Mandatory medication indications in electronic systems

As hospitals transition from paper to electronic medication charts, an opportunity exists to 'nudge' prescribers to document medication indications by making this data-entry field mandatory. The aim of this study was to explore hospital doctors' perceptions of mandatory documentation of indications in an electronic medication management (EMM) system. Ten junior doctors took part in brief semi-structured interviews. Participants identified improved communication among staff as a key benefit of indication documentation. Recording indications was also seen to act as a prompt for medication review. Despite these benefits, indication documentation for all medications would be challenging to implement in practice. Users of the EMM system (i.e. junior doctors) explained that they are time poor and are often tasked with transcribing medication orders into the electronic system with limited knowledge of why medications are being prescribed. Determining the indication for use would require additional time and effort, and prescribers reported a high risk of working around the system if indication documentation was made mandatory.