Errors, Confusion Common in Notes Field in e-Prescriptions

Tara Haelle

March 08, 2016

The free-text Notes field in electronic prescriptions frequently contains information that should be conveyed in other existing standard data fields, and leads to confusion or errors, according to a retrospective, qualitative study published online March 7 in JAMA Internal Medicine.

Other data from the notes field present an opportunity to develop additional fields in e-prescription messages to reduce confusion, suggest Ajit A. Dhavle, PharmD, MBA, from Surescripts LLC in Arlington, Virginia, and colleagues.

"The optional, 210-character, free-text Notes field available in the e-prescription message is a well-documented source of potential miscommunication between prescribers and pharmacists," Dr Dhavle and colleagues write. "This field is intended to allow prescribers the option of including additional patient-specific information that is relevant to the prescription but for which a dedicated field does not exist in the currently implemented version of the SCRIPT standard (version 10.6)."

They suggest that some potential reasons for inappropriately used free-text notes include restrictive or difficult electronic health record systems, insufficient user training, or the 140-character limit in the Patient Direction (Sig) field. Regardless, "[u]nnecessary or inappropriate free-text information can also lead to dispensing delays, medication errors, and adverse patient outcomes," they write.

Three certified pharmacy technicians independently analyzed 26,341 new ambulatory e-prescriptions randomly pulled from 3,024,737 e-prescriptions with notes that had been sent to US community pharmacies between November 10 and 16, 2013. The prescriptions with data in the notes field made up 14.9% of the 20,260,935 new e-prescriptions during the 1-week period. The 22,549 prescribers had used 492 different electronic health record or e-prescribing software systems.

In their qualitative analysis, the researchers determined whether the text in each note field of the e-prescriptions was appropriate, inappropriate, or unnecessary. Inappropriate entries included those that could have been included on a structured data-entry field, based on the National Council for Prescription Drug Programs' SCRIPT e-prescribing standard. Unnecessary notes were those irrelevant to pharmacists.

The pharmacist adjudicator classified 66.1% of notes as inappropriate, 28.6% as appropriate, and 5.3% as unnecessary. A closer examination of the inappropriate notes revealed 20,192 classification codes, 19.0% of which included patient directions different from those in the designated standard field for directions.

"Patient directions, included in 19.0% of the inappropriate notes, represent a potential safety concern since this information may conflict with what is transmitted in the standard Directions field" the authors write. "Vague, ambiguous, or conflicting patient directions in the Notes field are also disruptive to pharmacy workflow and can result in dispensing errors if unnoticed, ignored, or misinterpreted by pharmacy staff."

In addition, 30.9% of inappropriate notes should have been in the BEN (benefits/insurance or coupon information) field, and 23.9% should have been in the QQU (quantity or quantity qualifier/potency unit code information) field. Seven percent should have used the PRE (prescriber name) field, and 6.0% should have used the DX (diagnosis or indication information) field.

"The implications of these various types of free-text notes can range from the merely distracting for the community pharmacist to those that could be severely harmful for patients," writes Jeffrey L. Schnipper, MD, MPH, from Brigham and Women's Hospital and Harvard Medical School in Boston, Massachusetts, in an accompanying commentary. "However, even distractions can lead indirectly to patient harm if they result in lapses of attention that increase the rate of dispensing errors."

In his commentary, Dr Schnipper points out that an extrapolation of the e-prescriptions containing conflicting information in this study translates to more than 34 million of these errors annually. Clarifying some of these notes is also time-consuming and wastes healthcare resources, he added.

Among the appropriate notes, 47.3% of the 7785 classification codes could instead be included in structured fields planned in a future SCRIPT standard not yet available. "These codes included APPT (patient needs appointment/office visit/laboratory tests) (25.8%), HOLD (place prescription on hold/do not dispense until later date) (8.5%), ALGY (patient allergy notification/alert to pharmacy) (4.5%), LAN (label in patient's preferred language) (4.1%), and DEL (deliver this prescription) (2.8%)," the researchers write.

In addition, 9.6% of the appropriate notes were used to cancel a separate e-prescribed prescription, and 26.0% "are not supported in the current or any future approved version of the SCRIPT standard and may represent a need for the addition of new fields."

"Our findings call for changes in premarketing and postmarketing testing and surveillance of e-prescribing software applications," the researchers write.

Dr Schnipper suggested a variety of factors contributing to the problem of these inappropriately used notes.

"Failure of prescribers to use available structured fields likely reflects a combination of poor usability of electronic health records and e-prescribing tools plus a lack of adequate education, training, and feedback among prescribers," Dr Schnipper writes. "Failure of approved standards to be widely implemented reflects deficiencies in regulation and in the health information technology development process."

Among Dr Schnipper's recommendations to address the problem are expediting the update of the prescribing standards, developing new updates, considering new structured fields, improved training for prescribers, and ongoing surveillance of inappropriate free-text notes to inform future training needs.

"More ambitiously, changes to our health care system are needed to break down barriers between those who prescribe medications and those who dispense them," Dr Schnipper writes.

"The findings of the study by Dhavle and colleagues should be viewed as a wake-up call to health information technology vendors, prescribers, regulators, and health care systems that several changes need to be made to improve the safety of electronic prescribing and that these changes need to be made soon."

The research was funded by a grant from the Veterans Affairs Health Services Research & Development Service to the Houston Veterans Affairs Center for Innovations in Quality, Effectiveness, and Safety. Dr Dhavle and three coauthors are employees of Surescripts LLC, and one coauthor has received consulting fees from Surescripts LLC during the study. Dr Schnipper has disclosed no relevant financial relationships.

JAMA Intern Med. Published online March 7, 2016. Article abstract, Commentary extract

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