Allergies and Electronic Health Records, we’re doing it wrong

ACP Hospitalist: “About 10% of patients in the United States report a penicillin allergy, but most of these patients are not currently allergic, meaning that they could safely take drugs in the beta-lactam class. “The vast majority of patients who think they have penicillin allergies actually don’t when they undergo penicillin allergy skin testing,” said Emily Heil, PharmD, of the University of Maryland School of Pharmacy in Baltimore…. In fact, 96% of patients at one acute care facility who self-reported penicillin allergy had a negative skin test in a recent study by Dr. Heil and colleagues.”

I wrote about the problems surrounding patient allergies in the medical record several years ago. One would think that things have improved over time. Not even close. The proliferation of Electronic Health Records (EHRs) has only made things worse. The inaccuracy and incomplete nature of drug allergy information located in EHRs is causing more problems than ever before.

It might surprise you – or perhaps not – to find out that most patients don’t know whether or not they’re allergic to a medication, much less what the details are surrounding the allergy. Many perceived allergic reactions can be classified as an adverse reaction, intolerance, or simply an expected side effect.

Many of the allergies I see recorded in EHRs could easily be classified as intolerance, which in my mind means they shouldn’t be listed as an allergy. Having codeine listed as an allergy in the EHR because it causes GI upset is wrong. GI upset is not an allergy. GI upset to codeine does not preclude a patient from using any number of opioid analgesics. However, that little entry in the EHR will follow that patient around until the end of time, repeatedly rearing its ugly head whenever an opioid analgesic is prescribed. Each time a provider enters an order for an opioid analgesic, or a pharmacist verifies that order, or a nurse administers that order, they will have to contend with an allergy alert. The alert will fire, the provider will acknowledge it, quickly realize that it’s not really an allergy, and truck on. Not only does the alert provide worthless information with no value to the provider, it contributes to alert fatigue, which we all know is a very real and dangerous thing in today’s EHR-driven healthcare world.

Allowing poorly defined allergy information to appear, and remain, in the EHR should not be allowed. Facilities that allow it should be reprimanded. Providers that enter it should be educated. Improving the quality of allergy information found in EHRs benefits everyone. It should be a priority.

According to the ACP Hospital article cited above, accurate allergy information can lead to optimized therapy, decreased use of broad-spectrum antibiotics, and decreased costs. Is there anyone in healthcare that doesn’t want all of that?

Here’s the thing: it’s such a simple thing. Collecting better allergy information is so easy that it makes my brain hurt. It’s low-hanging fruit that often gets ignored. It requires no special education, training, or skill. No technology required. It cost nothing. This is one of those rare instances when a little common sense goes a long way.

Lack of interoperability, standardization and simplification is risky

I’m not a big fan of the using the “best of” model for hospital information systems (HIS). You know, when you buy the best pharmacy system you can find, and the best lab system you can find, and the best ED system you can find, and so on. All this does is create a giant headache for everyone involved because the systems don’t always play nice with each other, which means data gets lost or hijacked between systems by the Interface Noid. Data gets pushed, moved, shuffled, altered, chopped and converted, and it doesn’t always come out the way you intended. Or worse yet, you have a case where the systems aren’t interfaced at all.

I recently heard of a case where a hospitals ED system wasn’t interfaced with the rest of the facilities information systems and disastrous results ensued. A patient came in through the ED with a very specific allergy; noted in the ED system. The information wasn’t available in the nursing or pharmacy systems. The patient was admitted and transferred to the floor. The little detail about the allergy wasn’t passed on during report and the patient ended up receiving that very medication based on the attending physician’s order. To make a long story short, the patient had an anaphylactic reaction and won a three day, all expenses paid trip to the hospitals intensive care unit.

I wonder how often things like this happen due to short sided HIS implementation and deployment. Technology might not be the answer to all our problems in healthcare, but you have to admit it certainly could have helped in this particular example.

Local anesthetic allergies.

This has nothing to do with pharmacy technology, but I thought it would be worth posting. Questions about cross reactivity of one local anesthetic to another don’t come along often, but when they do it’s never easy to formulate a quick answer. Lucky for me I’m an electronic pack-rat and saved a small drug information consult I did a few years ago regarding the issue. Remember, this is for entertainment purposes only. ;-)
Continue reading Local anesthetic allergies.