RE: Inappropriate Antibiotic Allergy Documentation in Health Records: A Qualitative Study on Family Physicians’ and Pharmacists’ Experiences

The purpose of the article Inappropriate Antibiotic Allergy Documentation
in Health Records: A Qualitative Study on Family Physicians’ and Pharmacists’ Experiences was to perform a qualitative study on family physicians' and pharmacists' experiences to identify causes of inappropriate documentation of allergies and ways to combat such errors in the Electronic Health Record (EHR). The article states that it is hypothesized that up to 90% of documented allergies do not represent severe, life-threatening reactions. The group concluded that understanding the root cause of incorrect antibiotic allergy documentation is critical to reducing antibiotic resistance and healthcare costs while improving patient care.
A qualitative study with a naturalistic approach was used with a total of 4 focus groups (n=44, 34 family physicians, 10 pharmacists) from the Netherlands. Participants were recruited via email from existing cooperative groups using purposeful sampling. The study considered the participants' age, experience, academic vs. non-academic medicine, and region when assigning them to the four groups. A focus group topic guide was created using a literature review and interviews with three pharmacists and three physicians. The guide was reviewed and adjusted multiple times to ensure its comprehensiveness. Using this study design allowed researchers to anecdotally learn from the experiences of different groups of healthcare providers that could not be captured by mere numbers.
Identified themes included: magnitude and awareness of the problem, origin of problem, and approaches for addressing the problem. The participants were well aware of this problem and thought that most "allergies" documented were not actually allergies. At the same time, many participants did not know about the complications. For example, some participants shared that there are many alternative drugs to use in place of the drug the patient is allergic to. Therefore, we need to increase awareness regarding antibiotic resistance, increased care costs, and poorer outcomes associated with avoiding the ideal medication.
The origin of the problem was also broken down into a few different categories. The first was inaccuracy due to patient recall. It was determined some providers often go off what is in the chart instead of verifying with the patient. Part of this issue also stems from providers not documenting the expected side effects of the medication they are prescribing. Another factor is documentation of allergies based on self-report from patients who base it on what their parents told them, previous encounters, the internet, etc. Also, inappropriate documentation of allergies and adverse reactions is a contributor to the root of the problem. One problematic example is documenting allergies to avoid giving a patient a particular drug for various reasons (i.e., an alternative was cheaper)— the paper shares how one pharmacist shared their misuse of this documentation. As students, we have witnessed similar behaviors frequently. Adding a medication to a patient's allergy list because of non-allergic causes is the core of the problem. Adding a medication to the allergy list because the patient's insurance does not cover the drug, the pill is 'too big,' preferences in generic vs. brand medication, and many similar considerations should not be practiced. These considerations are valid, and they do deserve documentation in the EHR. However, this should be done outside the medication allergy list.
To address the problem, there needs to be a multifaceted approach. Physicians and pharmacists should be educated on the difference between adverse effects and an allergic reaction at a systematic level. The group agreed that health provider guidelines explaining how to differentiate allergy vs. reaction questions would be useful. It is also essential to educate the patient about allergies and what it means to have one. Regarding the EHR, there needs to be more flexibility within the system. This includes having actionable tabs/sections to document important, non-allergy related information regarding patients' medications without listing it as an allergy. Overall, this should be a shared responsibility between physicians, pharmacists, and EHR developers.
While this study was conducted in the Netherlands, the group agreed that the issues were similar in the United States. For example, verifying an allergy takes time that the expected patient encounter time may not allow for. This extra time to assess allergy lists is challenged by the strict hospital system dictated quotas on patient visits. Moreover, physicians also want to avoid malpractice, so they avoid giving medications with any documented contraindication. The often profit-driven approach of American medicine focusing on avoiding liability amplifies the magnitude of this issue in the US. Furthermore, primary care physicians in the US work less directly with pharmacists than in the Netherlands, which only accentuates the problem. Also, communication between different providers for the same patient is often lacking. This leads to medications getting started, stopped, and documented with an 'allergy' flag without fully understanding what was experienced by the patient.
Overall, addressing the problem of inappropriate antibiotic allergy documentation should start with fundamental physician-patient communication that includes the pharmacist. Physicians should regularly consult the pharmacist on site to inquire together what the best options for a patient are. Before prescribing medicine, a thorough discussion should then take place about side effects with ways to address and cope with them. Moreover, a detailed list of signs and symptoms of potentially life-threatening complications should be covered. The discussion should also include alternative treatments as well as the risk and benefits of each. The patient should leave the exam room understanding the possible symptoms that he/she may develop after starting the medicine, including benign side effects and life-threatening complications. As future physicians, we believe that framing our discussions with the patients as such can increase their understanding of their own health and decrease the likelihood of them misreporting a benign side effect as a life-threatening allergy when they see another healthcare provider. Ultimately, this will allow patients to receive the first-line treatment of choice for their ailment, thereby decreasing the likelihood of developing antibiotic resistance and lowering their own cost and duration of treatment.