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Nutrition Informatics Blog

Jul

2

Food Allergies and Patient Safety

Most of us have heard the frightening statistics reported in To Err is Human, the Institute of Medicine report published a decade ago on medical errors and patient safety.  That and subsequent reports – not to mention the attention received by Presidents Bush and Obama – helped put electronic health record (EHR) development and implementation into warp speed.    

One component within an EHR is an alert system.  Most of these alert systems focus on medication orders – is the dose wrong for the patient’s weight, is the patient allergic to this med, is the med contraindicated in pregnancy, etc.  But what about food allergies?  Most EHRs do not have alert systems for this.  Proposed Meaningful Use requirements included no mention of non-medication allergies.  Why the omission? The impact on the patient is the same.   Allergy lists and alerts within EHRs should include non-medication allergies and should address drug-nutrient interactions.  ADA has given testimony to this effect.

Why should this be a priority?  Just look at some of the statistics.  Up to 7 million Americans, including 2 million children, are affected by food allergies.  Thirty-five to 50 percent of cases of anaphylaxis are due to an allergic reaction to food, and 150-200 Americans die per year as a result of food allergies.  In addition to food allergies, as many as 6 million Americans are allergic to latex, including 5% to 15% of health care workers.  Because the proteins in latex are similar to those in certain foods, persons with a latex allergy are usually also allergic to bananas, chestnuts, kiwi, passion fruit, and avocado.

Several software systems exist to automate functions of food & nutrition departments.  Most include interfaces so that when a food allergy is entered in a patient’s EHR, this information is sent instantaneously to the software system.  The software system then removes items to which a patient is allergic and can insert appropriate substitute items in their place.    

We can’t adequately ensure patient safety without the presence of food allergy and drug-nutrient interaction alerts, as well as a mechanism to prevent items to which a patient is allergic from being served to them.  We need to continue this dialogue with EHR vendors and EHR implementation teams.

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Comments (5):
7/6/2010 5:22:35 AM by Ivonne Cueva_1

Vendors will incorporate food allergies as a separate data field when customer demand indicates the need. Rather than depend only on flawed government initiatives to drive our needs, we should also focus on ensuring that every RFP, every spec that is written includes the need for this component. Money talks to the vendors!

7/9/2010 4:07:20 PM by Ivonne Cueva_1

Thanks for your comment, Pam. I think that rather than having a separate field for food allergies, as long as EHR vendors include food allergies in their list of all allergies, they can be part of Clinical Decision Support, and transmitted to departmental software systems. This way, food allergies will be treated with an equal degree of urgency as medication allergies.

7/22/2010 3:08:11 AM by Pam Charney

Marty, As I'm sure you're aware, food allergies are a medical diagnosis. Therefore, they are in the EHR and therefore clinical decision support tools can be developed. So, why would we want/need another place for an allergy to be documented if it's diagnosed and documented (using ICD-9-CM) already? I'm actually not sure what you mean by clinical decision support tools; if the allergy is already diagnosed, there's no need for decision support (CDSS is for the most part used to facilitate the clinician's thinking when there's a diagnostic quandry). If the allergy is not diagnosed, then you wouldn't be eliminating foods from meals based on a non-entity. The ability to alert a food service program is already there, all depends on the time and money available to build the interface. As I'm sure you know, the ability to build an interface is incredibly expensive and time-consuming. I don't foresee this changing for quite a while, as regardless of meaningful use requirements, if vendors can demonstrate the "ability" to interface, the actual build is another story!

7/23/2010 11:57:50 AM by Ivonne Cueva_1

Hi Pam, I will answer for Marty as he is vacationing--but will return soon! Thank you for the conversation—I do believe it helps sort out best practices!! Several thoughts: 1. Food Allergies are a medical diagnosis. You are correct that they can be coded as such, but the conundrum in health care is that processes are never quite the same anywhere you go. While this may happen in some health care facilities, I wonder how consistently coding occurs. 2.Why would we want another place for a food allergy to be documented if it’s diagnosed and documented using ICD-9 already? To better clarify our point—we want ALL allergies to be kept together in the same area of the electronic health record—as food allergies can have as severe (or worse) an adverse impact on the patient as medication allergies. What caught our attention was the reference to recording only “medication allergies” in the NPRM for Meaningful Use (MU). In the Final Rule for MU, CMS responded to our concern: “We agree that information on all allergies, including non-medication allergies, provide relevant clinical quality data. However, while we agree that collecting all allergies would be an improvement, current medication allergy standards exists in a structured data format that may be implemented in Stage 1. We hope to expand this measurement to include all allergies as the standards evolve and expand to include non-medication allergies. We believe EP/eligible hospitals/CAHs should continue to document all allergies, regardless of origin, consistent with standard of care practice for that EP/eligible hospital/CAH. We encourage them to work with the designers of their certified EHR technology to make this documentation as efficient and structured as possible.” 3. If the allergy is already diagnosed, why would we need clinical decision support tools? Taken in the context of the typical clinical decision support use (which usually does not include nutrition), you are correct. There is a place for clinical decision support in prompting the provider to select nutrition related treatment choices. Once the presence of a food allergy is documented, the most important factor is transmission to Food Service to assure adherence to the restriction. 4.“As I'm sure you know, the ability to build an interface is incredibly expensive and time-consuming.” Interfaces from the EHR to Food Service ARE considered to be expensive, but when weighing the advantages—I would challenge that they are worth it. Given hand-written transcription of orders and questionable interpretation of what the patient should be served, I prefer transmission electronically. This is a great idea for an evaluation/publication! Lindsey

7/27/2010 5:19:47 PM by Ivonne Cueva_1

Thanks Lindsey, I"m sure we all agree that keeping things simple, yet complete is the goal of a well-designed EMR. If information is already in a database, than rather than create another field to keep that information, what is needed is to create the correct queries to find the information and make sure it goes to the right place! Yes, it is important to build interfaces, but I think we sometimes make it seem very much easier than it really is. A local facility, with one of the top rated informatics programs in the world, estimates that they spend about 4-6 months and $50-75,000 for each interface built. Right now, they maintain approximately 40 interfaces with department specific systems. However, as we improve technology and knowledge, I do anticipate that these costs will decrease. No one would argue (except perhaps for the occasional luddite among us) that it's best to go back to pen and paper, rather, we have to be prepared with plans B, C, and D for the gap between what we want and when we get it!

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