By Annette M. Boyle

Hardeep Singh, MD, MPH, chief of the Health Policy, Quality and Informatics Program at the Houston VA Health Services Research Center for Innovations at the Michael E. DeBakey VAMC and Baylor College of Medicine in Houston

Hardeep Singh, MD, MPH, chief of the Health Policy, Quality and Informatics Program at the Houston VA Health Services Research Center for Innovations at the Michael E. DeBakey VAMC and Baylor College of Medicine in Houston

HOUSTON — Pharmacists consult the free-text “Notes” field in ambulatory electronic prescriptions (e-prescriptions) for patient and dispensing information that physicians cannot communicate elsewhere. Instead, they often find instructions that contradict information elsewhere in the prescription or should be noted in other fields, according to informatics experts.

According to the report published recently in JAMA Internal Medicine, filling the Notes field with “irrelevant or inappropriate information can create confusion, workflow disruptions, and potential patient harm.”1

The Notes field is designed to provide flexibility for prescribers. “The optional 210-character free-text Notes field available in the new e-prescription message 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 currently exist in the standard,” according to study authors Hardeep Singh, MD, MPH, chief of the Health Policy, Quality and Informatics Program at the Houston VA Health Services Research Center for Innovations at the Michael E. DeBakey VAMC and Baylor College of Medicine in Houston, and Ajit A. Dhavle, PharmD, MBA, VP of Clinical Quality at Surescripts LLC.

For example, a physician could use the field to ask a pharmacist to reinforce selected aspects of the prescribed therapy with a noncompliant patient or to ensure a patient with cognitive issues fully understands the requirements of a more-complicated dosing regimen.

About 15% of e-prescriptions use the Notes field. Most prescribers do not use the field to add essential information, however. In fact, the researchers found that prescribers use the field inappropriately in two-thirds of cases.

The study analyzed 26,341 randomly-selected new e-prescriptions that used the Notes field from a total of 3,024,737 e-prescriptions that were transmitted to U.S. community pharmacies from Nov. 10 to Nov. 16, 2013. The prescriptions came through 492 electronic health records or e-prescribing software systems from 22,549 prescribers.

Slightly more than 66% of prescriptions were classified as inappropriate, meaning the prescriber used the Notes field instead of a structured data-entry field available in the widely-implemented national e-prescribing standard. The researchers categorized 28.6% of notes as appropriate and found that 5.3% contained unnecessary information.

e-prescribing graphic source is healthIT_reNineteen percent of the e-prescriptions with inappropriate content included patient directions that could be at odds with information provided in the designated standard field for patient instructions. For example, one prescription in the study specified one Dilantin (phenytoin sodium), 100 mg oral capsule every morning in the patient directions, but the free-text Notes field said two capsules every night.

When situations such as this occur, both pharmacy productivity and, potentially, patient safety suffer. “If contradicting information is sent in both a structured field and Notes field, then the pharmacist is uncertain about the prescriber’s intent and must call to seek clarification ‑ a best case scenario ‑ but if the pharmacist, without consulting, makes a wrong assumption, then it could lead to patient harm,” Singh and Dhavle told U.S. Medicine.

The authors offered several explanations for the high rate of misuse of the field, including “overly restrictive EHR/e-prescribing application system design and user interfaces, inadequate end-user training, and space limitations within the Patient Directions field.”

Dhavle and Singh also noted that the newer versions of the National Council for Prescription Drug Programs’ (NCPDP) SCRIPT standard, which contains additional structured data fields for much of the information now sent in the Notes section, have not been implemented, leaving prescribers with “no choice but to send this data in the free-text Notes field.” About half (47.3%) of notes with appropriate content could have used these fields.

In addition, while the currently deployed 10.6 version of the NCPDP SCRIPT includes a CANCELRx message type that prescribers could use to tell pharmacies to discontinue existing therapies or prescriptions of file, the industry has not yet implemented it. Nearly 10% of the notes classified as appropriate communicated cancellation instructions.

Even when the information in the Notes field simply repeats information provided elsewhere, it “causes workflow disruptions at the pharmacy because now the pharmacist or staff have to look, read, and interpret what is being sent in the notes field,” Dhavle and Singh wrote. The extra time spent double-checking the prescription can lead to delays for patients as well as potential medication errors and adverse patient outcomes, according to the study.

The problems with inconsistencies in e-prescriptions are neither new nor unique to retail community pharmacies. In an earlier study, Singh and colleagues found issues raised again in the JAMA Internal Medicine article, including the need to increase the usability of the CPOE interface, provide better training for prescribers and better integrate e-prescribing software into prescriber workflows.2

Singh noted the VA will likely update its long-standing electronic health record in the near future. When it does,  recommends keeping the following principles in mind to facilitate efficient and safe use of e-prescribing:

  • Design e-prescribing applications for prescribers and pharmacies with input from clinicians.
  • Support users and ensure rigorous training in use of these systems. “For example, many VA providers might not know that certain prescriptions, such as tapering doses of steroids, require the use of Complex Tab on the CPOE user interface,” they said.
  • Monitor use of e-prescribing. “It took a research study to describe prescription inconsistencies almost a decade after CPOE was implemented in the VA. Any new implementation must be accompanied by efforts to collect and analyze data on safety,” Singh and Dhavle said.
  • Ensure both internal staff (IT) and external vendors remain responsive, so the systems can support continuous improvements.
  • Emphasize that the communication between prescriber and pharmacist on the prescription order is absolutely essential for safe and effective care to all stakeholders involved in design, development, implementation and use of e-prescribing, and create a collective commitment to continuously improve the quality of that communication.

1 Dhavle AA, Yang Y, Rupp MT, Singh H, Ward-Charlerie S, Ruiz J. Analysis of Prescribers’ Notes in Electronic Prescriptions in Ambulatory Practice. JAMA Intern Med. 2016 Apr 1;176(4):463-70.

2 Singh H, Mani S, Espadas D, Petersen N, Franklin V, Petersen LA. Prescription errors and outcomes related to inconsistent information transmitted through computerized order entry: a prospective study. Arch Intern Med. 2009 May 25;169(10):982-9.