Analysis of Prescribers’ Notes in Electronic Prescriptions in Ambulatory Practice

Abstract

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.

The Challenges of Electronic Health Records and Diabetes Electronic Prescribing: Implications for Safety Net Care for Diverse Populations

“…Research shows electronic prescription error rates ranging from 5 to 38% [ 16 ], which is similar to rates reported in the era before computerized prescribing [ 32 ]. In addition, studies have shown that 16–19% of electronic prescriptions convey contradictory information within a single prescription, with 2.7% of all prescriptions having the potential for a severe ADE [ 15 , 33 ]. Meanwhile, although electronic prescribing platforms technically support the ability to discontinue medications, these electronic messages incur charges to pharmacies and thus may not be accepted, leaving providers to embed discontinuation instructions in free-text fields [ 33 – 35 ].…”

“…In addition, studies have shown that 16–19% of electronic prescriptions convey contradictory information within a single prescription, with 2.7% of all prescriptions having the potential for a severe ADE [ 15 , 33 ]. Meanwhile, although electronic prescribing platforms technically support the ability to discontinue medications, these electronic messages incur charges to pharmacies and thus may not be accepted, leaving providers to embed discontinuation instructions in free-text fields [ 33 – 35 ]. Patients with diabetes may be disproportionately affected, as a study showed that, among the top nine medications dispensed after EHR discontinuation, seven were commonly used in diabetes, hypertension, and hyperlipidemia [ 36 ].…”

“…Second, EHRs and electronic prescribing vendors should focus on enhancing bidirectional communication between prescribers and pharmacists, integrating pharmacists electronically into the healthcare team supporting patients [ 16 ]. Providers currently use free-text electronic prescribing fields to communicate a diverse set of information to pharmacists, including requests to discontinue refills because the per-message feedisincentivizes pharmacies from accepting structured discontinuation messages [ 33 – 35 ]. Policies to remove this financial barrier will improve safety due to adverse drug events from failed discontinuation and allow providers to focus on conveying clinically meaningful information not captured through structured fields.…”

Pros and cons of electronic prescribing

“…A 2016 study published in JAMA Internal Medicine reviewed how often prescribers attempted to include additional information in an e-prescription in free text form instead of including it in structured data entry elds. 4 The study reviewed more than 26,000 free text notes included with ambulatory care prescriptions and found that more than 66% contained inappropriate content for the prescription, 29% contained appropriate content, and 5% contained information considered unnecessary.…”

Analysis of the Practice of Network Technology in Electronic Information Technology

“…For example, if a certain highway collapses and causes a serious traffic jam, many netizens can learn about the actual situation of highway jam in such forms as radio, network TV and social media, evade this highway as far as possible, choose a more convenient and safe travelling route and alleviate the traffic jam at the site of the accident effectively. Moreover, relevant departments can also understand road conditions at the site instantly through advanced network technology, take appropriate measures to remedy and restore the highway in the shortest time possible [3]. Thus it can be seen that it is very necessary to use network technology in electronic information technology rationally, to give full play to the actual role of electronic information technology and increase the speed of information transmission.…”