Allergies - Clinical Safety edition

[davidmiller]

Two possible features discussed today, feedback requested from all:

Display in antimicrobials

Would it be helpful to display allergy information in the antimicrobials modal - to the right of the form. This is the clinically relevant time that you really need the information?

Confirm conflicting allergy/antimicrobial

Allergies and antimicrobials come from the same lookup list - e.g. we have good understanding of equivalence. It would then be possible to answer the question

Is this user allergic to this antimicrobial according to elCID

when a user saved an antimicrobial. If the answer is yes, you can inform the user.

Pings: @michaeledwardmarks @GabPoll @drcjar @ollyharvey @7575colli @jonnylambourne

[michaeledwardmarks]

+5

[GabPoll]

I wonder whether we can look at drug allergy in a slightly different way.

The way I see it, drug allergy is a clinical safety issue that overrides all clinical encounters, whether it's adding diagnoses, adding antimicrobials or clinical advice being given.

I really like the idea that allergy can be to the side of a modal as it's being entered, but rather than restricting it to the antimicrobial modal for example, why not make it a hover alert that follows all clinical interactions of that patient, perhaps to the right of any modal opened or even any point of the single patient view.

(this follow-up paragraph obviously is a separate issue if it's of interest)

The extension of the above is whether we should think of drug allergy as a safety alert, rather than its own discrete category. If done so, then designing a hover alert box (which usually would be empty), we can easily expand into other relevant areas of clinical safety beyond just drug allergy. Examples that spring to mind are a) alert organisms (e.g. multi-drug resistant gram negatives), and b) alert drugs with important safety profiles (e.g. gentamicin, linezolid).

[7575colli]

The idea of elcid providing 'prescribing' advice is maybe a step too far - If there was a bug or error on elcid and a drug was entered onto the antimicrobial plan that wasn't flagged as a contraindicated (because of allergy) but it was in fact contraindicated - if this were then to be prescribed and administered resulting in a prescribing error, unfortunately elcid would have had a role to play in the error.

I think that it is safest to keep it simple - Record the allergies and reaction as 'suspected' or 'known' allergies. Make this information available in places where drugs are recommended as part of the treatment plan (the antimicrobial plan). The onus then remains on the clinician to consider the allergy information presented to them when adding drug advice. For elcid to be used as a tool to highlight drug contraindications could be potentially hazardous and maybe difficult to get past clinical governance.

[GabPoll]

@7575colli I agree with you that we should not be setting up elCID as THE place to record drug allergy advice, and hence use it as the main basis for highlighting contraindicated drugs due to allergy.

Keeping it simple is also an approach that I support, and if we keep the status quo, or we highlight allergies only in the antimicrobial plan, that is also ok. My only addition was that in other non-OPAT uses of elCID, awareness of drug allergies does not only come up when discussing the antimicrobial plan, and so a more generic alert system may be easier for coding, so that it alerts re allergies when entering the antimicrobial plan and clinical advice section (and could potentially be used to alert for other things other than just drug allergies).

If the prevailing opinion on this is that we should stick with a simpler system for now, then happy to go with that, but before @davidmiller built something, thought it was worth discussing.

[davidmiller]

Once you've added drug allergy information to the side of one modal, the difference in labour to add it to n becomes practically speaking, 0.

I would imagine it's a subset of all modals - e.g. do you really want allergy information in "General Notes" ?

The thinking in general was very much geared towards first play for a general "clinical safety, are you sure/alerting" system/component.

Incidentally, I have recently been thinking about making all modals fullscreen, which would give us a whole world more screen real-estate to play with.

[GabPoll]

OK, let's wait for others' feedback on the allergy / alert issue. Good to have an idea of the technical perspective involved.

Re full screen modals - I support widening of modal (#171) - just need to make sure we can make it remain obvious which patient is being looked at - some kind of minimal transition interface out of patient view to modal and back again. Will not comment further here, and stick to #171

[davidmiller]

Nobody is suggesting that we build a fully fledged Electronic Prescribing System into elCID at this precise juncture :)

Simple, self-contained features can be powerful for demonstrating possibilities.

Conversation here is v. much framed in terms of the long-term strategic goals && how these inform short-term implementation decisions.

In general, an additional context/error condition is something that would provide huge benefits && opportunity.

n.b.

The "Bugs here could cause Adverse Effects &/or Death" ship sailed quite some time ago ;) We are already in that place.

[jonnylambourne]

antimicrobial allergies must be documented, whether for OPAT patients or for patients for whom the only interaction with 'team infection' is phone advice to the primary team

not documenting means it wasn't asked about and wasn't considered in giving the advice

logical place in my mind is in the 'antimicrobials' tab, as, even when giving phone advice, this tab is relevant as a record of 'antimicrobials advised'

this information, and that regarding some alert organisms, is already pretty clearly seen in CDR (with the 'active alerts' system)

the allergies bit on elCID and CDR should match - as a longer term plan, would there be any mileage in importing this (akin to demographics)?

[davidmiller]

as a longer term plan, would there be any mileage in importing this (akin to demographics)?

May well be part of the demographics feed we get. Yet to see tech documentation for available data feeds...

[michaeledwardmarks]

Personally I am with @davidmiler on this.

I think at a minimum the antimicrobials and assorted advice modals should display your allergies - that is a big step forward - and I also know Vanya is keen on that function given a failure for that to happen frequently with paper records and that this leads to prescribing errors.

I think basic "This person has a reported allergy to X" if they try and prescribe an antibiotic matching X is very sensible. We can limit to broad drug class - e.g Beta-lactams, macrolides etc. I can easily generate that list, then we ask Preet and SMJ or equivalent to look at it too.

I would add a generic statement when people try and list a drug that the patient is reported to be allergic to: "The clinician is responsible for safe and appropriate prescribing - Please confirm the nature of the patients allergy status"

and also obviously as David says this isn't an actual prescription - just a record of conversations so the clinician is still free to do whatever they want.

Probably don't need to limit this to OPAT development - I think this has huge potential across all elCID users.

[GabPoll]

This has become a good thread, I like it! I just want to clarify my position:

• I fully support the idea of displaying the allergy status next to antimicrobial and clinical advice modals - this would be a massive step forward and a big sell on clinical safety grounds.
• I also agree that we're not in any way trying to produce some kind of electronic prescribing system - this is at best an opportune system to try to reduce risk & also a way to improve the clinical governance of advice given
• @jonnylambourne I worry that allergy status is not up to date enough on CDR to make it a reliable feed. A 2 way integration on this would be fantastic, but I suspect some way off.
• @michaeledwardmarks agree about this having a wide impact on all elCID users, hence why I wanted to discuss future applications of the allergy field, not just restricted to v1 implementation.

[michaeledwardmarks]

I think this can be closed at present and replaced by specific development needs if they arise.

[davidmiller]

I think this has some specific developments in it.

re-opening to keep it high in the mind/queue.

[michaeledwardmarks]

closing and opening #407

[davidmiller]

/cc @rossjones This goes on the list of DDD use cases - e.g. the ruleset is

When "allergy.name" intersects "drug.name"

[michaeledwardmarks]

I'm not sure there is anything actionable here so closing.