435 Indication documentation and indication-based prescribing within electronic prescribing systems: a systematic review and narrative synthesis of interventions that aid indication documentation
Authors: Feather C , Applebaum N , Darzi A , Franklin B 
Published: April 2023

Abstract

Introduction
Indication documentation is one part of the prescribing process that can aid safer prescribing practice with a positive impact on the patient, prescriber, and the wider healthcare team (1,2). Despite recommendations, documentation of indication on prescriptions and inpatient medication orders is not routinely practiced. Literature describing the impact of interventions aimed at improving indication documentation is scarce.

Aim
We aimed to provide: (1) an overview of existing interventions aimed at affecting indication documentation and indication-based prescribing within electronic prescribing systems in primary and secondary healthcare; (2) recommendations for practice and research.

Methods
A systematic literature search was conducted using Medline, Embase and CINAHL using two search concepts: Electronic prescribing systems, and indication documentation and/or indication-based prescribing. Studies were included if they examined interventions aimed at affect indication documentation and/or indication-based prescribing, or if they provided participant insights on this subject. Qualitative, quantitative, and mixed methods studies were included; outcome measures and results were extracted to produce a narrative synthesis. The protocol is registered on Prospero, the international prospective register of systematic reviews, reference CRD42021278495.

Results
25 studies were identified, evaluating interventions that aid indication documentation. Indication documentation was either via free-text, selection from a list or by the use of indication-based order sentences. Outcome measures and findings are presented in the table below. Commonly reported outcome measures were appropriateness of the medication order, accuracy of indication documentation, rates of medication use and rates of prescribing error. Clinical and workflow related outcomes, the time to complete a medication order and the number of problems requiring pharmacy intervention were less commonly reported outcomes. Qualitative insights from prescribers and other healthcare professionals provided mixed feedback, highlighting both barriers and facilitators to the use of existing methods for indication documentation. For example, barriers included long drop-down lists and the need to use workarounds to navigate approval systems due to time or knowledge constraints. Facilitating factors included the perceived benefits of indication documentation on communication among the healthcare team and with the patient. This knowledge can be utilised create opportunities to maximise the benefits whilst reducing existing or potential workflow barriers.

Conclusion
Indication documentation has potential to improve appropriate prescribing and reduce prescribing errors. Further benefits to the prescriber, multidisciplinary team and patient may be realised by developing methods of indication documentation that integrate more efficiently with prescriber workflows.

References
1. 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.
2. 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.