Perspective
Redesigning the allergy module of the electronic health record

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Introduction

Adverse drug reactions (ADRs) are a major cause of morbidity in modern health care,[1], [2] with 20% to 35% of patients reporting 1 or more ADRs.[3], [4] Some ADRs warrant entry into the electronic health record (EHR) to inform future prescribing and prevent recurrence. This clinical documentation is typically placed in the allergy section of the EHR. Although this section is termed allergy, only a few of the reactions are immunologically mediated, with even fewer mediated through antigen-specific IgE (ie, classic allergy). Widespread overuse of the term allergy makes patients, and even health care professionals, think that anaphylaxis could occur with reexposure or that desensitization is an appropriate management plan.

Although the allergy section of the EHR was designed to improve patient safety, it is currently failing to do so.[5], [6] Routine, inconsequential warnings can result in all warnings being ignored; alarm fatigue has been previously observed with biomonitors in the intensive care unit.7 Allergy alerting has been similarly affected; prior estimates indicate that a clinician would need to review more than 100 allergy alerts to identify one that could prevent an adverse drug event, and alerts are overridden by health care professionals 90% to 95% of the time.[5], [6], [8] To reverse this trend and make the allergy field a useful tool, substantive changes in EHR design and clinician documentation are required. In this perspective, we aim to envision and describe a redesigned allergy module that could use EHR patient data and interactive decision support to provide clarity of assessments and rational management recommendations for patients with a variety of drug intolerances.

Section snippets

Common Drugs and Reactions

Although ADRs can happen with any drug, a relatively short list accounts for most allergy entries.[3], [4] The most frequently reported allergies are to antibiotics, opiates, nonsteroidal anti-inflammatory drugs (NSAIDs), angiotensin-converting enzyme inhibitors, other antihypertensive agents, lipid regulators, radiocontrast agents, antiepileptics, antidepressants, corticosteroids, stimulants, and local anesthetics.[3], [4] However, although these drug classes represent most entries, most EHRs

The Intolerance Module: Renamed and Redesigned

The allergy field should be renamed intolerances to more accurately reflect the variety of information populating this field, including patient preference, contraindications, adverse effects, and immunologic reactions (Fig 1). Although the word intolerance is often used to describe mild adverse effects, its meaning is literally the inability to take a drug without adverse effects and does not intrinsically convey severity. Immunologic reactions and true, IgE-mediated drug allergy would remain a

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    Disclosures: Dr Blumenthal reported creating clinical decision support for drug allergies used within Partners HealthCare Systems. Dr Macy reported being a partner in the Southern California Permanente Medical Group, receiving research grants from ALK Abello Inc to study adverse drug reactions, and being a member of clinical trial safety and monitoring committees for BioMarin Pharmaceutical Inc and Ultragenyx.

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