Clearer Sigs Can Reduce Errors in E-Prescribing

A decade has passed since e-prescriptions became common. It’s now estimated that 73% of all U.S. prescriptions are filed electronically.

One benefit of e-prescriptions is that, compared to paper, phoned-in, and faxed-in prescriptions, patients are 10% more likely to adhere to first-fill prescriptions when they are delivered electronically.

A study published in the Journal of Managed Care and Specialty Pharmacy reviewed 25,000 e-prescriptions, issued by 22,152 community-based prescribers across the United States, using various electronic health records (EHRs) or e-prescribing software applications. The study found that although e-prescriptions are commendable, there’s room for improvement. 

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The existence of several hundred e-prescribing software applications means there is considerable variation in the way patient directions, or Sigs, are written. A simple instruction such as “take one tablet by mouth once daily” can be expressed in hundreds of ways and wording proved problematic in 10% of the Sigs studied. Confusing Sigs can disrupt the work day of both prescribers and pharmacists, potentially posing risks to patient safety.

“The most common ‘problem’ we see is when a medication has a default sig (e.g., take one tablet three times a day) and the intent is to prescribe it in a different way (e.g., take one tablet once daily),” says Marvin R. Moore, PharmD, owner of The Medicine Shoppe in Two Rivers, WI. “Instead of clearing out the default, we'll see prescriptions that have two sets of directions. They might both appear in the Sig field (e.g., take one tablet three times a day take once daily), or they might have one set of directions in the Sig field with a different set of directions in an ‘other’ field,” he says. “Either way, we end up calling to clarify, which isn't a good use of resources for either end.”

Such insights are helping health information networks such as Surescripts to recommend improvements in the design and functionality of electronic EHRs and e-prescribing applications. The Surescripts Network Alliance, which includes EHRs, PBMs, pharmacies, clinicians, health plans, long-term care settings, and specialty pharmacy organizations, recommends a structured and codified e-prescribing system.

“When prescribers match drugs to their e-prescribing preferred name (EPN) and corresponding drug identifiers like NDC and RxNorm, adopt structured and codified Sig, complete prior authorization while the patient is still in the office and change or cancel prescriptions when needed, we effectively remove the friction from the process and improve medication adherence. This has a combined effect of enhancing patient safety and increasing efficiency for everyone involved,” said Stacy Ward-Charlerie, PharmD, author of the Surescripts position paper, The Perfect Prescription.”

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System-wide consistency would help ensure that drug codes and descriptions match, standardized instructions are applied, and that prescriptions can be replaced and modified electronically. Training can also help.

“I think it still comes down to making sure that the person entering the prescriptions into the e-prescribing software is properly trained,” Moore tells Drug Topics. “We see a lot of Sigs, quantities, and sometimes dosage forms that simply don't make sense. I feel most of the time it's due to the person who is entering the information simply not having the necessary training or experience with the system. It seems that we see fewer mistakes/confusion with the medical staff that's been using the software for a longer time.”