy domain, sociotechnical theory has been utilized often in relation to ePrescription. For example, Aarts  explains that prescribing occurs in social settings and that related technologies influence the behaviors of those involved. Prescribing is sociotechnically a complex event, which completes the interaction between a physician and a patient. The prescription as a technology can “nudge” the related stakeholders in a certain direction – e.g., ePrescription increases transparency, which may steer patients’ and physicians’ behavior (previous prescriptions cannot be hidden). Understanding these sociotechnical aspects, as Aarts  argues, is crucial to the success of the adoption of ePrescription.
To summarize a few other sociotechnical studies, it is, for example, argued that new types of medication error might occur in connection with the interplay of several electronic systems [5, 24] or pharmacists may simply exhibit mental resistance towards new kinds of systems .
Another line of discussion involves deskilling workers. It is argued that technology will change professional boundaries and identities, including in pharmacy settings [1, 26]. Whereas some pharmacy workers may benefit from the deployment of a new technologies, some will be affected detrimentally, as they lose control of their work and their incentives to develop their professional skills. The same applies to ePrescription; it has a sociotechnical impact through changing organizational relationships and tasks, which may entail deskilling for some and reskilling for others .
To counterbalance an overly deterministic view of technology, recently, the concept of “affordance” has received much attention in information systems and marketing research. According to the concept of affordance, technology provides – i.e. affords – opportunities and risks based on the materiality of the technological artefacts . It is up to the social subsystem to utilize or avoid them. Technology shapes the social rather than other way around, which, in practice, may lead to novel forms of usage, which may be different than those the solution was originally designed for (consider, for example, how firms have begun to use Twitter for marketing, which is not the intended model for using it). Petrakaki et al.  discuss how the affordance of ePrescription as a technology can construct risks, such as blame-shifting, which takes place when responsibility is displaced – in this case, it entails widening the jurisdiction of pharmacy staff. This happens through a social process, rather than being determined by the technology.
Harvey, Avery, Waring and Barber  researched the sociotechnical impact of ePrescription in community pharmacies in the UK in relation to the upcoming release of a national ePrescription service. They discovered that pharmacies can be divided into three categories based on the sociotechnical orientation: technically oriented, improvising and socially oriented.
According to Harvey et al. , technically oriented pharmacies have tightly governed workflows and typically utilize technologies such as robots, computerized prescription order entry systems and pharmacy manager systems. In their study, they measured dispensing lead times in these three types of pharmacies. The dispensing lead times were reported as being 2–5 min. At the other end of the spectrum, they found socially oriented pharmacies that based dispensing on adaptive and customized workflows with few technical aids. The workflows were, however, found to be effective, and the dispensing journey took 3–8 min on average. In the middle were the improvising type of pharmacies, which were not oriented in either direction and were often troubled by disorganized and unpredictable workflows. The dispensing lead times with improvising pharmacies were reported as being 10–14 min.
The aim of this study
Whereas ePrescription implementations in different environments have been studied widely, research on the ePrescription system is scarce in terms of its impact on pharmacy workflows, practices, and digital transformation, which is also true in the Finnish setting. The dispensing process ending in the handing of the medicine to the customer is the “moment of truth” in the prescribing process, and has a crucial impact on the further acts of the customer. It is the last point at which it is typically possible to give personal guidance about the medicine to the customer, and it may even be decisive in the customer’s decision to consume or not consume the prescribed medicines. Therefore, the dispensing process deserves careful attention from researchers.
Given that the Finnish ePrescription system is relatively developed and widely adopted, studying it can give valuable input to countries where the development is in more nascent phases. We utilize a sociotechnical lens to understand the disruption these new technologies may generate for pharmacy staff. The particular research questions are as follows:
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