Russ – and all,

I am fine with that resolution.

Elaine

Thanks, Julia.

I saw the JIRA updates earlier this morning.

Copying Elaine Ayres and Lindsey Hoggle to make sure it passes their review.

Russ

This issue has been addressed in the 2017 Annual Update.

Thank you for all of the feedback, the CRP public comment period is now over. We will review these comments and discuss amongst EP measure developers.

I concur with Rob's recommendation.

We should ensure consistency with CMS117.

I share Rob and Floyd's angst. And I concur with Rob's recommendation.

Floyd has summarized exactly what I have to say. In essence, given how the clinical community currently practices and how EHRs capture information, the proposed CRP solution would correctly identify more patients where "an allergy to egg" is used as the clinical reason for not giving a vaccine.

That said, Floyd also is correct that current evidence categorically states that there is no clinical support to withholding a vaccination based on "allergy to egg", either as a diagnosis or as a substance. Hence the angst some of us have with expanding the logic.

Given the use of "egg allergy" is not clinically justified, the value set proposed is as good as any.

If the measure developers want to continue to support not giving vaccinations because of "allergy to egg" then the proposed solution is likely the best way to accomplish this.

I agree with the proposed CRP solution

The proposal seems appropriate based on other comments and the fact that allergies to substances or medications are often managed as allergies rather than diagnoses. I also support the comments that egg allergy may no longer be a necessary exclusion or exception. The ACIP no longer considers egg allergy a contraindication for immunizations. This fact was a reason for the HIMSS Immunization Integration program to test EHRs for immunizatoin workflow (including clinical decision support) to remove egg allergy from the scenario.

I think the proposed CRP solution looks good. If Rob McClure is still commenting I would like to hear his input as well.

Thank you for your feedback regarding allergy not being captured as a diagnosis in your system. We will certainly flag this issue for future discussion and consideration. In addition, we would appreciate learning more about how allergies are captured in your system, so please feel free to share any additional details. We would also like to provide some additional context around our rationale for including egg allergy as an allowable medical exception, to address the comment that egg allergies are not a valid reason to not provide the flu vaccine. In instances where a patient has a known egg allergy, a primary care physician may choose to send the patient to an allergist to have the influenza vaccine administered so that the patient can be observed for reactions. The Advisory Committee on Immunization Practices (ACIP) recommends that the influenza vaccine should be administered by a health care provider who is familiar with the potential manifestations of egg allergy.

I've been generating some queries using the eCQM guidance for this measure. In my real world findings approx 80% of our patients have egg allergy in the allergy module of the eHR (actually, 2 eHR's I've worked with have allergy modules separate from a diagnostic history module) but have not used a dx code for addressing an egg allergy during a visit. Maybe an allergist would but not a General Medicine provider. Both systems also check drug interactions and contraindications from both spots because either would show evidence of an allergy.

ONC and CMS also welcome feedback on the utility and appropriateness of the egg exclusion in the measure. ONC did receive this feedback from an allergist in the field who notes:

"The latest practice guidelines issued jointly by the American Academy of Allergy, Asthma, and Immunology and the American College of Allergy, Asthma and Immunology which state that no special precautions are needed for any child, even those with history of severe reactions to eggs.

http://www.sciencedaily.com/releases/2013/10/131001090039.htm"

Thank you,
Julia Skapik
Medical Officer, ONC

Rob,

I like the idea of grouping existing concepts for now, we can put these into the EP update this year and then continue the conversation during our summer stakeholder meetings. We should probably involve FDA as well.

Thanks,
Julia

What we want is a concept that represents a general idea that is either already linked to specific concepts that show up in systems, or those linkages are easy to construct. We want this approach to work in general, not only just eggs. In the case that the substance is a drug component, it is pretty straight forward, the concept should be a drug-thing, best from RxNorm (like Egg extract). This time it is a food, but we want the linkage to act like a drug-thing when we are doing drug checking, so it's a bit harder. Bottom line, we should record a concept that is linked (used) in "alert generating" systems. To be honest, the question of which code system should be used is in flux right now because multiple code systems have been suggested and are working on solving the problem: RxNorm, UNII, SNOMED CT being the leading contenders.

For "whole" Egg (food):
UNII code is Egg | 291P45F896
SNOMED CT code is Eggs (edible) | 102263004
Closest RxNorm code is Egg extract | 1315115

So should we make a value set (it would be a grouping since we have multiple code systems) with an entry from each of the contenders? Or just pick one?

I can't see how egg extract by itself would be the right value to use. People are documented as allergic to eggs, not egg extract, and I don't see how egg can be mapped to egg extract. This highlights the problem of using RxNorm as the code set. It is limited to chemicals that are used as or in drugs, it does not include food, which is what is required here.

This change will require a logic change to add clause(s) for the medication, allergy (and also likely medication, intolerance) and a new value set with some sort of code(s) for egg. I'd be interested in receiving input on what representation of the "egg substance" would be best for the value set to be used in these clauses. I'm sure EHRs might have this recorded as a proprietary code, but would the RxNORM concept of Egg extract [RxCUI 1315115] (which has the correct TTY of IN = ingredient) be the best single concept in the value set? That means we'd expect either EHRs would natively include the RxNorm concept, or all would map to this one idea.

Thank you Howard for noting this mistake--

Sincerely,
Julia

Our organization agrees that there should be an substance allergy datatype for egg allergy exclusions.