Patient Care WG Allergies and Intolerances June 25, 2015 - SDWG DSTU Comments Patient Care WG Allergies and Intolerances June 25, 2015 - SDWG
PCWG Allergies & Intolerances DAM and Clinical Models in V3 (DSTU) C-CDA R1.1 and R2.0 QRDA/HQMF FHIR AllergyIntolerance OpenEHR Version 3 C-CDA OpenEHR FHIR 11/15/2018
Area of Focus 11/15/2018
Requested Relationship Allergy Intolerance Observation Reaction Severity Criticality Status Observation 11/15/2018
DSTU R1.1 – Comment 643 11/15/2018
DSTU R2.0 - Comment 644 11/15/2018
Criticality Definition: A clinical judgment as to the worst case result of a future exposure (including substance administration). When the worst case result is assessed to have a life-threatening or organ system threatening potential, it is considered to be of high criticality. 11/15/2018
Criticality vs. Severity There is not a 1:1 relationship between the severity of a reaction and the criticality of the condition Examples Severe reaction to medication (nausea), low criticality (can still be prescribed if indicated) Mild reaction (first exposure to a peanut), high criticality (repeat exposure may be life threatening) 11/15/2018
Additional Examples (from DAM) Reaction History Reaction Severity Allergy List Entry Criticality Treatment Indication Decision Hives and swelling after PCN shot for strep throat as teenager Moderate Penicillin allergy High 23 yo with abnormal aortic valve needs penicillin prophylaxis for dental procedure Substitute erythromycin Pregnant 23 yo with + serology and tertiary syphilis needs high dose parenteral penicillin Penicillin desensitization protocol in ICU Red eyes, sore mouth after 2 doses trimethprim-sulfamethox Mild Bactrim allergy 25 yo with pneumocystis pneumonia Treat with dapsone and trimethoprim Severe nausea during numerous courses of trimethprim-sulfamethox Low Treat with trimethoprim-sulfamethoxazole and anti—nausea medication Severe anxiety, dysphoria, and palpitations after epinephrine SQ for respiratory distress Epinephrine intolerance Urgent presentation with moderate respiratory distress, diffuse wheezing during URI Treat with albuterol aerosol Urgent presentation with moderate respiratory distress, diffuse wheezing, hives, periorbital edema Treat with SQ epinephrine Measles-like rash while on amoxicillin for “bronchitis” as toddler Amoxicillin allergy 14 yo with skin abscess due to staphylococcus sensitive only to tetracycline and dicloxacillin Treat with oral dicloxacillin Hives and facial swelling while on amoxicillin for “bronchitis” as toddler, required ED visit Treat with oral tetracycline 11/15/2018
Bottom Line Patient Safety Issue: A reaction with mild severity is reported but it is a condition of high criticality – and there is the chance of a life threatening reaction. A drug or food is ordered despite risk Prevent most effective treatment: Current use of severity associated with an allergy or intolerance condition may deny the most effective treatment for a condition. A severe reaction reported but not high criticality Alert fatigue: an alert for a critical condition will have meaning. An alert for severity is usually ignored. Note current alert over-rides at ~90% EHR’s call a condition severe when in fact they are referring to criticality Confusion with using severity in two contexts 11/15/2018
Reference SMART C-CDA Collaborative Study of 91 C-CDA samples to look at correctness and consistency. D’Amore, J.D. et al. Are Meaningful Use Stage 2 certified EHRs ready for interoperability? Findings from the SMART C-CDA Collaborative. J Am Med Inform Assoc 2014;21:1060–1068
Reference SMART C-CDA Findings From 91 notes looked at total of 615 observations
References - Alerts Phansalkar S, et al. Evaluation of medication alerts in electronic health records for compliance with human factors principles J Am Med Inform Assoc 2014;21:e332–e340 Payne T, et al. Recommendations to Improve the Usability of Drug-Drug Interaction Clinical Decision Support Alerts J Am Med Inform Assoc. 2015 Mar 30. pii: ocv011. doi: 10.1093/jamia/ocv011. [Epub ahead of print] 11/15/2018