A comparative evaluation of national e-prescribing platforms in a fragmented multi-payer health system: evidence from Iran

Background Electronic prescribing (e-prescribing) is a key digital health intervention for improving medication safety. In multi-payer health systems, however, parallel insurer-specific platforms may lead to fragmentation and inconsistent user experiences. Iran, as a low- and middle-income country (LMIC), operates three national e-prescribing platforms under different insurance organizations. This study aimed to comparatively evaluate these platforms and identify system-level implications for fragmented digital health environments. Methods A cross-sectional comparative study was conducted in six public teaching hospitals in eastern Iran. Fifteen physicians with experience using all three national e-prescribing platforms—developed by the Social Security Organization (SSO), Iran Health Insurance Organization (IHIO), and Armed Forces Medical Services Insurance (AFMSI)—completed a validated multidimensional checklist assessing system infrastructure, patient data access, interoperability, security, and clinical decision support system (CDSS) features. In addition, 318 patients evaluated access pathways and user experience across insurer-specific platforms. Given the formative nature of the study and the limited number of expert users, regression analysis was conducted for exploratory purposes to examine associations between key system attributes and overall physician satisfaction, rather than to establish causal or statistically generalizable predictors. Results Significant differences were observed across platforms. The SSO platform showed relatively more favorable ratings in perceived system infrastructure and access to patient data, while the IHIO platform demonstrated relatively better CDSS alert functionality. The AFMSI platform consistently scored lower across several domains. Exploratory regression analysis indicated that perceived infrastructure reliability and ease of data access were the variables most strongly associated with overall physician satisfaction among participating physicians. Conclusions In fragmented, multi-payer health systems, effective e-prescribing performance depends primarily on robust infrastructure and reliable access to patient data rather than advanced functionalities alone. Coordinated digital health governance and interoperability across insurer-based platforms are essential to improve usability, safety, and sustainability of national e-prescribing initiatives in LMICs.