10 Realities in Translating Drug Directions to SIG Codes

Growing up, every winter break my family and I would take a trip to Taiwan. Despite seeing it as somewhat of a cumbersome tradition that’d inevitably pull me away from my friends and my progress in whatever video game I was playing at the time, my dad always found a way to make  the trip fun.

In 2015, he came up with this brilliant idea: “I’ll give you [a retrospectively inconsequential amount of money] to eat anything I point at throughout the trip.” Most of it was pretty good, some were clearly chosen to mess with me, but one item quickly became the iceberg to my stomach’s Titanic.

A batch of quail eggs prepared in a takoyaki pan mercilessly sent me to the hospital. After a shot of something for the cramps, an IV to keep me hydrated, and a bed to spend the night; the $100 dollars was still solidly in play, as I was quick to remind.

Can you guess how much the hospital bill was?

What makes American healthcare so expensive? It’s not just the massive amounts of capital required for drug development, but it's also the cost of the manual and time consuming administrative work required to navigate and adhere to the system's complexities and regulations.

With that in mind - I’ll focus on one topic in particular: the inefficiencies around processing SIG codes.

SIG codes are abbreviations of drug administration instructions for pharmacists and care teams. For example:

Take 1 tablet by mouth two times a day for anxiety >>> T1T PO BID ANX

Typically, technicians follow a [Administration] [IntakeMethod] [DailyAmount] [Diagnoses] format, though different conventions are used across both organizations and drug types, which makes processing them complicated and time consuming. They're often done by hand.

What’s inefficient with the SIG code process as it is?

SIG Codes are often manually written by humans:

Naturally, there are lots of mistakes. Misspellings, misinterpretations, typically anything that involves a pair of sentient eyes and hands ends up inconsistent.

Drug direction formatting is inconsistent and involves semantics:

“By mouth” and “orally” both map to “PO”. “For sleep”, “insomnia”, and “sleep aid” map to both “SLEEP” and “FOR INSOMNIA”. Both “FOR DIARRHEA” and “FOR LOOSE STOOLS” exist.

Drug direction formatting occasionally requires human input:

Technically, “before meals and bedtime” is functionally the same as “four times a day” (mapping to “QID”), despite having codes like AC and QHS for meals and bedtime, respectively.

Drug directions themselves often omit information:

One of the most common errors in SIG codes is the exclusion of drug delivery format (i.e. tablet, capsule, liquid etc.), resulting in missed administration elements (e.g. T1T/T2C).

Some processes just do not have SIG codes:

Typically the ones that fall under this category relate to drugs with topical applications. While some natural language conventions are ignored, for the most part words are spelled out, save for the [DailyAmount] which usually comes after the location of application.

Total dosages are sometimes required:

When tablets or capsules need to be split in half, or taken multiple times throughout the day, providers need to know. That being said, drug manufacturers typically give no indication on this front.

Ordering of SIG code components:

An addendum to the above point - total dosages may appear in different places throughout the SIG code. For example, for multiple pills, they appear in parentheses between [Administration] and [DailyAmount]; for multiple pills with different individual dosages, they appear standalone at the end, preceded by a TD.
Not to mention, some administration methods, such as subcutaneous injections have their own conventions, such as [DailyAmount] being appended directly without a space to [Administration] (i.e. INJQD or INJBID) followed by the amount of units.

Specific SIG codes are sometimes assigned to individual drugs, known as “default SIGs”:

For example, any time “Symbicort” products appear, “RINS” must appear in the SIG code. The same goes for MIRA in Miralax-based instructions.

Drug names, generic and brand, are difficult to keep track of:

Acetaminophen and antihistamines, Xyzal and Zyrtec. If people are paid to make up words, put me in touch with them. I have a background in Linguistics.

Organizations sometimes have abbreviations for abbreviations (known as “speed codes”):

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Our team at Plenful, through a mixed-method business logic and NLP approach addresses these issues by automatically standardizing SIG codes in a way that not only simplifies data entry roles to human-in-the-loop auditing, but in turn allows healthcare teams to spend more time caring for patients.

While SIG codes represent only a fraction of the work healthcare organizations have to deal with, the platform being built at Plenful addresses more than that. Including (but not limited to) automated document processing and confidential information warehousing.

And to answer the question as to how much my hospital stay in Taiwan was, it happens to be the same number in the title of this blog.

It was 10. Dollars… $10. And to answer your other question, no, I never saw that $100.

- Jonathan Lin