Alysse Wurcel, MD, of Boston Medical Center

Alysse Wurcel, MD

A recent qualitative study maps 6 barriers to 

 delabeling onto 8 concrete strategies primary care practices can adopt, from non-physician-led conversations to EHR-based flagging tools.¹

Investigators drew on 119 interviews and focus groups conducted across 3 Boston hospital networks, including Brigham and Women's Hospital, Massachusetts General Hospital, and Tufts Medical Center, using the CFIR-ERIC Implementation Strategy Matching Tool to translate patient and clinician interview data directly into actionable tactics. Barriers included clinicians avoiding penicillin allergy conversations, patients reporting they were never asked about their allergy, language and cultural factors, time constraints, perceived risk in delabeling, and limited allergist access.¹

Mapping the 5 ERIC strategies produced 8 specific tactics, including:

Expand urgent care access for post-delabeling testing

Support non-English-speaking patients in finding safe delabeling opportunities

Translate clinical champions into primary care champions

Use data experts to automate the identification of patients who safely received penicillin despite an active label

Incentivize delabeling (billing, pay-for-performance)

Educate patients and clinicians on the concept

The research team is now developing a shared decision-making worksheet clinicians could use directly with patients during a visit. The tool is designed to walk through common facts and misconceptions about penicillin allergy in an accessible, single-page format.

All clinics in the study used Epic as their electronic health record, researchers noted. This shared platform could support future EHR-embedded reminders and asynchronous messaging tools.¹

spoke with Alysse Wurcel, MD, of Boston Medical Center and Boston University Chobanian and Avedisian School of Medicine, about which of these 8 strategies are feasible today and what she tells clinicians who feel too pressed for time to raise the topic.

Q&A: 8 Strategies to Improve Access to Penicillin Allergy Delabeling

How much of clinicians' fear about incorrectly removing a label is grounded in actual clinical or legal risk versus perception?

: I’ve never seen someone [who was] truly allergic to penicillin in my life. I think they truly exist, and it's a very scary experience, [but] I don't think the average clinician who's fearful about going through delabeling has ever seen anyone [with] a penicillin allergy.

It's more we live in a very litigious society, and the idea that you knew that someone had a penicillin allergy and you proceeded with delabeling, [may lead to the] consequence of being sued, rather than the actual truth of the likelihood: that the person would have a terrible reaction necessitating intubation.

Of the 8 strategies from the five ERIC domains, which is most feasible for practices to adopt now without new funding or infrastructure?

: Anything that's digitally or electronically based is the right way to go. Clinical documentation advisories or reminders embedded into the EHR, although kind of annoying for the average clinician, have been shown to change practice. That's the 1 that I think is most likely to help.

How close is the EHR-based strategy to being deployable today?

: Our team is working on it, [as] part of this grant. The whole question is whether, if you put [something] into place in an EHR reminding clinicians to talk about penicillin allergy, is it going to just be the 10th thing on that list of things to discuss for that primary care doctor? Is it going to be ignored? Why should the clinician actually use it? That's the harder. It's easy to make it, but it's harder to make it in a way that will actually change [clinical] practice.

What's the next step for this research? Are you planning to pilot or test any of these eight strategies directly?

: That is our hopeful next step. We are starting to develop shared decision-making tools because what we learned is that clinicians don't feel comfortable talking with patients [about penicillin allergy]. We've started the process of developing a sheet of paper that the doctor could walk through with the patient [to discuss] facts and misunderstandings about penicillin allergy.

 What would you say to a clinician who feels they simply don't have the bandwidth to add this to an already-packed visit?

: I hear you. I am that clinician, so you're not alone. I don’t think it has to be every patient’s visit. If you're seeing 20 patients in a day and notice 1 has a penicillin allergy, I would see it as a victory for talking about that penicillin allergy.

There's something to be said for just saying, “I know we have a lot of things talking about today, but I just want to let you know, most people with penicillin allergies don't really have them. What do you think about that?” Just trying to put in 1 sentence or [having] the goal of talking about it with 1 patient every day creates small measures of success that will then go into habit.

Is there anything else you'd like to highlight about this study?

: What's interesting about penicillin allergy is that it sits at the intersection of implementation science and de-implementation science. Implementation science is about putting something into place; de-implementation science [is about taking] something harmful out. This study is at the intersection between implementation science, where we're putting something into place, and de-implementation science, where we're trying to remove incorrect allergies, and that's why I think it's really exciting.

Read part 1 of the Q&A with Wurcel here: 

Q&A: 6 Barriers to Penicillin Allergy Delabeling, With Alysse Wurcel, MD

Wurcel A, Crabtree D, Asupoto O, et al. Strategies to increase equitable access to penicillin allergy de-labeling interactions: a qualitative multi-center study. JAMA Open. 

Wurcel A. Q&A: 6 Barriers to Penicillin Allergy Delabeling, With Alysse Wurcel, MD. HCPLive. Published September 15, 2026. Accessed September 15, 2026. 

https://www.hcplive.com/view/6-barriers-penicillin-allergy-delabeling-wurcel

Articles

A qualitative, multi-center effort used CFIR-ERIC mapping to translate 119 patient and clinician interviews into implementable primary care tactics to expand penicillin allergy delabeling. Core barriers included clinician avoidance, patients not being asked, language/cultural constraints, visit time pressure, perceived medicolegal risk, and limited allergist capacity. Eight pragmatic strategies emphasized nonphysician-led workflows, faster testing and e-consults, EHR-enabled identification and reminders, incentives, and targeted education. Next development focuses on a single-page shared decision-making worksheet to standardize discussions and correct misconceptions.

In this Q&A, Alysse Wurcel, MD, translates qualitative barriers into 8 concrete tactics healthcare practices can use to expand penicillin allergy delabeling.

8 Strategies to Improve Access to Penicillin Allergy Delabeling

A new qualitative study of 119 patients, clinicians, and stakeholders across 3 Boston hospital systems identifies race, language, and communication gaps driving unequal access to penicillin allergy delabeling in primary care.¹

More than 95% of people who currently carry a penicillin allergy label are not truly allergic.² Multiple professional societies recommend evaluation and delabeling for anyone with an unconfirmed penicillin allergy, given the added risk of adverse effects associated with second-line agents. However, primary care adoption of these recommendations remains inconsistent.

Alysse Wurcel, MD, of Boston Medical Center, and colleagues carried out a qualitative multi-site study to understand, from a broad range of perspectives, the factors that help and hinder penicillin allergy delabeling, with the goal of shaping practical strategies to address them. The team conducted in-depth interviews and focus groups from March through September 2024 with 119 participants, including 69 patients and 50 clinicians and stakeholders, guided by the updated Consolidated Framework for Implementation Research.

Interview guides were translated into Spanish, Mandarin, and Cantonese to reach patients across each site's patient community.

 Brigham and Women's Hospital serves large numbers of Black residents from Dorchester, Mattapan, and Roxbury, including people of Haitian, Dominican, and Puerto Rican descent.

 Massachusetts General Hospital's Chelsea community health center, in particular, serves a population 50% Latino, with 30% of patients preferring Spanish. Tufts Medical Center, based in Boston's Chinatown, serves a predominantly Asian, Cantonese-speaking patient community.

In total, 6 barriers emerged: clinician avoidance of the topic, patients never being asked about their allergy, language barriers, time constraints, perceived risk of removing a label, and limited access to allergists.

Prior work from the same research group found an inverse relationship between social vulnerability and penicillin allergy delabeling rates in Boston, and current findings extend those results into direct patient and clinician accounts.

 Patients from underrepresented racial and ethnic groups and non-English speakers described facing distinct, additional barriers to even having the initial conversation about their allergy history.

 spoke with Wurcel about why an equity-focused qualitative approach was needed for this kind of research and what these 6 barriers reveal about current primary care practice.

What prompted this study, and why was a qualitative, multi-stakeholder approach the right way to investigate penicillin allergy delabeling?

: We recognized that several clinical societies worldwide recommend evaluation and potential delabeling for everyone with a penicillin allergy because most people who report one are not truly allergic. In our clinical practice, this [was] not happening a lot. Many patients who had penicillin allergy were never evaluated for whether this was a true or false allergy.

One of the reasons why that's important is, if you have a penicillin allergy, it means you can't often get the first-line antibiotics, and you have to get antibiotics that have more adverse side effects. That was the impetus for the study.

The reason why qualitative in-depth interviews and focus groups [were] chosen is the contextualization. You can say to someone in a survey, Do you have a penicillin allergy? Yes. Would you consider getting that allergy evaluated? They can say no, but you don't really know why they don't want that penicillin allergy evaluation.

What we were able to show was people had a lot of fears about getting penicillin allergy delabeling, and that's why the qualitative work was so powerful.

You found associations between penicillin allergy labeling and race/ethnicity reflecting differential treatment patterns rather than biology. Can you unpack that?

: It's not a quantitative study, so I [can’t] say statistically this happened. We tried to get people who were both male and female, and we also tried to get people from underrepresented minorities. What we saw was often people who either were from underrepresented minorities or spoke other languages faced barriers to discussing penicillin [allergy].

Language barriers emerged as a theme, with patients describing feeling ignored during communication gaps. What does that tell us about current practice?

: If you have a clinician who does not speak the same language as a patient, I think the clinician is often less likely to discuss penicillin allergy. Maybe the nuances of penicillin allergy would not be translated correctly, and maybe because of concerns that the clinician had to use 5 minutes or so to get the interpreter on the line, and so that extra 5 minutes would have been the 5 minutes that they could have used for penicillin allergy delabeling, but there [were] just like other things to talk about.

If a patient was given a penicillin allergy, let's say in another country, and then we're saying through a translator that we don't believe that that's a true penicillin allergy, sometimes that can come across as our feeling like the care in their country was poor. That's not what we're trying to say, but it's a very tricky conversation.

How did findings differ, if at all, across your 3 hospital sites?

: Our findings really didn't differ across the sites. It was just more that the populations varied a little bit between the sites.

Clinicians describe avoiding penicillin allergy conversations as delicate, while patients report frustration that it's not brought up enough. What's driving that mismatch?

: What happens is maybe a clinician has brought up the idea of penicillin, let's say 10 times, and 1 of those times the person got very sort of upset about it. The [1] conversation not going well kind of sits in the clinician's memory and prevents them from wanting to talk about it anymore.

On the other side, there's so many patients with penicillin allergy, and they're all out there not knowing anything about delabeling or that having a penicillin allergy [label] is not a good thing.

I also think that the amount of things that each primary care doctor needs to do in a 20-minute or 30-minute slot is excessive, and so it's just not a priority on the clinician's mind.

Time constraints and competing priorities came up repeatedly. Realistically, how does penicillin allergy delabeling compete for attention in a primary care visit?

: The average person coming into the primary care doctor has multiple things to talk about, whether it be diabetes or hypertension. It's very hard to carve out time to talk about penicillin allergies.

The other thing that's a little bit tricky is there's certain things that we can bill for, like you can bill for talking about diabetes.

There is a potential movement towards incentivizing clinicians to talk more about penicillin allergies with their patients, but that would have to have some sort of money associated with it, some sort of benchmarking where the clinician would be more likely to talk about penicillin allergy because they want to show that 90% of the people that they've spoken with about their penicillin allergy got delabeled, and that was attached to some sort of quality marker.

Shenoy ES, Macy E, Rowe T, Blumenthal KG. Evaluation and management of penicillin allergy: a review. JAMA. 2019;321(2):188-199. 

Blumenthal KG, King AJ, Stone VE, et al. Geospatial socioeconomic indicators and penicillin allergy delabeling in primary care patients. JAMA Netw Open. 2025;8(8):e2528714. 

Penicillin allergy labels are frequently inaccurate, yet primary care implementation of delabeling remains uneven despite guideline support. A multi-site qualitative study across three Boston health systems used interviews and focus groups with 119 patients, clinicians, and stakeholders—incorporating multilingual materials—to surface equity-relevant implementation barriers. Six recurring obstacles were identified, with underrepresented racial/ethnic groups and non-English speakers reporting additional friction even initiating discussions. Findings emphasize workflow, communication, and structural constraints that perpetuate unnecessary second-line antibiotic use and its attendant harms.

A multi-site qualitative study identifies communication, language, and access barriers standing in the way of removing incorrect penicillin allergy labels.