PerspectiveRedesigning the allergy module of the electronic health record
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
References (32)
- et al.
The costs of adverse drug events in community hospitals
Jt Comm J Qual Patient Saf
(2012) - et al.
Multiple drug intolerance syndrome: prevalence, clinical characteristics, and management
Ann Allergy Asthma Immunol
(2012) - et al.
Safely diagnosing clinically significant penicillin allergy using only penicilloyl-poly-lysine
J Allergy Clin Immunol Pract
(2013) - et al.
Health care use and serious infection prevalence associated with penicillin “allergy” in hospitalized patients: a cohort study
J Allergy Clin Immunol
(2014) - et al.
Impact of a clinical guideline for prescribing antibiotics to inpatients reporting penicillin or cephalosporin allergy
Ann Allergy Asthma Immunol
(2015) - et al.
Delayed hypersensitivity reactions caused by iodixanol: an assessment of cross-reactivity in 22 patients
J Allergy Clin Immunol
(2011) - et al.
A survey of physician practice and knowledge of drug allergy at a university medical center
J Allergy Clin Immunol Pract
(2014) - et al.
Effect of a drug allergy educational program and antibiotic prescribing guideline on inpatient clinical providers' antibiotic prescribing knowledge
J Allergy Clin Immunol Pract
(2014) - et al.
Practical approach to determining costs and frequency of adverse drug events in a health care network
Am J Health Syst Pharm
(2001) - Zhou L, Dhopeshwarkar N, Blumenthal KG, et al. Drug allergies documented in electronic health records of a large...
High override rate for opioid drug-allergy interaction alerts: current trends and recommendations for future
Stud Health Technol Inform
Insights into the problem of alarm fatigue with physiologic monitor devices: a comprehensive observational study of consecutive intensive care unit patients
PLoS One
Clinically inconsequential alerts: the characteristics of opioid drug alerts and their utility in preventing adverse drug events in the emergency department
Ann Emerg Med
Drug allergy: an updated practice parameter
Ann Allergy Asthma Immunol
Improving clinical outcomes in patients with methicillin-sensitive Staphylococcus aureus bacteremia and reported penicillin allergy
Clin Infect Dis
Cited by (41)
Qualitative analysis of healthcare provider perspectives to evaluating beta-lactam allergies
2023, Journal of Hospital InfectionUsability of Graphical User Interfaces With Semiautomatic Delabeling Feature to Improve Drug Allergy Documentation
2023, Journal of Allergy and Clinical Immunology: In PracticeDynamic reaction picklist for improving allergy reaction documentation: A usability study
2023, International Journal of Medical InformaticsAddressing the Challenges of Penicillin Allergy Delabeling With Electronic Health Records and Mobile Applications
2023, Journal of Allergy and Clinical Immunology: In PracticeAdvances in the Understanding of Drug Hypersensitivity: 2012 Through 2022
2023, Journal of Allergy and Clinical Immunology: In Practice
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.