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Clinical pharmacy services can and do create significant value by enhancing the achievement of positive patient outcomes and by avoiding negative outcomes. Research to develop reliable methods for measuring and monitoring the value of clinical pharmacy services must continue. Mechanisms must be created to encourage and reward pharmacists who consistently provide services that add measurable value to patient care.

BACKGROUND: For many years, community pharmacies provided mail delivery as a convenience for a small segment of special circumstance patients who requested it. Fueled by a movement among plan sponsors and prescription benefit managers to encourage or require its use, growth in mail service pharmacy began to accelerate in the 1980s and now accounts for nearly 25% of the market in the general population and a much higher percentage of seniors.

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The optional free-text Notes field in ambulatory electronic prescriptions (e-prescriptions) allows prescribers to communicate additional prescription-related information to dispensing pharmacists. However, populating this field with irrelevant or inappropriate information can create confusion, workflow disruptions, and potential patient harm. OBJECTIVES To analyze the content of free-text prescriber notes in new ambulatory e-prescriptions and to develop recommendations to improve e-prescribing practices. DESIGN, SETTING, AND PARTICIPANTS We performed a qualitative analysis of e-prescriptions containing free-text prescriber notes for conformance to the intended purpose of the free-text field as established in the national e-prescribing standard. The study sample contained 26 341 new e-prescriptions randomly selected from 3 024 737 e-prescriptions containing notes transmitted to community pharmacies across the United States during a 1-week period (November 10-16, 2013). The study e-prescriptions were issued by 22 549 community-based prescribers using 492 different electronic health record (EHR) or e-prescribing software application systems. Data analysis was conducted from February 23, 2014, to November 4, 2015. MAIN OUTCOMES AND MEASURES Reviewers classified free-text prescriber notes as appropriate, inappropriate (content for which a standard, structured data-entry field is available in the widely implemented national e-prescribing standard), or unnecessary (irrelevant to dispensing pharmacists). We developed and applied a classification scheme to further characterize and quantify types of appropriate and inappropriate content. RESULTS Of the 26 341 free-text notes, 17 421 (66.1%) contained inappropriate content, 7522 (28.6%) contained appropriate content, and 1398 (5.3%) contained information considered to be unnecessary. Further characterization of inappropriate content resulted in 20 192 classification codes, of which 3841 codes (19.0%) were assigned because of patient directions that conflicted with directions included in the designated standard field intended for this purpose. Characterization of appropriate content resulted in 7785 classification codes, of which 3685 (47.3%) contained information that could be communicated using structured fields already approved in a yet-to-be implemented version of the e-prescribing standard. An additional 745 (9.6%) were prescription cancellation requests for which a separate e-prescribing message currently exists but is not widely supported by software vendors or used by prescribers. CONCLUSIONS AND RELEVANCE The free-text Notes field in e-prescriptions is frequently used inappropriately, suggesting the need for better prerelease usability testing, consistent end user training and feedback, and rigorous postmarketing evaluation and surveillance of EHR or e-prescribing software applications. Accelerated implementation of new e-prescribing standards and rapid adoption of existing ones could also reduce prescribers' reliance on free-text use in ambulatory e-prescriptions.

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