Realising the untapped potential of indication documentation and indication-based prescribing

At present, there are a number of agreed-upon ‘right’ components to prescribing: the right patient, the right medication, the right dose, the right route, the right formulation, to be given at the right time. A conversation has been growing that suggests that another component should be added to this list: the ‘right’ indication1-4. This additional component of clear and correct indications could be the key to unlocking a safer and more efficient prescribing process5,6, by supporting the prescriber in making a more conscious selection of the medication and dose based on why the medication is being used.

Once the indication has been considered and a medication and dose chosen, documenting the indication on medication orders and prescriptions seems a logical next step. Indication documentation has long been recommended by leading authorities5,6; however, its practice is still somewhat limited. Even when organisations advocate documentation of indication on prescriptions, this is typically required only for antimicrobials and “when required” medications.

By documenting the indication, prescribers can inform other staff as to why the medication has been prescribed. Prescribing errors are more likely to be spotted when indications are available, not only by the prescriber but also by downstream staff when checking the prescription prior to dispensing or administering the medication. Deprescribing can be aided by having a clearer overview of the patients’ medications and reasons for use, which is particularly relevant with co-morbidities and polypharmacy on the rise. In addition, indication documentation can be used to aid communication amongst staff, especially when transitioning between care settings or providers. Similarly, indications can improve communication of medications with patients and their caregivers, both when discussing verbally and via discharge summaries and prescriptions. Furthermore, stewardship of medications, whether for antimicrobials or other groups of medication, can be improved with indication documentation through organisational and patient-level surveillance of medication usage. In some cases, documented indications can also trigger alerts and/or other forms of decision support within electronic prescribing systems. Through such strategies, it is becoming increasingly clear that indication documentation has potential to have more far-reaching benefits, with overall improvements to the safety and efficiency of medication use.

In relation to antimicrobials specifically, a recent systematic review from Saini and colleagues provides a thorough overview of the state of play regarding indication documentation and its impact on antimicrobial prescribing7. First, the authors described the measurement of indication documentation: prevalence, accuracy, and clarity. They then went on to review the reported outcomes of indication documentation. The most commonly reported outcomes were for appropriateness of prescribing and antimicrobial utilisation, with less commonly reported outcomes including economic and patient outcomes and adherence to restriction criteria. Seventeen of the nineteen studies that reported the impact on patient and prescribing outcomes demonstrated a benefit.

However, it isn’t all rosy in the world of indication documentation – unfortunately, a seemingly simple addition of a box for indication on a medication order form is not so straightforward. The review by Saini and colleagues also presented qualitative aspects extracted from the included studies, utilising the COM-B model for behaviour change to classify the barriers and facilitators to indication documentation. Their findings suggest that a closer look at these barriers and facilitators will be required for indication documentation to be implemented successfully. It seems likely that the current barriers to indication documentation outweigh the potential benefits in many settings, as feedback from clinicians highlights how time-consuming it is to include the indication for all medications8. Some systems present the prescriber with cumbersome drop-down lists, which can be frustrating to use and can lead to accidental mis-selection. It is also notable that a prescriber might not always know the indication, particularly when a trainee is delegated a prescribing task by a more senior colleague or when someone is transcribing medications that the patient is already taking during a transition of care.

All, however, is not lost. By leaning on facilitating factors to overcome such barriers, indication documentation can be supported through a multipronged approach. Raising awareness of the benefits of indication documentation for error prevention, communication and medication stewardship could increase the prescribers’ knowledge and motivation to add this to their current prescribing practice. At a systems level, the increase in electronic prescribing and associated clinical decision support can also aid indication documentation. In some settings, indication documentation is now facilitated via the use of indication-based order sentences. For example, a prescription might read, ‘Oseltamivir for the prevention of influenza, by oral administration, 60mg once per day’ rather than ‘Oseltamivir for the treatment of influenza, by oral administration, 60mg twice per day’. In these cases, order sentences have an indication explicitly linked to the medication along with the dose, frequency, route etc. When the medication is ordered, the indication is automatically documented along with the medication and dosing information.

Teams in the United States have gone one step further than indication documentation. To harness the aforementioned benefits whilst reducing the burden on prescribers, they have developed ‘indication-based prescribing’9,10. These interventions have redesigned the typical prescribing workflow to begin the prescribing process with the indication. The prescriber is then presented with the most appropriate medications for the patient along with suitable dosing regimens. Thus, the indication can be automatically documented on the prescription or medication order and, in some cases, simultaneously populate the patient’s Problem List. Studies of these indication-based prescribing interventions demonstrate promising results, with reductions in time to prescribe, fewer mouse clicks and more appropriate prescribing9,10. Adoption of such systems could be encouraged by developing partnerships between healthcare settings and system developers to create solutions that address potential barriers prior to implementing new systems into practice. The use of human-centred design approaches will aid this process, working across all stakeholders from the health system leadership level down to the prescribers and patients from inception of the intervention through to implementation and beyond.

By incorporating comprehensive formulary databases and guidance into the electronic prescribing system, indication documentation and indication-based prescribing workflows have the potential to provide users with up-to-date guidance and recommendations for treatment options. Such workflows can reduce the burden of trying to remember ever-changing advice and complex drug regimens from memory, making prescribing safer and more tailored for the patient while creating an easier and more efficient process for the prescriber. Now is the time to maximise on this opportunity, through disruptive innovations that can make a lasting and positive change to prescribing practice.

Calandra Feather

Calandra Feather (@calandrafeather) is a Doctoral student and Researcher at the Centre for Medication Safety and Service Quality at Imperial College NHS Trust. Prior to her doctoral studies, she has worked as a paediatric intensive care nurse.

References
1. Kron K, Myers S, Volk L, Nathan A, Neri P, Salazar A, et al. Incorporating medication indications into the prescribing process. American Journal of Health-System Pharmacy. 2018;75(11): 774–783. https://doi.org/10.2146/ajhp170346.
2. Schiff G, Mirica MM, Dhavle AA, Galanter WL, Lambert B, Wright A. A prescription for enhancing electronic prescribing safety. Health Affairs. 2018;37(11): 1877–1883. https://doi.org/10.1377/hlthaff.2018.0725.
3. Schiff G, Volk LA, Wright A, Garabedian PM, Salazar A, Amato MG, et al. Enhancing Medication CPOE Quality & Safety by Indications Based Prescribing- Final Report. 2018; 1–20.
4. Baysari MT, Moran M, del Gigante J, Day RO. Indications-based prescribing: A challenge for hospital prescribers. British Journal of Clinical Pharmacology. 2021;87(3): 730–731. https://doi.org/10.1111/bcp.14532.
5. Recommendations to Enhance Accuracy of Dispensing Medications. NCCMERP. p. 8–9. https://www.nccmerp.org/recommendations-enhance-accuracy-prescription-writing [Accessed 5th November 2020].
6. UK General Medical Council. Good practice in prescribing and managing medicines and devices. Good Medical Practice. 2021;(April): 1–17. www.gmc-uk.org/guidance%0Ahttp://www.gmc-uk.org/Prescribing_guidance.pdf_59055247.pdf
7. Saini S, Leung V, Si E, Ho C, Cheung A, Dalton D, et al. Documenting the indication for antimicrobial prescribing: a scoping review. BMJ Quality & Safety. 2022; bmjqs-2021-014582. https://doi.org/10.1136/bmjqs-2021-014582.
8. Baysari MT, Gigante J del, Moran M, Sandaradura I, Li L, Richardson KL, et al. Redesign of computerized decision support to improve antimicrobial prescribing. Applied Clinical Informatics. 2017;8(3): 949–963. https://doi.org/10.4338/ACI2017040069.
9. Garabedian PM, Wright A, Newbury I, Volk LA, Salazar A, Amato MG, et al. Comparison of a Prototype for Indications-Based Prescribing With 2 Commercial Prescribing Systems. JAMA network open. 2019;2(3): e191514. https://doi.org/10.1001/jamanetworkopen.2019.1514.
10. Goss FR, Bookman K, Barron M, Bickley D, Landgren B, Kroehl M, et al. Improved antibiotic prescribing using indication‐based clinical decision support in the emergency department. Journal of the American College of Emergency Physicians Open. 2020;1(3): 214–221. https://doi.org/10.1002/emp2.12029.

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