Arlington, VA—Pharmacists look to the optional free-text “notes” field in ambulatory electronic prescriptions (e-prescriptions) for valuable additional information before they dispense the medication.

A study published recently in JAMA Internal Medicine cautions, however, 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, Arizona; and the Houston Veterans Affairs Center for Innovations in Quality, Effectiveness the Department of Medicine at Baylor College of Medicine, both in Houston. They sought to analyze the content of free-text prescriber notes in new ambulatory e-prescriptions and to develop recommendations to improve e-prescribing practices.

For the qualitative analysis of e-prescriptions containing free-text prescriber notes, 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 November 10-16, 2013.

E-prescriptions examined in the study were issued by 22,549 community-based prescribers using 492 different electronic health record or e-prescribing software application systems. Free-text prescriber notes were classified 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).

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.

“This misallocation may be partly owing to electronic health record (EHR) systems 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. “Regardless of the reasons, the inclusion of unnecessary or conflicting prescription information in the Notes field can cause confusion at receiving pharmacies and workflow disruptions at prescribing clinics when pharmacists must contact the prescribers to clarify the intent. Unnecessary or inappropriate free-text information can also lead to dispensing delays, medication errors, and adverse patient outcomes.”

Further characterization of inappropriate content resulted in 20,192 classification codes; 19% of those were assigned because of patient directions that conflicted with directions included in the designated standard field intended for that purpose.

Overall, characterization of appropriate content resulted in 7,785 classification codes, of which 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 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.

“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 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.

“Several of these categories of notes are time consuming for pharmacists and sometimes for prescribers (e.g., if telephone calls are needed to clarify a prescription), therefore wasting valuable health care resources.”

Schnipper also points to a finding in the study that conflicting information apparently occurred in 14.6% of all prescriptions with free-text codes, or approximately 2.2% of all e-prescriptions. “If extrapolated nationally, assuming Surescripts captures two-thirds of all new e-prescriptions in the United States, this would mean that more than 34 million such errors occur each year,” he notes.

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