Prescribing has been practised for a long time throughout history and the symbol ‘Rx’, generally used to denote a prescription, is said to have been around for centuries. Prescribing of medicinal therapy is the most commonly used form of treatment intervention (Lundborg, 1999).
The use of medicinal therapy has grown dramatically as the range of medication used for different diseases has widened. To ensure that patients are getting the maximum benefit from their medicinal therapy, prescribers as well as other health professionals need to conduct appropriate and safe prescribing.
The World Health Organization (WHO) provided a guide to good prescribing (WHO, 1994). The aim was for future prescribers not just to be able to select the right drug, but also to use existing clinical guidelines to achieve rational and appropriate prescribing. Healthcare institutions and regulatory bodies also play a role in ensuring the appropriateness and safety of prescribing.
Prescribing is carried out by different health professionals both independently and as supplementary to medical doctors. As healthcare services became more challenging and medication regimes more complex, the need arises for more non-medical prescribers in the healthcare sector to improve clinical care and enhance desired healthcare outcomes. One of the recent changes in non-medical prescribing is that all Master of Pharmacy graduates in the UK will become independent prescribers upon registration in 2026.
The cognitive approach to prescribing is considered to be based on two criteria (Elstein and Schwartz, 2002):
- ‘Problem solving’, which is the early reasoning process involved in diagnosis
- ‘Decision making’, which is the final opinion and judgement part of the clinical decision.
Appropriate prescribing
Prescribing, and in particular appropriate prescribing, is advocated as a mixture of science and art (Buetow et al, 1997).
One of the definitions given for appropriate prescribing is when ‘the benefits anticipated from the treatment prescribed far outweigh any risks’ (Brook, 1994). Another definition of appropriate prescribing is ‘the outcome of a process of decision making that maximises net individual health gains within society's available resources’ (Buetow et al, 1997). This later definition makes it a necessity for prescribers to use an holistic approach when making decisions about prescribing, including scientific evidence, experience, ethics, patient preferences and the type of healthcare system.
The concept of prescribing changes gradually as prescribers become more experienced (Higgins and Tully, 2005). For junior prescribers, appropriate prescribing meant the match between the right drug and the patient presentation. This match was made easier by the availability of protocols and guidelines. For senior prescribers, appropriate prescribing was perceived to be a more complex approach, which could include factors related to the healthcare system such as considering cost-effective treatment. However, that does not always make senior prescribers better at achieving appropriate prescribing than juniors as was argued from earlier studies (Stolley et al, 1972). Furthermore, a distinction has been made between rational prescribing and appropriate prescribing (Aronson, 2004). Whereas rational prescribing is considered to end up with the decision to prescribe and the choice made, appropriate prescribing is considered as the whole process resulting in desirable outcomes (Buetow, et al, 1997; Aronson, 2004).
These outcomes can make a rational prescribing decision inappropriate and, on some occasions, an appropriate prescribing decision irrational (Yu et al, 1991; Aronson, 2004). However, this does not minimise the importance of rational decision-making as it is more likely that rational prescribing will lead to appropriate prescribing (Aronson, 2004).
Factors influencing prescribing
The presumption that different prescribers can make different decisions when presented with the same medical condition is attributed to the fact that there are medical and non-medical factors that influence prescribing (Hemminki, 1975; Segal and Hepler, 1982; Denig et al, 1993). The importance of these factors in prescribing can differ between prescribers, healthcare organisations and countries. The prescriber's characteristics, such as age, training and experience, are believed to influence the quality of prescribing. Some of these factors influencing prescribers have been easier to modify, such as the effect of the pharmaceutical industry, while the challenging ones have been factors such as the characteristics of the doctor and the patient.
In more recent published studies from different parts of the world, other classifications were given. Factors influencing prescribing were generally classified as either directly drug related or indirectly drug related. That is, the non-drug factors, such as the prescriber's characteristics, were not considered in these studies.
Most of the prescribers in different studies claimed that several factors affected their prescribing, including recommendations in clinical guidelines, the cost of treatment, the hospital drug formulary and advertisement provided by the pharmaceutical industry (Greenfield et al, 2005; Nutescu et al, 2005; Joyce et al, 2011; Oshikoya et al, 2011). However, the importance of any factor in drug choice varied between prescribers in different settings and countries where the studies were conducted. For example, in a study in Nigeria by Oshikoya et al (2011), most of the prescribers involved reported using the pharmaceutical company representative as a source of drug information for prescribing. This is different from prescribers in other countries in Europe and the USA, where information provided by pharmaceutical companies is considered to be of less influence (Schumock et al, 2004; Theodorou et al, 2009).
Not only medical prescribers' views but also the views of non-medical prescribers were sought in some studies that described the influences on drug choice for patients (Schumock et al, 2004; Nutescu et al, 2005). Both physicians and clinical pharmacists who participated in these studies considered drug-related factors, such as effectiveness of the drug, as having a greater influence than non-drug-related factors; for example, the effect of the pharmaceutical industry.
However, physicians and clinical pharmacists differed in their responses regarding the influence of experience in prescribing. While physicians considered personal experience to be an important influence, clinical pharmacists thought of it as being of less importance compared to direct drug-related factors.
The different factors that can lead to variation in prescribing, as discussed earlier, may lead to patients with similar conditions not receiving similar pharmaceutical therapies required for their conditions. It has been proposed that the use of clinical guidelines could limit the unjustified variation in prescribing, and ensure that patients are getting the drugs that, according to evidence from research, can improve their medical conditions (Ljungberg et al, 2007; Theodorou et al, 2009).
Many doctors, as well as other health professionals, in a number of studies, explained that one of the factors directly affecting their drug choice was prescribing guidelines (Nutescu et al, 2005; Ljungberg et al, 2007). However, using recommendations from clinical guidelines may not be strictly followed in all situations. For example, in the US study, participant doctors in community hospitals considered that when prescribing within the same therapeutic class, they depended on their experience and not guidelines for the choice of the suitable member within the same class (Nutescu et al, 2005).
Electronic systems
The need for developing electronic systems that facilitate appropriate prescribing has become increasingly evident (Horsky et al, 2012). Creating effective decision support systems within clinical settings is a multifaceted process. Designing digital solutions for medical services requires careful consideration of patient, societal and healthcare system factors. To address this challenge, software designers using software models and integrating artificial intelligence tools must adopt a human-computer interaction design approach that prioritises patient-centeredness, iterative development, and continuous re-evaluation.
However, interacting with these systems remains a central barrier to adoption and hinders routine use. In addition to specificity and patient-centred approaches, these systems must also prioritise user experience. Strategies such as regular assessments to trigger rules related to patient conditions and distinguishing between genuine warnings and unnecessary alerts are crucial for ensuring relevance and accuracy. Despite progress, existing digital systems still fall short of achieving desired outcomes. Continued innovation and refinement are essential to bridge this gap and enhance clinical decision support.