All too often, pharmacists receive a prescription without knowing why the patient will be taking the medication.
Having the indication included with the script allows the pharmacist to provide more specific counseling information, and the data can be used to improve quality efforts. Including the indication on the prescription also allows the pharmacist to print that information on the container label, which may improve patient adherence. This is especially true for patients who are on multiple medications or who have memory problems. Remembering complicated drug names (brand or generic) or having several products that look alike (for example, a small, white tablet) can be confusing for patients. A simple addition to the label, such as “take one tablet by mouth each day for blood pressure,” can be valuable.
Indication vs. diagnosis
First of all, we should clear up the distinction between indication and diagnosis, as the terms are often used interchangeably. The diagnosis is a specific condition, i.e., the patient has Hepatitis C. However, indication refers to the reason a medication might be used, i.e., liver failure.
From a documentation perspective, providers are generally accustomed to coding the diagnosis to support billing. They are less accustomed to associating an indication to a prescription and documenting that “reason for use” in the chart or on the prescription. Diagnoses are coded using ICD-10 (International Classification of Diseases, 10th edition), while indications are coded using SNOMED CT® (Systematized Nomenclature of Medicine-Clinical Terms). Both of these coding systems are widely used today to support interoperability. The use of the codes is required for some programs, or to achieve certification of an electronic health record. The NCPDP SCRIPT Standard, which is used for electronic prescribing, supports the inclusion of both ICD-10 and SNOMED CT codes, and NCPDP has published guidance regarding the inclusion of indication.
A pharmacist might use the information on diagnosis to
- Infer the indication
- Support billing, especially for Medicare Part B supplies
- In some cases, support prior authorization requests and/or renewals
There are certainly risks in inferring indication from diagnosis, especially if the prescriber is using a medication for an off-label purpose.
A recent article in JAMA Internal Medicine by Dr. Tewodros Eguale, et al, investigated the correlation between off-label drug use and adverse drug events. The authors reviewed the records of more than 46,000 Canadian patients who received more than 151,000 prescriptions. The distinction of the patients being Canadian is important, as the EHR used in Quebec province requires the prescriber to document the indication for each new prescription. In addition, prescribers are also required to capture the reason a prescription is discontinued. This allows for more complete capture of adverse drug event data. With this data, the researchers identified a relationship between off-label drug use, drug class, poly-pharmacy, and adverse events.
The key takeaway is the importance of capturing data — the indication and the reason for a prescription’s discontinuation. While U.S. systems and standards currently support the capture and exchange of indication data, reason for discontinuation likely isn’t getting the same level of attention.
Dr. Gordon Schiff of Brigham and Women’s Hospital has also done extensive research into the benefits of including the indication on prescriptions. His most recent article in the New England Journal of Medicine (July 28, 2016) outlined a number of the benefits of indication-based prescribing:
“First, when medication choices are narrowed to those indicated for a specific problem, decisions are much less prone to error…
Second, we know that if patients are to understand and adhere to their medication regimens, they need to know the reason each medication is being prescribed…
Third, prescribers need and want help choosing the best drugs for their patients’ problems...
Fourth, knowledge of indications is key to getting prescribers, pharmacists, nurses, and patients on the same page regarding what is being treated and what outcomes are desired. Pharmacists who are uncertain about the reason a medication is being given will be unable to explain it to the patient …
Fifth, problems with medication reconciliation are a substantial source of confusion and error, including inadvertent duplicate therapy and inappropriate continuation of medications that are no longer needed…
Finally, one cannot meaningfully measure a drug’s long-term effectiveness (or comparative effectiveness) without reference to the reason for its use…”
Dr. Schiff addresses concerns expressed about inclusion of indication, which range from time and impact on workflow to confidentiality. Many, if not all, of the concerns can be addressed with system enhancements, he says. Starting with the indication can allow prescribers to then select from the medications most commonly used to treat the condition. This wouldn’t deter off-label uses, but it would allow for better capture of the data associated with those uses. Systems supporting opt-out features can protect privacy in cases where additional protections are in place (mental health, HIV).
Marsha K. Millonig, MBA, BPharm, is president and CEO of Catalyst Enterprises, LLC, and an Associate Fellow at the University of Minnesota College of Pharmacy’s Center for Leading Healthcare Change.