Division of General Internal Medicine & Primary Care, Brigham & Women's Hospital, Boston, MA, USA.
Harvard Medical School, Boston, MA, USA.
Stud Health Technol Inform. 2022 Jun 6;290:120-124. doi: 10.3233/SHTI220044.
Allergy information is often documented in diverse sections of the electronic health record (EHR). Systematically reconciling allergy information across the EHR is critical to improve the accuracy and completeness of patients' allergy lists and ensure patient safety. In this retrospective cohort study, we examined the prevalence of incompleteness, inaccuracy, and redundancy of allergy information for patients with a clinical encounter at any Mass General Brigham facility between January 1, 2018 and December 31, 2018. We identified 4 key places in the EHR containing reconcilable allergy information: 1) allergy modules (including free text comments and duplicate allergen entries), 2) medication laboratory tests results, 3) oral medication allergy challenge tests, and 4) medication orders that have been discontinued due to adverse drug reactions (ADRs). Within our cohort, 718,315 (45.2% of the total 1,588,979) patients had an active allergy entry; of which, 266,275 (37.1%) patient's records indicated a need for reconciliation.
过敏信息通常记录在电子健康记录 (EHR) 的不同部分。系统地协调 EHR 中的过敏信息对于提高患者过敏清单的准确性和完整性以及确保患者安全至关重要。在这项回顾性队列研究中，我们检查了 2018 年 1 月 1 日至 2018 年 12 月 31 日期间在任何 Mass General Brigham 设施就诊的患者的过敏信息不完整、不准确和冗余的患病率。我们确定了 EHR 中包含可协调过敏信息的 4 个关键位置：1) 过敏模块（包括自由文本注释和重复过敏原条目），2) 药物实验室测试结果，3) 口服药物过敏挑战测试，以及 4) 因药物不良反应 (ADR) 而停止的药物医嘱。在我们的队列中，718,315 名（总共有 1,588,979 名患者的 45.2%）患者有活跃的过敏条目；其中，266,275 名（37.1%）患者的记录表明需要协调。
