Healthcare Technology Featured Article

November 16, 2016

Taking e-Prescribing to the Next Level with the Structured and Codified Sig

Electronic prescribing (e-prescribing) is no longer in its infancy. Today, 80 percent of ambulatory physicians use this method to prescribe medications for their patients and send that information electronically to the pharmacy. However, e-prescribing patient safety benefits and efficiencies cannot be fully realized without increased use of functionalities that already exist in the National Council for Prescription Drug Programs (NCPDP) SCRIPT Standard v. 10.6. An example is the Structured and Codified Sig (short for Signatura). This part of the prescription communicates dosing instructions to the pharmacy that will then be conveyed to the patient. However, the Structured and Codified Sig is not used to its full potential. In fact, it is seldom used at all.

Work on the Structured and Codified Sig has been ongoing for more than a decade. With impetus from the government and a federal advisory group, a task group was convened to address the issue by NCPDP, which develops and maintains the SCRIPT standard. The idea was to standardize communication of dosing instructions within the e-prescribing process to create unambiguous and complete directions for the pharmacy filling the e-prescription. Other benefits include decreased opportunities for transcription errors and improved efficiencies and work flows for both prescribers and pharmacists. 

Despite the progress that has been made, the Structured and Codified Sig is rarely used by prescribers or supported by many electronic health records (EHRs) enabled for e-prescribing. Reasons include work-flow and technical challenges, as well as lack of user demand.

Workflow challenges. Work-flow challenges that serve as barriers to adoption still exist for the prescriber and pharmacy.

Currently, there are two ways for prescribers to indicate their dosing directions in e-prescribing using NCPDP SCRIPT v. 10.6. The first is a mandatory 140-byte free text field. The second is the additional optional use of separate fields that provide coded data for the various components of the instructions: the verb, route, dosage form, indication, vehicle, site, timing and duration. Most users simply prefer to enter whatever they want in the free text field. 

Manually entering dosing instructions into the free text field is an efficiency issue for prescribers as well as for pharmacists, who must rekey the information from free text Sig into the pharmacy system once an e-prescription is received. This creates the potential for numerous time-consuming calls for clarification between pharmacists and physicians. All this manual entry and rework additionally open the door to errors and have implications for the quality and safety of patient care.

Technical challenges. Several technical challenges limit adoption of the Structured and Codified Sig. For example:

There is the complexity of the mandatory standardized, interoperable code sets for many of the Sig segment fields. SNOMED-CT was selected for all fields except one. The remaining field must be populated using federal medication terminologies and National Cancer Institute code set. Needless to say, this is a lot for vendors to understand and complex to program.

Sig builders are available in most e-prescribing-enabled EHRs. These include drop-down menus for common terms and favorites the prescriber can add. Once selected, however, this information is populated into the free text field, which can never be left blank. Even though the data are already being created by the prescriber in individual fields, most EHRs lack the ability to transfer the same data into the codified Sig segment.

Vendors must create behind-the-scenes tables to map the various elements of the dosing instructions into the e-prescription — or the reverse when the pharmacist receives the e-prescription. These changes are costly to develop and release, and vendors prioritize their enhancements based on user demand and mandate. Tepid demand and lack of a mandate have caused support of Structured and Codified Sig to be a low priority for EHR vendors.

Anecdotally, pharmacies are wired to accept data but don't yet "process" or use the information in the Structured and Codified Sig segment. Since few prescribers are using it, pharmacies have been slow to adapt their systems to support it.

Opportunities. The groundwork for the Structured and Codified Sig has been laid. Opportunities exist to make it more valuable and usable to prescribers, as well as enhance vendor offerings. These include:

  • Develop a commonly used subset of codes for each Sig field. This is something that perhaps an NCPDP task group could address. A good start has been made by providing a lot of this information in the standard’s implementation guide.
  • Identify gaps and usability challenges. Now that e-prescribing is commonplace, it is time to revisit the barriers and opportunities that exist for use of the Structured and Codified Sig in both the ambulatory and inpatient settings.
  • Continue enhancements to NCPDP SCRIPT. According to experts, enhancements incorporated in SCRIPT version 2012+ include a more robust Structured Sig Segment, which supports a text field size of 1000, as well as other enhancements and recommendations from a pilot. As use of the Sig becomes more commonplace, NCPDP will likely receive more requests for enhancements.
  • Develop additional pilots. Once gaps and challenges have been identified, stakeholders could develop pilots to test potential solutions.
  • User improvements. Vendors should continue to seek ways of implementing the Structured and Codified Sig to make its use easier for prescribers. This could create competitive advantage. For example, vendors could improve Sig favorite’s capabilities by including the most commonly used Sigs. Many of these have already been identified by NCPDP. As a best practice, Surescripts recommends that vendors should determine the 100 most commonly prescribed Sig concepts and make sure the system can fully accommodate construction and transmission of these Sig strings.  
  • Training is needed. Physicians will have to be educated about the need for — and use of — the Structured and Codified Sig so it can be used to its full potential. Although it is part of a technical transaction and should be invisible to the user, prescribers must be educated about functionalities available in the electronic Sig and their importance to quality and safety of patient care.
  • Work with the government on rule making. Currently, the Structured and Codified Sig is optional for use in certified EHRs. At some point, the government will consider the standard mature enough to be made mandatory for EHR certification. As we have learned from previous standards adoption efforts, early involvement in the rule-making process is crucial for outcomes that are acceptable and workable for stakeholders. 

Moving forward. The value of e-prescribing cannot be fully realized without enhancements to — and use of — the Structured and Codified Sig. It’s important for stakeholders to find a way to stimulate user adoption and move the ball up the field. Let’s hope the industry and users can continue to work together to make measurable progress in addressing some of the barriers and challenges surrounding its use. The quality and safety of health care demand it. 

The author thanks NCPDP member Laura Topor, who has led NCPDP’s Structured and Codified Sig efforts, for her review and comment on a draft of this article.

Edited by Alicia Young
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