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Background In England, national safety guidance recommends that ciclosporin, tacrolimus and diltiazem are prescribed by brand name due to their narrow therapeutic windows and, in the case of tacrolimus, to reduce the chance of organ transplantation rejection. Various small studies have shown that changes to electronic health records (EHR) interface can affect prescribing choices. Objectives Our objectives were to assess variation by EHR system in breaches of safety guidance around prescribing of ciclosporin, tacrolimus and diltiazem; and to conduct user-interface research into the causes of such breaches. Methods We carried out a retrospective cohort study using prescribing data in English primary care. Participants were English general practices and their respective electronic health records. The main outcome measures were (1) variation in ratio of breaching / adherent prescribing all practices (2) description of observations of EHR usage. Results A total of 2,575,411 prescriptions were issued in 2018 for ciclosporin, tacrolimus and diltiazem (over 60mg); of these, 316,119 prescriptions breached NHS guidance (12.3%). Breaches were most common amongst users of the EMIS EHR (in 23.2% of ciclosporin & tacrolimus prescriptions, and 22.7% of diltiazem prescriptions); but breaches were observed in all EHRs. Conclusion Design: choices in EHR strongly influence safe prescribing of ciclosporin, tacrolimus and diltiazem; and breaches are prevalent in general practices in England. We recommend that all EHR vendors review their systems to increase safe prescribing of these medicines in line with national guidance. Almost all clinical practice is now mediated through an EHR system: further quantitative research into the effect of EHR design on clinical practice is long overdue.

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