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Original Investigation |

Analysis of Prescribers’ Notes in Electronic Prescriptions in Ambulatory Practice

Ajit A. Dhavle, PharmD, MBA1; Yuze Yang, PharmD1; Michael T. Rupp, PhD2; Hardeep Singh, MD, MPH3,4; Stacy Ward-Charlerie, PharmD1; Joshua Ruiz, CPhT1
[+] Author Affiliations
1Surescripts LLC, Arlington, Virginia
2Department of Pharmacy Practice, Midwestern University, Glendale, Arizona
3Houston Veterans Affairs Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey Veterans Affairs Medical Center, Houston, Texas
4Section of Health Services Research, Department of Medicine, Baylor College of Medicine, Houston, Texas
JAMA Intern Med. 2016;176(4):463-470. doi:10.1001/jamainternmed.2015.7786.
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Importance  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.

Figures in this Article


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Figure 1.
Analysis of Electronic Prescription Notes Content

Flowchart illustrating the analysis and classification of electronic prescription notes content.

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Figure 2.
Recommended Accommodations for Appropriate Electronic Prescription Notes Content

Recommended future solutions for accommodating the communication of appropriate e-prescription clinical notes content.

aExcludes notes content classified as “other.”

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