Implementation challenges and unintended financial consequences of e-prescribing in an integrated payer–provider health system: a qualitative study from Tehran, Iran

Abstract

Electronic prescribing (e-prescribing) is increasingly used to improve the efficiency, safety, and continuity of healthcare. However, implementation challenges may produce unintended consequences, particularly in health systems where a single organisation combines payer and provider functions. This study explored patients’ and healthcare providers’ experiences of e-prescribing implementation in Social Security Organization (SSO)-owned healthcare facilities in Tehran, Iran, focusing on workflow disruption, care-pathway fragmentation, access to insured services, and financial consequences. A qualitative study using conventional qualitative content analysis was conducted from April to June 2024 in SSO-owned hospitals and outpatient healthcare facilities in Tehran. Purposive sampling recruited 28 participants with direct experience of e-prescribing, including 15 patients and 13 healthcare providers. The two groups were selected to capture complementary perspectives on implementation at the points of care and service delivery. Semi-structured interviews were conducted in Persian and analysed iteratively. Patient and healthcare-provider interviews were analysed separately, with data collection continuing until saturation was reached within each group. The study was reported in accordance with the Consolidated Criteria for Reporting Qualitative Research (COREQ). Six interrelated themes were identified: (1) unreliable digital infrastructure and system performance, (2) workflow friction and increased time burden, (3) disrupted insurance-linked access and financial burden, (4) fragmented care pathways and limited interoperability, (5) unequal capacity to navigate digital care, and (6) conditional acceptance and unrealised benefits. Participants described how system instability, infrastructure limitations, and limited interoperability contributed to workflow disruption, delays, repeated interactions, and fragmented care. Patients also reported difficulties accessing services through insurance-linked pathways and, in some cases, unintended out-of-pocket payments despite insurance coverage. Older patients and individuals with limited digital skills experienced greater difficulties navigating digital processes. In this integrated payer–provider context, e-prescribing implementation challenges extended beyond technical performance to affect care pathways, equity, and financial burden. Reliable infrastructure, effective interoperability, user-centred implementation, and safeguards to maintain access to insured services during system disruptions are essential for equitable and effective digital healthcare delivery.