Factors Contributing to CPOE Opiate Allergy Alert Overrides.

CONTEXT: Increasing regulatory incentives to computerize provider order entry (CPOE) and connect stores of unvalidated allergy information with the electronic health record (EHR) has created a perfect storm to overwhelm clinicians with high volumes of low or no value drug allergy alerts. Data sources include the patient and family, non-clinical staff, nurses, physicians and medical record sources. There has been little written on how to collect hypersensitivity information suited for drug allergy alerting. Opiates in particular are a frequently ordered class of drugs that have one of the highest rates of allergy alert override and are often a component of pre-populated Computerized Provider Order Entry (CPOE) order sets. Targeted research is needed to reduce alert volume, increase clinician acceptance, and improve patient safety and comfort. DESIGN SETTING AND PATIENTS: An FY10 retrospective, quantitative analysis of 30321 unique adults with opiate allergies triggering CPOE alerts at a large academic medical center. MEASUREMENTS: The prevalence of opiates ordered with opiate allergy alerts triggered and overridden is described. The effect of age, race, gender, visit type (medical, procedural), provider type (physician, advance practice nurse), and reaction/severity (e.g. nausea/mild) on the likelihood of provider override of the patient's first opiate alert was analyzed using Generalized Estimating Equations (GEE).
RESULTS: Analysis of a patient's first opiate allergy alert (n=2767) showed that only prescriber role had a significant effect on alert override compared with all other variables in the model. Advanced practice nurses (APNs) were generally less likely to override the patient's first opiate alert as compared to physicians (GEE, β=-.793, β=.001). However, override rates remained high, with 80% for APN's and 90% for physicians. Over half of all discharges had opiates ordered during their stay. Of those, 9.1% of the patients had recorded opiate allergies triggering 25461 CPOE opiate allergy alerts. The largest sub-group of alerts was triggered by gastrointestinal (GI) "allergies" such as nausea and constipation. Removing these types of non-allergic, low severity GI reactions from the alert pool reduced the first alert volume by 15% and the overall alert volume by 22%. Of note is that a history of codeine allergy triggered a significant volume of opiate alerts, yet was rarely ordered.
CONCLUSION: With an increasingly complex, information dependent healthcare culture, clinicians do not have unlimited time and cognitive capacity to interpret and effectively act on high volumes of low value alerts. Drug allergy alerting was one of the earliest and supposedly simplest forms of CPOE clinical decision support (CDS), yet still has unacceptably high override rates. Targeted strategies to exclude GI non-allergic type hypersensitivities, mild overdose, or adverse effects could yield large reductions in overall drug overrides rates. Explicit allergy and severity definitions, staff training, and improved clinical decision support at the point of allergy data input are needed to inform how we process new and re-process historical allergy data.