Free-Text Notes as a Marker of Needed Improvements in Electronic Prescribing.

Abstract

In this issueof JAMAInternalMedicine,Dhavleandcolleagues1 presenttheresultsofastudyindicatingthat,of the14.9%ofelectronic prescriptions with free-text notes, 66.1% contained inappropriate content forwhicha structureddata field (ie, a field intended for certain specific piecesof information, suchas days’ supply or indication for a medication) exists in the mostcommonlyusednationale-prescribingstandard.Mostconcerning, almost 1 in5 (19.0%)of these inappropriatenotes contained conflicting medication directions from the structured fields intended for this purpose. Of the noteswith appropriate content, almost half (47.3%) contained information that could be communicated using structured fields approved in a version of the e-prescribing standard that has yet to be implemented. An additional 9.6% were prescription cancellation requests for which a separate e-prescribing message exists but is not widely supported in most currently available e-prescribing software. 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 (Table). However, even distractions can lead indirectly to patient harm if they result in lapses of attention that increase the rate of dispensing errors. Several of these categories of notes are time consuming for pharmacists and sometimes for prescribers (eg, if telephone calls are needed to clarify a prescription), therefore wasting valuable health care resources. Moreover, the final category in this Table (ie, conflicting information), as illustrated in the phenytoin sodium (Dilantin) example in the Discussion section by Dhavle and colleagues1 (and included in the present Table) is not infrequent: conflicting informationapparentlyoccurred in 14.6% of all prescriptionswith free-text codes sampled byDhavle et al, or approximately 2.2% of all e-prescriptions. If extrapolated nationally, assuming SureScripts captures two-thirds of all new e-prescriptions in the United States, this wouldmean that more than 34 million such errors occur each year. As with most medication safety issues, the causes of the problemaremultifactorial. Failure of prescribers to use available structured fields likely reflects a combination of poor usabilityof electronichealth records ande-prescribing toolsplus a lack of adequate education, training, and feedback among prescribers. Indeed, in common practice, few such educationalopportunities exist: prescribersoftenhavea single training sessionwhen a new system is implemented or when they join a new practice and have no opportunities for feedback, especially frompharmacists. Failure of approved standards to bewidely implemented reflects deficiencies in regulation and in the health information technology development process. The types of information in these free-text notes also reveals awide communication gulf betweenprescribers andpharmacies, agulf that canonlybepartiallybridgedwithcurrent tools, technologies, and health care structures. Because the causes of this problemaremultifactorial, the solutions must be as well. Vendors of electronic health records and e-prescribing software should view the findings of Dhavle and colleagues1as a guide to improvements thatmust bemade in theusability of their products. For example,many vendorsoftenmake itdifficult toefficientlyandaccuratelyprescribe sliding scales, tapers, or other complicated regimens (eg, “take 1 capsule in themorning and 2 capsules in the evening,” which was likely the intention of the prescriber of the above-mentioned phenytoin example). Updates in currently approvede-prescribing standards shouldbeexpeditedand integrated into thenextgenerationof tools; suchchanges should receive the highest priority by regulators and vendors. Future updates to the standards will also need to be developed and expedited. New structured fields should be considered when there is risk for this type of information to be omitted or incomplete when not prompted. Prescribers need adequate training in theuseof e-prescribing tools.Moreover, onRelated article page 463