Personally, I think āabatementā is clinically dodgy for Condition and a technical simplification, much like saying pregnancy status is binary. The comment that āthis is called abatement because of the many overloaded connotationsā is a little ironic. In my opinion, it creates as many problems as it attempts to solve.
In the Problem/Diagnosis qualifier we have both a āResolution phaseā and a āRemission statusā, precisely because these are different clinical concepts. To then have a single date of āabatementā that conflates them is problematic from the outset. Conditions that go into remission can be reactivated, whereas something that is resolved generally does not recur. The date of remission is semantically unique and clinically important and should be treated separately. The condition will often require long-term surveillance to ensure that the patient remains in remission.
When it comes to adverse reactions, the situation is even more problematic. Can clinicians ever say with certainty that there is no longer a risk of a reaction? Only a brave one, unless there is evidence that the original allergy record never represented a true allergy in the first place. The risk or propensity of a reaction on re-exposure may decrease significantly after hypersensitivity treatment, and some children may appear to outgrow a reaction. However, could the average clinician safely conclude that there is zero future risk and remove it from the active health record or from active drug interaction checking? Is the risk dose-dependent? Will the effect of hypersensitivity treatment diminish over time? Who knows? More importantly, who is willing to take responsibility for that decision? Not me. Recording an allergy as āresolvedā or cured seems fraught with medicolegal risk.
However, Australia is often described as the allergy capital of the world. Epidemic proportions, apparently. But how real is it? That is the question that has been posed to our National Allergy Council (NAC). A significant part of the issue concerns the apparently low threshold at which a suspected allergy is documented in our clinical systems. In response, NAC are developing a strategy for ādelabellingā documented allergies that are found to have no supporting evidence. As I understand it, this work is focused primarily on penicillin allergy and they are aiming for it to be scalable so that it can be replicated in the community and not dependent on allergy specialists alone.
Importantly, this is not the same as assigning the technical status āentered in errorā. The clinician may have had legitimate concerns that the clinical story was consistent with an allergy, but this precautionary approach has resulted in many allergy labels being recorded without adequate evidence. It is the process of disproving precautionary or poorly substantiated allergy labels that were originally recorded because the clinician preferred to record a possible allergy rather than risk missing a genuine one.
The dilemma for allergy specialists is that every claim of a penicillin allergy may need to be formally tested. Positive results should be accompanied by clear documentation of the supporting evidence. Negative results should also include the evidence from testing so that the same allergy label cannot simply be re-added later by another clinician acting ājust in caseā an undocumented penicillin allergy might otherwise have been missed, perpetuating the never-ending cycle.
We are working with the NAC to understand the implications for AUCDI and, by extension for me, the openEHR archetype that underpins it. We are about to release AUCDI R3, in which we proposed including āVerification statusā. However, in response to clinical feedback, āVerification statusā has been removed from the specification pending further discussion with NAC clinicians. I anticipate that this discussion may result in proposed changes to the archetype in the future. Verification methods and supporting evidence will need to be represented explicitly, potentially using the existing CLUSTER.clinical_evidence as part of a proposed solution.
