MU Stage1 Final Rule - Drug-Drug Drug-Allergy Checks

SECTION #  Section 170.302(a)—Drug-Drug, Drug-Allergy, Drug-Formulary Checks

MU OBJECTIVE Implement drug-drug and drug-Allergy interaction checks

MU STAGE 1 MEASURE The EP/eligible hospital/CAH has enabled this functionality for the entire EHR reporting period

CERTIFICATION CRITERION Final Rule Text: §170.302(a). (1) Notifications. Automatically and electronically generate and indicate in real-time, notifications at the point of care for drug- drug and drug-allergy contraindications based on medication list, medication Allergy list, and computerized provider order entry (CPOE). (2) Adjustments. Provide certain users with the ability to adjust notifications provided for drug-drug and drug-Allergy interaction checks.

STANDARDS N/A

TEST CRITERIA # §170.302 (a) http://healthcare.nist.gov/docs/170.302.a_DrugDrugDrugAllergy_v1.1.pdf

SOLUTION DESIGN / TECHNOLOGY (Add details here)

SOLUTION COMPONENTS (Add details here - Ex. KIDS patch, Delphi code, User guide, Web resources, Manual test script, etc)

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PREVIOUS NOTES (none)

DEVELOPMENT STATUSAlthough VistA does this now, the need for other interaction checking will be coming and the ability of the purely open source VistA to do this will be leaving because the VA is implementing the use of FirstData and will not be maintaining the interactions in the National Drug File. ePrescribing that is being built by Oroville will need to pick up that function for both patients who have new prescriptions and those who don't as outpatients and it is the current understanding that will not be a problem for outpatients.

Drug-Drug interactions are supposed to be editable in a way to allow some users to have them not displayed to avoid "alert fatigue." In version 1.0 of the scripts, editing of the interaction data itself, much like editing the National Drug File or the First Databank database was required. That was corrected.

The commercial drug databases generally allow the system to display varying Severity levels of interaction to avoid alert fatigue. That should be possible with ePrescribing for outpatients.

For inpatients using the National Drug File for interaction checking, VistA has the option of locally editing the Severity of a drug-drug interaction from "significant" to "critical" and then allowing the display of significant reactions to be optional. It is in the Drug Interactions Menu which includes several local drug interaction editing options that are quite limited.

Enter/Edit Local Drug Interaction [PSS INTERACTION LOCAL ADD] option will be deleted with pharmacy re-engineering in the VA. In the US, the requirement for use of a commercial drug database is almost certain if we can't identify or create and open source interaction database or the National Library of Medicine does not get involved, which is not likely as that would cause an uproar and a massive increase in lobbying, but overseas, the need for using the National Drug File Inteactions or something like it in places that cannot afford a commercial drug database will continue so NOT deleting that menu item should be considered seriously outside of the VA.

A link to a document describing how to do that needs to be added here.Please creating such a document and add it here! A link to a file with a screen shot that can help found here http://download.opensourcevista.net/downloads/SignificantDrugInteractionTurnOff.doc and the the use of the local drug interaction menu items should help someone write that document.

A document describing adding and Allergy, marking it entered in error and also editing an entry in the roll and scroll instead of marking it entered in error and reentering it with corrections can be found at this link:

http://download.opensourcevista.net/downloads/Drug-Drug_Drug-Allergy302a.doc

It is it very interesting that the description of of an observed vs. Historical reaction is different and more in line with what physicians generally expect in the roll and scroll versus what is in CPRS when it comes to entering allergies. CPRS describes Historical as something of no significance any longer (paraphrasing) and the roll and scroll describes it as "Historical data gathered by the patient. Nancy will see if she can get some information about this from the VA to see if it might be something that will be changed in the future.  If not, we might consider changing it.

To quote, CPRS has

"Historical: reported by patient as occurring in the past. No longer requires intervention"  (See the yellow highlighting in the document).

CPRS also has "OBSERVED: directly observed and occurring while the patient was on the suspected Causative Agent. Use for new information about an Allergy/adverse reaction and for recent reactions caused by VA-prescribed medications."

This, too, is also not quite right for our purposes, or frankly, I would think also not for the VA's use either.

Meaningful Use criteria requires that certain allergies be able to be changed and implies that they not be displayed for certain users. Nancy Anthracite has written to the Office of the National Coordinator as this is almost certainly a mistake and just an inadvertent spillover from the desire to mark particular Drug/Drug interactions not to display for certain users to avoid "Alert Fatigue".

Nancy has proposed that we not put any work into adding this functionality to VistA in hopes that ONC testers will accept being able to edit an Allergy as sufficient to pass because this is something we DO NOT WANT VISTA TO DO!

If we elect to write code for this, Nancy thinks we make that one of the last things we do as it is likely to be removed when the 1.2 criteria are released and it would be a shame to waste a lot of effort on something nobody should ever use.

There is information in the roll and scroll which might help with the mapping of the allergies to meds to RxNorm. See the green highlighting.

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