1. Patient Care WG Allergies and Intolerances June 25, 2015 - SDWG
DSTU Comments
Patient Care WG
Allergies and Intolerances
June 25, SDWG

2. 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
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3. Area of Focus
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4. Requested Relationship
Allergy Intolerance Observation
Reaction
Severity
Criticality
Status Observation
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5. DSTU R1.1 – Comment 643
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6. DSTU R Comment 644
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7. 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.
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8. 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)
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9. 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
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10. 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
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11. 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

12. Reference SMART C-CDA Findings
From 91 notes looked at total of 615 observations

13. 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 Mar 30. pii: ocv011. doi: /jamia/ocv011. [Epub ahead of print]
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