JAMA Internal Medicine Study Provides Wake-Up Call: Improving e-Prescription Safety and Standards Adoption

With 77 percent of all prescriptions in the U.S. being routed electronically in 2015, e-prescribing is now the industry norm. However, there is still room for improvement when it comes to e-prescription quality and the user experience. One area for continuing quality improvement is the Notes field, as described in a recent Surescripts-led study published in the JAMA Internal Medicine last month.

The free-text Notes field allows prescribers to enter free-text comments to the receiving pharmacy thereby enabling prescribers to communicate additional information about the patient that does not otherwise have a structured field available in the currently implemented 10.6 version of the NCPDP SCRIPT standard. When not used correctly, however, the Notes field—designed to improve clarity—can actually create confusion, disrupt workflow and threaten patient safety.

To identify data trends and better understand how prescribers are using—or misusing—the Notes field, Surescripts and industry partners analyzed over 26,300 e-prescriptions with prescriber comments in the Notes field. The study included e-prescriptions from over 22,000 prescribers using nearly 500 different e-prescribing software application systems*

Highlights from the research findings include:  

• Nearly 15 percent of e-prescriptions analyzed contained prescriber comments in the Notes field
• Over 66 percent of the free-text Notes contained inappropriate content for which another structured field should have been used, and an additional 5.3 percent contained unnecessary or irrelevant information
• 19 percent of e-prescriptions that contained inappropriate Notes included patient directions that conflicted with information included elsewhere in structured patient directions (Sig) fields   
• Of the Notes that were determined to be appropriate, over 47 percent contained information that could be communicated using a structured field in a yet-to-be implemented version of the e-prescribing standard

Given the relatively high incidence of inappropriate Notes field use, a number of best practice recommendations can be made to improve the overall quality of e-prescriptions:

1. Consistent end-user training and feedback: E-prescribing software application vendors including EHR vendors, must provide better end-user training and support. This should include the solicitation of user feedback and more rigorous system training and updates on a regular basis.  
2. Improved usability and increased testing: EHRs must improve the design of EHR systems’ e-prescribing applications. Better product and interface design means better usability, and it all starts with applying user feedback to improve a solution’s ease of use and functionality. 
3. Implementation of ancillary messages and adoption of approved newer versions of NCPDP Script standard: Vendors must implementation new messaging transactions, such as RxChange and RxCancel available in the widely implemented 10.6 version of the NCPDP SCRIPT standard, and the industry as a whole, should adopt and implement approved newer versions.

In summary, the results of the analysis suggest the need for enhanced user training and feedback, improved systems design and testing and prompt implementation of approved new messages and SCRIPT standard versions. Implementing these recommendations will improve e-prescribing quality, prescriber workflow, clinician communication and, ultimately, patient safety.

Make sure to visit Surescripts’ Quality Management Program for more information.

* 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 from November 10-16, 2013. The e-prescriptions analyzed in the study 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.