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Physician’s Misuse of E-Prescription Fields Could Endanger Patients

ARLINGTON, VA – Incorrectly using the optional free-text “notes” field in ambulatory electronic prescriptions (e-prescriptions) can waste pharmacists’ time and put patients at risk.

That’s according to a study published recently in JAMA Internal Medicine, which cautions physicians and other prescribers that “populating this field with irrelevant or inappropriate information can create confusion, workflow disruptions, and potential patient harm.”

The study involved researchers from Surescripts LLC, the Department of Pharmacy Practice at Midwestern University in Glendale, AZ, and the Houston Veterans Affairs Center for Innovations in Quality, Effectiveness the Department of Medicine at Baylor College of Medicine, both in Houston. For the study to develop recommendations to improve e-prescribing practices, free-text prescriber notes in new ambulatory e-prescriptions were analyzed.

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 Nov. 10-16, 2013. The e-prescriptions were from 22,549 community-based prescribers using 492 different electronic health record (EHR) or e-prescribing software application systems.

Researchers classified free-text prescriber notes as one of the following:

  • 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).

Of the 26,341 free-text notes, 66.1% were found to contain inappropriate content, while just 28.6% were deemed appropriate and 5.3% contained information considered to be unnecessary.

Some of the fault lies with EHRs that are “overly restrictive or difficult to use, inadequate user training, and/or space limitations, such as the 140-character limit on the Patient Direction (Sig) field in the presently most widely implemented SCRIPT standard (version 10.6),” researchers point out.

Whatever the cause, they warn prescribers that “unnecessary or inappropriate free-text information can also lead to dispensing delays, medication errors, and adverse patient outcomes.”

The inappropriate usage suggests “the need for better prerelease usability testing, consistent end-user training and feedback, and rigorous post-marketing evaluation and surveillance of EHR or e-prescribing software applications,” study authors concluded.

“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 report points out that the SCRIPT standard continues to be revised regularly with addition of new structured data segments and fields and refinements to existing ones.

In an accompanying commentary, Jeffrey L. Schnipper, MD, MPH, of Brigham and Women’s Hospital and Harvard Medical School, both in Boston, writes, “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. However, even distractions can lead indirectly to patient harm if they result in lapses of attention that increase the rate of dispensing errors."