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Communication through the electronic health record: frequency and implications of free text orders.

MedStar author(s):

Citation: Jamia Open. 3(2):154-159, 2020 Jul.PMID: 32734153Institution: MedStar Institute for Innovation | MedStar Washington Hospital CenterDepartment: Emergency Medicine | National Center for Human Factors in HealthcareForm of publication: Journal ArticleMedline article type(s): Journal ArticleSubject headings: IN PROCESS -- NOT YET INDEXEDYear: 2020 ISSN:

2574-2531

Name of journal: JAMIA openAbstract: Communication for non-medication order (CNMO) is a type of free text communication order providers use for asynchronous communication about patient care. The objective of this study was to understand the extent to which non-medication orders are being used for medication-related communication. We analyzed a sample of 26 524 CNMOs placed in 6 hospitals. A total of 42% of non-medication orders contained medication information. There was large variation in the usage of CNMOs across hospitals, provider settings, and provider types. The use of CNMOs for communicating medication-related information may result in delayed or missed medications, receiving medications that should have been discontinued, or important clinical decision being made based on inaccurate information. Future studies should quantify the implications of these data entry patterns on actual medication error rates and resultant safety issues. Copyright (c) The Author(s) 2020. Published by Oxford University Press on behalf of the American Medical Informatics Association.All authors: Hettinger AZ, Hoffman DJ, Kandaswamy S, Marquard J, Ratwani RMFiscal year: FY2021Digital Object Identifier:

https://dx.doi.org/10.1093/jamiaopen/ooaa020

Date added to catalog: 2020-09-02

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Title notes ( 2 )

Holdings
Item type	Current library	Collection	Call number	Status	Date due	Barcode
Journal Article	MedStar Authors Catalog	Article	32734153	Available		32734153

Communication for non-medication order (CNMO) is a type of free text communication order providers use for asynchronous communication about patient care. The objective of this study was to understand the extent to which non-medication orders are being used for medication-related communication. We analyzed a sample of 26 524 CNMOs placed in 6 hospitals. A total of 42% of non-medication orders contained medication information. There was large variation in the usage of CNMOs across hospitals, provider settings, and provider types. The use of CNMOs for communicating medication-related information may result in delayed or missed medications, receiving medications that should have been discontinued, or important clinical decision being made based on inaccurate information. Future studies should quantify the implications of these data entry patterns on actual medication error rates and resultant safety issues. Copyright (c) The Author(s) 2020. Published by Oxford University Press on behalf of the American Medical Informatics Association.

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