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\begin{document}

\title{Indications-based prescribing: A challenge for hospital prescribers}



\author[1]{Melissa Baysari}%
\author[1]{Maria Moran}%
\author[2]{Jessica Del Gigante}%
\author[3]{Richard Day}%
\affil[1]{The University of Sydney Faculty of Medicine and Health}%
\affil[2]{St Vincent's Hospital}%
\affil[3]{St Vincent's Hopsital, Australia}%


\vspace{-1em}



  
  \date{May 30, 2024}


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\textbf{}

Clinicians, patients, administrators and researchers have become
increasingly frustrated by the lack of indication (i.e. problem)
information included in prescriptions, despite the obvious benefit this
would provide to patients and other healthcare providers {[}1{]}.
Medication indications are not routinely documented by prescribers, both
in inpatient and outpatient settings.{[}2, 3{]} Calls have been made to
introduce a sixth `right' into the medication management process,
whereby the right patient is given the right drug and dose at the right
time via the right route for the \emph{right indication} {[}4{]}.
Indications-based prescribing has recently gained traction as a
potential way forward to facilitate indication documentation {[}4, 5{]}.
Indications-based prescribing, not currently supported by most
electronic prescribing systems (EPSs), describes the scenario where
prescribers initially select an indication, not a medication, and the
EPS presents the user with suggested medications for addressing the
problem. There are clear advantages with this approach, including those
associated with guided prescribing (e.g. more appropriate drug
selections) and with indication documentation (e.g. improved
communication between providers), prompting work to begin on developing
EPS functionality in the US to support indications-based prescribing. In
a recent usability evaluation of a prototype of this functionality,
indications-based prescribing was more efficient to use, resulted in
fewer medication errors and in higher usability scores than the
traditional EPS functionality {[}6{]}.

\textbf{Prescribing in hospitals -- A challenging context of use}

Although the focus of renewed efforts, indications-based prescribing is
not new, and has formed the basis of many EPSs for antimicrobial
prescribing. In reflecting on the lessons learnt from those
implementations, a particular challenge comes to mind, one that relates
to the context of use. The recent usability evaluation {[}6{]} was
undertaken in an ambulatory care setting where diagnosis represents a
core activity of users of the EPS. But in thinking about how hospital
work is done, users of the EPS are rarely diagnosticians and a large
proportion of prescribing work is in fact transcribing work undertaken
by junior doctors. Observational studies in the UK and Australia have
shown that users of hospital EPSs are rarely the decision-makers {[}7,
8{]}. Our discussions with hospital prescribers about the possibility of
introducing indications-based prescribing prompted some interesting
responses from junior doctors and highlight some of the practical
difficulties associated with indications-based prescribing. For example,
a doctor said: \emph{``You don't really think about it like, this
patient has heart failure and therefore I am going to prescribe this
medication. I know it should be that way but it doesn't really happen.
If you are a GP (General Practitioner) and a patient comes in with a
complaint, absolutely, you know that would be a great system for GPs but
in the hospital\ldots{}As a junior doctor, I have to stress this, junior
doctors, they are the least experienced but they are the ones that are
charting the majority of medications, I would argue. So, we get a lot of
our advice and a lot of the things we have to chart, we are not charting
them because we think it is a good idea, we are charting them because
our consultant or our registrar thinks it's a good idea, so it would be
a nightmare to have to type in a disease profile and then have to find a
medication''{[}9{]}.}

One of the main impetuses for redesigning EPSs to support
indications-based prescribing is that current systems are viewed to be
cumbersome, requiring users to enter or select an indication from a
drop-down menu after-the-fact, which deters users from documenting an
indication. There is good evidence to show that when a computerised
system prevents users from doing their job, or doing their job quickly,
workarounds transpire, a potential consequence of which is inaccurate
documentation of indications. Audit studies have shown that indication
documentation in hospital EPSs is often inaccurate, with one study, for
example, reporting that accurate documentation of indications for
off-label use of medications was as low as 29\% for some drug classes
{[}10{]}. The flow-on effects of inaccurate indication documentation in
a hospital EPS can be more widespread than a single setting or
organisation. The inaccurate indication can follow the patient out of
hospital (via discharge scripts, patient medication lists and medication
labels), potentially resulting in confusion and misinterpretation by the
patient and their healthcare providers. In one study, when questioned
why some indications recorded in a hospital EPS did not reflect true
indications, doctors reported the EPS was ``a barrier'' to giving
patients the right medications {[}3{]}. We would argue that indications
are not documented by hospital prescribers in many cases because the
indication is not known by the EPS user. In an Australian study which
explored hospital prescribers' perspectives on recording indications, a
key barrier to indication documentation was identified to be prescriber
knowledge of the indication: \emph{``I think that {[}recording
indications{]} would be really beneficial only if the person doing it
knew what they were doing. I can just remember as an intern, you know,
you just copy whatever they are usually on, and sometimes you don't know
why they are on this rather than something else} '' {[}9{]}. Doctors
were also concerned about the additional work associated with
identifying indications (i.e. contacting patients' general practitioners
or pharmacists), because hospitalised patients, often acutely unwell,
are not always able to provide an accurate list of medications and their
indications. Thus, the time savings that may be achieved with
indications-based prescribing in ambulatory care would unlikely be
realised in a hospital setting.

Indications-based prescribing represents an ambitious attempt to improve
patient safety, not only because it requires a significant redesign of
EPS but because it requires an enormous shift in prescriber thinking and
practices. Occasionally, designing information technology
to\emph{misalign} with current work practices is needed, particularly to
achieve transformation in healthcare. Whether hospital doctors, both
senior and junior, are ready to be `transformed', well, only time will
tell.

\textbf{Conflicts of interest}

None

\textbf{Funding}

Not applicable

\textbf{Availability of data}

Not applicable

\textbf{References}

1. Garada M, McLachlan AJ, Schiff GD, Lehnbom EC. What do Australian
consumers, pharmacists and prescribers think about documenting
indications on prescriptions and dispensed medicines labels?: A
qualitative study. BMC Health Serv Res. 2017;17(1):734.
doi:10.1186/s12913-017-2704-3.

2. Salazar A, Karmiy SJ, Forsythe KJ, Amato MG, Wright A, Lai KH et al.
How often do prescribers include indications in drug orders? Analysis of
4 million outpatient prescriptions. Am J Health Syst Pharm.
2019;76(13):970-9. doi:10.1093/ajhp/zxz082.

3. Baysari MT, Del Gigante J, Moran M, Sandaradura I, Li L, Richardson
KL et al. Redesign of computerized decision support to improve
antimicrobial prescribing. A controlled before-and-after study. Appl
Clin Inform. 2017;8(3):949-63. doi:10.4338/ACI2017040069.

4. Schiff GD, Seoane-Vazquez E, Wright A. Incorporating Indications into
Medication Ordering--Time to Enter the Age of Reason. N Engl J Med.
2016;375(4):306-9. doi:10.1056/NEJMp1603964.

5. Kron K, Myers S, Volk L, Nathan A, Neri P, Salazar A et al.
Incorporating medication indications into the prescribing process. Am J
Health Syst Pharm. 2018;75(11):774-83. doi:10.2146/ajhp170346.

6. 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-e.
doi:10.1001/jamanetworkopen.2019.1514.

7. Baysari MT, Westbrook JI, Richardson KL, Day RO. The influence of
computerized decision support on prescribing during ward-rounds: are the
decision-makers targeted? JAMIA. 2011;18:754-9.
doi:10.1136/amiajnl-2011-000135.

8. Bell H, Garfield S, Khosla S, Patel C, Franklin BD. Mixed methods
study of medication-related decision support alerts experienced during
electronic prescribing for inpatients at an English hospital. Eur J Hosp
Pharm. 2019;26(6):318-22. doi:10.1136/ejhpharm-2017-001483.

9. Baysari M, Del Gigante J, Moran M, Lehnbom E, Day R. Mandatory
Medication Indications in Electronic Systems - The Prescriber
Perspective. Stud Health Technol Inform. 2019;265:95-100.
doi:10.3233/shti190145.

10. Walton SM, Galanter WL, Rosencranz H, Meltzer D, Stafford RS,
Tiryaki F et al. A trial of inpatient indication based prescribing
during computerized order entry with medications commonly used
off-label. Appl Clin Inform. 2011;2(1):94-103.
doi:10.4338/ACI-2010-11-RA-0072.

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