Electronic prescriptions allow for providers to enter any free-text directions (Sig) they wish, just as if they were writing a paper prescription. The patient directions are one of the most critical parts of a prescription. It’s a huge safety risk if patients do not understand how to use their prescription or if a pharmacist has to try to interpret what the provider means. In a recent study that analyzed 25,000 electronic prescriptions issued by 22,152 community-based prescribers using 501 e-prescribing software applications, it was found that there was a large number of variations in the electronic prescription directions¹. The quality of the directions also varied greatly.

The study was conducted by Yuze Yang, PharmD, from Surescripts and colleagues, and published online in the Journal of Managed Care & Specialty Pharmacy. Out of the 25,000 e-prescriptions, there were 3,797 unique Sigs concepts identified in the Sig text strings. However, more than half of all patient directions could be classified into just 25 unique Sig concepts. There were large numbers of variation of even what would be considered simple and straightforward directions found. For example, over 800 permutations of words and phrases used to convey "take one tablet by mouth once daily" were identified.

The researchers not only looked at the variations, they also analyzed the Sig text strings for quality-related events which were defined as “Sig text content that could impair accurate and unambiguous interpretation by staff at receiving pharmacies.” The biggest quality issue observed was incomplete Sigs. Prescriptions were commonly missing relevant dosages or administration frequency/timing information. They found that more than one in ten prescriptions contained some sort of quality issue.  Considering the number of electronic prescriptions that are sent and the not only time-wasting potential but possibly catastrophic results that could come from such quality issues, that figure is way too high.

The authors' recommendations for reducing the quality issues and variations include:

• Enhancing e-prescribing application user interfaces and Sig creation tools
• Improving end-user training and usability testing for optimal use of system functionalities
• Adopting and implementing the currently available Structured and Codified Sig format by both prescriber and pharmacy systems to facilitate improved standardization and interoperability

At MDToolbox, patient safety and ease of use for prescribers are two of our main focuses when designing our directions input fields. We offer several options designed to make entering quality directions as easy as possible:

• Sig builder – build complete directions in just a few easy clicks
• Common Sigs – choose from the most commonly used Sigs already available in the system
• Saved favorite directions – prescribers can enter directions that they commonly use and save them as a favorite with a shortcut that can be quickly accessed
• Free-text directions – although free-text directions open it up to possible quality errors, MDToolbox has implemented quality checkers to ensure that free-text directions are not missing any of the information the contributes to many of the quality issues such as “how much” or “how often” the prescription should be used.

MDToolbox is also constantly looking for ways like our quality checkers to enhance these areas even more. Part of the way we do this is by conducting usability tests and end-user trainings in order to get feedback from users and ensure users are taking advantage of the available tools. We share a goal with Surescripts to have zero-error e-prescribing and are continually striving towards this goal.

1. Quality and Variability of Patient Directions in Electronic Prescriptions in the Ambulatory Care Setting https://www.jmcp.org/doi/10.18553/jmcp.2018.17404