New Recommendations to Improve Drug Allergy Capture and Clinical Decision Support

The Partnership for Health IT Patient Safety, a national collaborative convened by ECRI Institute, has released a new report on drug allergy interactions and how clinical decision support (CDS) and health information technology (IT) can be used to improve safety.¹ The report, Safe Practices for Drug Allergies—Using CDS and Health IT, presents the findings of a multistakeholder workgroup composed of members from the Partnership, including healthcare providers, members from professional and patient safety organizations, safety and quality advocates, health IT developers, and academic researchers. The workgroup was co-chaired by ISMP President Michael Cohen and ISMP Medication Safety Specialist Christina Michalek and funded in part by the Gordon and Betty Moore Foundation. The report sets forth evidence-based safe practices and suggested implementation strategies for using technology to standardize allergy documentation, enabling CDS tools to provide more actionable allergy information, monitoring alerts for effectiveness, and engaging patients. A summary of key highlights from the report follows.¹

Importance of Drug Allergy Information and CDS Tools

Timely access to accurate, up-to-date drug allergy information is critical to avoid potentially life-threatening adverse drug reactions that can delay the delivery of an appropriate treatment, necessitate additional treatments, increase care costs, and negatively impact patient outcomes. To facilitate the appropriate triggering of alerts, the information must be documented using the correct allergy terminology, coded properly, and captured in a standard location. Outdated allergy information must also be removed from the patient’s list of active allergies.

How drug allergy information is gathered, documented, communicated, and used remains a challenge. The process is increasingly influenced by various CDS tools, including immediate electronic alerts and reminders in the electronic health record (EHR), as well as allergy information available in patient assessments, order sets, care plans, protocols, patient data summaries and flowsheets, medication administration records (MARs), and knowledge resources. Much of the focus with drug allergy interaction prevention has been on CDS alerts; however, alert override rates have risen from 50% in the mid-1990s to almost 90% in 2015 because many alerts are considered insignificant or unclear, or do not provide all the information needed for effective decision-making.

Excessive alerts and subsequent overrides are also caused by inaccurate or outdated allergy information; inappropriate detection of cross-reactivity or sensitivity; and unnecessary triggers for mild, non-immune-mediated adverse drug reactions. On the other hand, an appropriate alert may not be triggered at all if the drug allergy information has not been gathered and accurately documented in the EHR, or if the information is captured in a free-text field.

Despite the use of CDS, including alerts and informational content provided during electronic prescribing and transmission, adverse events due to drug allergies continue to occur. To reduce the frequency of these events, organizations must focus on optimizing CDS for drug allergy interactions and providing tools to facilitate and communicate the right drug allergy information at the right time within the workflow. Technologies, both those presently available and those still in development, offer potential solutions for decreasing the incidence of drug allergy events, enabling safer and less costly healthcare.

Methodology of Collaborative Workgroup

Expert recommendations. To explore the goal of optimizing CDS for drug allergy interactions, the Partnership’s workgroup first considered the findings of a multidisciplinary group of experts who, in 2017, identified a set of conceptual and practical recommendations for improved drug allergy alerts:² 

• Improved allergy documentation, including a more detailed specification and characterization of the patient’s allergies to ensure that alerts are triggered when they matter most and avoided for mild intolerances or previously tolerated medications

• Patient engagement in the allergy reconciliation process to create and maintain a meaningful allergy list in the EHR

• Improved alerting mechanisms that consider reaction severity and other contextual information (e.g., match between the allergen and prescribed medication, probability of reaction occurrence, information on whether the alert was fired or overridden in the past) when presenting alerts to clinicians

• Policies and guidelines for clinicians to support a more patient-centered allergy alerting system

• Continuous alert monitoring and improvement by tracking the frequency of drug allergy alerts and override rates over time and making appropriate changes to impact allergy safety

These recommendations formed the foundation of the workgroup’s investigation regarding how technology could be used to improve safety. 

Literature review. The workgroup conducted a literature review that identified 62 studies published between 2003 and 2018 about drug allergy documentation and CDS. Seven studies met inclusion criteria for the analysis and were associated with one of the following outcomes: improved accuracy of drug allergy documentation; more appropriate triggering of drug allergy alerts; improved efficiency of clinical care; or change in the rate of prescriptions for drugs to which the patient is allergic. Review of these studies suggested that, while drug allergy alerts have the potential to improve safety, alerts are frequently overridden and may fire inappropriately. While health IT interventions such as patient portals and risk stratification algorithms have shown potential, little evidence of their effectiveness was available.

Event analysis. The workgroup also examined 320 events gathered from the Partnership’s members, ECRI Institute Patient Safety Organization (PSO), other collaborating PSOs, and ISMP. Most events were associated with drug allergy interaction alerts and reminders in the EHR, and CDS related to ordering, administration, or documentation. Events were most frequently linked to drug allergy alerts that did not function as intended or were overridden. Examples include alerts that were not triggered at various stages in the workflow or for various clinicians; alerts that were not triggered because allergy information was not recorded or in a computable format; serious alerts that were overridden due to alert fatigue; and unavailable alerts caused by workarounds. The most common allergens involved in the events were anti-infectives, opioids, cardiovascular drugs, nonsteroidal anti-inflammatory drugs (NSAIDs), and anticoagulants. 

Recommended Safe Practices

Building upon information from the literature, event analysis, and other discussions around allergy interactions, the workgroup identified four evidence-based safe practices and implementation strategies for healthcare providers and IT vendors/developers for using technology to ensure the “five rights” of allergy information and CDS:

• the right drug allergy information

• presented to the right person

• in the right format using CDS tools

• through the right channel within the EHR

• at the right time in the workflow.

1. Use technology to standardize the documentation of drug allergy status.

To help achieve CDS interoperability, documentation of drug allergy information must be standardized to facilitate mapping and aid in triggering drug allergy alerts based on criticality and necessity. To do this:

• Characterize and distinguish adverse drug reactions as a side effect, toxicity, intolerance, idiosyncrasy, or allergy.

• Use CDS to provide standard definitions of these characterizations and require practitioners to document these fields for optimization.

• Collect detailed information about patient allergies at the time of entry or reconciliation to ensure alerts are triggered when they matter most and to avoid unnecessary alerts for mild intolerances or previously tolerated medications.

• Consider including standardized fields for reaction type, reaction description, and patient preference.

• Eliminate free-text allergy or intolerance documentation.

• Ensure drug allergy information is reconciled with the patient and that inaccurate information is updated or corrected.

2. Provide actionable drug allergy alerts to improve the safety and effectiveness of drug allergy communications.

To reduce unnecessary alerts, minimize clinician burden, and facilitate greater attention to alerts with the highest severity, develop an oversight team, including appropriate subject matter experts, to evaluate the following:

• Criteria for triggering an alert (should be founded on appropriate alert tiering based on allergy severity, clinical relevance, and history of clinician response to the same alert [e.g., different clinicians receiving the same alert or notice])

• Display and format of alert text (should promote understanding and appropriate action)

• Alert intrusiveness (a combination of interruptive and informative alerts should be used as necessary)

• Alert frequency

• The timing of when the alert fires (should be close to the point of decision)

• Clinician time to decision (from when alert fires until next keystroke)

• Alert overrides (and reasons)

3. Use technology to monitor the effectiveness of allergy alerts.

To improve the appropriateness and effectiveness of allergy alerts and decrease clinician burden, employ technology to collect the following metrics:

• Alert frequency

• Alert adherence rates (e.g., discontinued or retracted orders) 

• Override rates

• Override reasons

• Appropriateness of overrides (e.g., overriding an alert does not mean it was not useful)

• Feedback from clinicians regarding commonly encountered issues and usefulness of specific alerts

It is important to not only gather and monitor this information regularly but also to communicate it to those who can then analyze it and take action (e.g., oversight team). This information may be displayed in clinician dashboards, provided in summary reports, and discussed by those working to improve allergy alerting. The full report includes a sample CDS drug allergy dashboard that can be used to display the gathered metrics, and an algorithm to assist with the review process for CDS and drug allergies. 

4. Engage patients through the use of technology to provide accurate drug allergy communications.

To ensure readily available, accurate, and up-to-date drug allergy information:

• Develop and use patient-facing technologies (e.g., web-based patient portals that are easy to understand and interpret) in order for patients themselves to communicate and update allergy information (and changes) with caregivers and the healthcare team.

• Encourage patient input of allergy information into the web-based patient-facing technologies.

• Review and validate patient-supplied allergy information, including information provided through web-based patient-facing technologies, using appropriately trained clinicians.

• Reconcile drug allergy information with the patient at every encounter (similar to medication reconciliation) and make any necessary updates and corrections.

Conclusion

ISMP encourages every healthcare provider to read the report¹ and to fully consider the expert workgroup’s evidence-based safe practices to guide organizational improvements in drug allergy interaction prevention. The full report provides several tools to assist with implementation of these recommendations, including a checklist of safe practices for improving drug allergy CDS and an educational PowerPoint file describing the workgroup’s findings and recommendations, which can be used to garner support for the organization’s effort. Developing technologies that will incorporate fields to capture accurate information will allow external CDS tools to function more effectively and accurately. Development of allergy alert tiering, attention to alert appropriateness, and encouragement of patient involvement are also important, but these efforts require vigilant attention. It is essential to monitor these activities to ensure that the right information is available and that it gets to the right person, in the right intervention format, through the right channel, at the right time in the workflow.

References

1. Partnership for Health IT Patient Safety. Safe practices for drug allergies—using CDS and health IT. ECRI Institute. 2019;1-42.
2. Topaz M, Goss F, Blumenthal K, et al. Towards improved drug allergy alerts: multidisciplinary expert recommendations. Int J Med Inform. 2017;97:353-5.