Putting indications on all prescriptions may reduce errors.
The five “rights”- the right patient, right drug, right dose, right time, and right route are essential for safe medication ordering and use. But some medication safety experts assert that the time has come to add a sixth element: the right indication.
Adding the indication on either print or electronic prescriptions can help prevent medication errors and improve medication use in a variety of ways, says Gordon Schiff, MD, Associate Professor of Medicine, Harvard Medical School, and Associate Director, Center for Patient Safety Research and Practice, Brigham and Women’s Hospital in Boston.
Currently, less than 10% of prescriptions have the indication listed.
How close are we to indications-based prescribing being commonplace?
“In a primitive form, we are already there. Various EMR vendors include options for attaching indications to the prescription. Some VA medical centers are also requiring their clinicians to include indications,” Dr. Schiff told Drug Topics.
But Schiff said that it will be years before the sort of visionary prototype that he and his team are designing becomes a reality for prescribers. The best case scenario, he said, would be that some enlightened vendors would redesign their CPOE systems in a way that would allow clinicians to start with an indication.
“People from the patient safety, pharmacy, and health policy communities, along with patients, will need to keep pushing to make indications-based prescribing a reality,” Schiff said.
Schiff and his team at Brigham and Harvard have identified several key areas as to why the indication should be on the prescription and why it will result in better outcomes. He also admits there are some obstacles. The idea, for instance, has not been very popular among physicians or among those concerned about patient confidentiality (Table 1).
“The indication is something that can really help us know what the right drug is, what the right dosing is, and prevent and spot errors,” said Schiff.
Up next: Obstacles and challenges
In an article published in the July 28, 2016, New England Journal of Medicine entitled: “Incorporating Indications into Medication Ordering - Time to Enter the Age of Reason,” Schiff and his co-authors claim: “patients are often still in the dark regarding the purposes of their medications. We believe it’s time to add to each prescription an ingredient that’s currently conspicuously missing: the right indication.”
Christine Cheng, PharmDChristine Cheng, PharmD, Clinical Pharmacist in the Disease Decision Support Group at First Databank, has conducted research to identify attributes of drug indication information based on review of FDA-approved labeling, to model requirements needed to support application of indications data for different use cases, and to identify challenges associated with representing indications in a drug knowledge base.
“What we are trying to do at First Databank is take that very granular description of a drug indication and try to display it terms clinicians may use, and what consumers may recognize,” said Cheng.
For example: if a drug were FDA-approved for “uncomplicated skin and skin structure infection” then one term that might be displayed to the clinician is “cellulitis” and a term that might be intended for the consumer might be “bacterial skin infection.” There are different ways of describing an indication that may be useful for different applications of that information.”
What are the obstacles to indications-based prescribing?
“Creating a construct of drug indications data that would best support indications-based prescribing is the main challenge from the knowledge management perspective. The data need to be structured in a way that would allow a provider or the health information system to query and filter drug indications based on multiple attributes and at varying levels of granularity,” said Cheng.
For example, a provider looking up “multiple sclerosis” should be able to drill down to more specific indications (e.g., relapsing multiple sclerosis, secondary-progressive multiple sclerosis, acute exacerbation of multiple sclerosis, walking impairment due to multiple sclerosis, fatigue due to multiple sclerosis) to find the exact drug(s) appropriate for the patient’s diagnosis. “We also need to consider that different conditions can be subdivided differently,” said Cheng.
Bacterial infections, for example, can be modeled based on the causative organism, site of infection, patient characteristics, and/or therapy intent (e.g., prophylactic versus empiric versus definitive therapy) and so should be searchable by these attributes. Some drugs treat a symptom (e.g., pain) that could be associated with a variety of conditions, so these symptoms, noted Cheng, may need to be associated with multiple primary diseases.
Cheng explained that there are also cases where one drug would need to be associated with other drugs for a given indication (e.g., triple therapy for H. pylori infection) so that the provider is presented with a treatment regimen for a given indication as opposed to only the individual drugs. “In short, the indications data structure would need careful and thorough vetting in order for indications-based prescribing (integrated into the electronic workflow) to become a reality.”