Paperless Prescriptions, Persistent Doubts: The Trust Gap in Digital Health

Replacing paper prescriptions with digital systems looks like an obvious step toward safer, faster and more connected healthcare. However, the transition is not simply a matter of installing software, issuing QR codes or linking hospitals with pharmacies. It depends on whether frontline professionals believe the system protects patients, fits clinical workflows and delivers visible improvements in access to medicines.

The study "Initial Implementation of E-Prescribing: Evidence from Eastern Taiwan", published in the journal Healthcare and conducted by Ching-Yu Chang, Chia-Lung Chen, Hui-Ying Chu, Chung-Hung Tsai and Yi-Yuan Chen, examines how healthcare professionals responded to Taiwan's first regional e-prescribing pilot during its initial deployment phase.

Based on responses from 107 physicians, pharmacists, nurses, medical administrators and information engineers in Hualien County, the researchers found that access to medicines, digital trust and user satisfaction strongly influenced willingness to adopt e-prescribing. Digital service quality also mattered, but its effect was indirect: better service encouraged continued use only when it created a satisfactory experience.

Governments worldwide are investing in electronic health records (EHRs), telemedicine, digital identification and interoperable health platforms. However, many digital health programmes continue to treat user acceptance as a communications problem rather than a design and governance challenge. The Taiwan study offers a sharper lesson: trust, satisfaction and medicine access are not peripheral outcomes of digital transformation. They are part of its core infrastructure.

A Digital Prescription Changes the Whole Care Chain

Taiwan's e-prescribing initiative builds on earlier digital health investments, including the PharmaCloud medication-information system launched in 2013. The newer programme, introduced nationally in 2025, aims to replace paper prescriptions with standardized, traceable electronic records.

The pilot studied in Hualien converts prescription data from hospital information systems into the international FHIR format, adds digital signatures and generates QR codes. Pharmacies can scan those codes, retrieve prescription details, verify whether medicines have already been dispensed and upload completed dispensing records to the national system.

The potential benefits are substantial. E-prescribing can reduce errors caused by illegible handwriting, improve access to medication histories, lower duplication and reduce the need for pharmacists to contact physicians for clarification. It can also support telemedicine, repeat prescriptions and more coordinated treatment across institutions.

However, digitalisation creates new dependencies. Hospitals, clinics, pharmacies, government platforms and mobile applications must exchange accurate information in real time. A failure in authentication, connectivity or system integration can interrupt the entire process. It also changes professional responsibility: who is accountable when a digital prescription is wrong, delayed or inaccessible?

These questions are particularly important in Eastern Taiwan, where geographic isolation, a dispersed population and shortages of healthcare personnel make coordination difficult. Digital systems could reduce travel and ease pressure on limited staff. However, if they are unreliable or poorly integrated, they could create new burdens for the same professionals they are meant to support.

Access to Medicines Gives Adoption a Practical Purpose

The study found that perceived improvements in access to medicines significantly increased both user satisfaction and intention to use e-prescribing. Access to medicines had a standardized effect of 0.381 on satisfaction and 0.286 on intention to use. It shifts attention away from the technology itself and towards the service outcome it enables. Health workers are more likely to support e-prescribing when it makes the journey from consultation to medicine collection faster, smoother and more dependable.

For policymakers, success should be measured by more than the number of electronic prescriptions issued. More meaningful indicators include dispensing times, prescription errors, failed transactions, patient travel requirements and the amount of manual intervention still needed. The study also found that digital health service quality significantly improved satisfaction, with a standardized effect of 0.411. However, service quality did not directly increase intention to use. Its effect operated through user satisfaction.

The finding challenges a common assumption in public-sector digitalisation: that fixing technical problems automatically secures adoption. A system may be stable and functional, yet still feel disruptive, time-consuming or poorly aligned with clinical practice. Professionals continue using technology not because it exists, but because repeated experience convinces them that it improves their work.

It makes frontline involvement essential. Training should not be limited to showing users which buttons to press. Implementation teams need to understand how e-prescribing changes consultation routines, pharmacy checks, patient communication and responsibility for errors. Complaints from clinicians and pharmacists should be treated as implementation evidence, not resistance to modernisation.

Trust Is the Hidden Infrastructure Behind Use

Digital trust emerged as one of the strongest drivers of adoption. It significantly increased user satisfaction and had a direct effect of 0.449 on intention to use, stronger than the direct effect of medicine access.

The reason is straightforward. In healthcare, technical failure can have serious consequences. An incorrect prescription, missing allergy record or delayed medicine can put a patient at risk. Professionals therefore need confidence that the system will transmit information accurately, protect patient data and function reliably under real clinical conditions.

Institutional trust was central to building that confidence. The study found an exceptionally strong relationship between institutional trust and digital trust, with a standardized coefficient of 0.981. Participants' belief that privacy and personal information were protected strongly shaped whether they trusted the platform.

However, formal rules alone are not enough. Governments can publish privacy policies and security standards, yet users will judge the system by what happens in practice. They need to know who can access prescription data, how identities are verified, how breaches are handled and who is responsible when records are wrong.

Hospitals and pharmacies also need regular security audits, vulnerability testing, software updates and staff training. A secure national platform can still be undermined by weak local passwords, outdated devices or poorly managed access rights.

The researchers initially tried to distinguish "trust in technology" from broader "digital trust," but the two concepts were so closely correlated that they were merged. That overlap is revealing. A pharmacist using an e-prescription is simultaneously judging the software, the hospital that issued the order, the government platform carrying the data and the rules governing the process. A failure in one layer can damage confidence in all of them.

User satisfaction also directly increased intention to use, with a coefficient of 0.432. It mediated the effects of medicine access, service quality and digital trust. Satisfaction is therefore not a secondary outcome. It is the mechanism that turns digital policy into sustained behaviour.

The Global Lesson Is to Digitise Care, Not Just Paper

The Eastern Taiwan pilot offers a valuable but deliberately limited window into e-prescribing adoption. Its sample was small and geographically concentrated, involving 107 professionals from institutions that had volunteered to participate. Those organisations may have been more receptive to digital innovation than non-participants.

The research also measured perceptions and intentions rather than long-term usage, patient outcomes or operational performance. It did not establish whether e-prescribing reduced medication errors, lowered costs, shortened dispensing times or improved adherence. Patients were not surveyed, and differences between medical specialties were not analysed.

That said, the study offers a strong warning for governments planning national rollouts. E-prescribing cannot be treated as a standalone application. It must be supported by interoperable systems, reliable connectivity, cybersecurity, workforce training, legal clarity and inclusive access.

This is especially relevant for developing countries. Digital prescriptions cannot improve medicine access where pharmacies lack stock, clinics lack electricity or institutions use incompatible systems. They may even deepen inequality if patients need smartphones, digital identities or reliable internet access to obtain essential medicines.

Short-term implementation should focus on system integration, technical support and contingency plans for outages. Clinicians need confirmation that prescriptions have been transmitted correctly. Pharmacists need real-time verification. Patients need clear information and non-digital alternatives when systems fail.

Longer-term policy must clarify the legal status of electronic prescriptions, responsibility for errors, data-retention rules and procedures for correcting records. Transparent reporting of security incidents will also be essential to maintaining confidence. E-prescribing can support home delivery, refill reminders, medicine-inventory planning and earlier detection of dangerous drug combinations. However, those gains depend on responsible data governance and safeguards against exclusion, surveillance and misuse.