Indeed, many patients wound up in the hospital, or the emergency department, when their INR scores-an international standard used to assess patients on the medication-were off. To tackle the problem, Brooks led an effort at the 65-physician and mid-level provider group practice to devise an electronic tracking system. Rather than buy an off-the-shelf niche product, however, Martin's Point decided to tweak a forms management component in its ambulatory EHR, the Centricity suite from Waukesha, Wis.-based GE Healthcare, and build the tool internally.
Martin's Point did consider one other vendor, which offered an anti-coagulation management tool. Brooks had seen the application in action during an EHR site visit at another Centricity site. After visiting the anti-coagulation management therapy room the practice had set up, she knew some automation was needed to help streamline the tracking of the INR scores and improve the way they were communicated to patients. But Kim Fallona, EHR manager, and other members of the information technology staff determined that the interfaces with Centricity with the other vendor (which Fallona and Brooks decline to name) were inadequate. "If we went with a specialty module, it would almost be another medical record," says Fallona, who helped build the module and conduct the pilot tests that led to its expansion across Martin's Point's nine primary care sites. "Centricity enables customized development," she says. Thus, a combination of factors led to the decision to build the Coumadin management module internally.
The module relies on Centricity's ability to receive lab results electronically and disperse them to appropriate channels within the EHR. "We took some of the management out of the providers' hands and wrapped it around an algorithm," Fallona says. "That helped bring consistency to how Coumadin is managed."
Building the homegrown module required participation from the medical staff, nurses and I.T. For her part, Brooks completed a certification program in anti-coagulation management therapy to bolster her own expertise. She turned to Margaret Shepp, M.D., to help pilot and test the new module. Shepp and Brooks devised a protocol, which became the backbone of the automated form the practice now uses. The pilot effort began in early 2007, unfolding gradually as Shepp and Brooks validated the protocols they had created. Once Brooks verified that Shepp's patients were maintaining appropriate INR scores, she added another physician to the pilot group. The group gradually expanded in a step-wise fashion, until 15 physicians were involved. "We proved the protocol at our Veranda clinic (one of nine primary care sites run by Martin's Point), then showed it to others," Brooks recalls. The group recently expanded, adding about 35 physicians. They will learn the Coumadin management process as they become oriented to the EHR, which enables a variety of tasks including electronic prescribing, orders and charge entry.
Here's how the Coumadin management module works: If a physician prescribes the medication for a patient, he will alert the nursing staff. "We take it from there," Brooks says. The physician will prescribe an initial dose, good for two days, after which patients return for a blood draw and lab work. Patients also receive in-house education on the medication at that point. The lab will send back the results, pouring the results directly into the EHR. Once the nurse signs off on the lab, the appropriate portions of the lab are ported into the Coumadin management module. "You go into the form, select 'new patient,' and select their diagnosis," Brooks says. "A button comes up and says 'calculate INR level.'" The system then reveals the current INR level and tells what range it should be in, thus alerting the nurse to any discrepancy.
For example, a patient may have a condition that warrants an INR range from 2 to 3. If the INR returns as 1.8, the system will calculate a recommended change in dosing. Sometimes, a patient may just have to take the Coumadin pills less often. Keeping tabs on INR levels is challenging, Fallona says. "Some patients need labs drawn several times a week," she says. "A glass of wine can throw off the level. When it was the physician's job, it was a lot of work."
Now, nurses can handle the lion's share of the Coumadin management. Knowing when to ask a patient to return, based on changes in their test scores, was not easy to do manually, Fallona says. That kind of intelligence is built into the system. "The form does a lot of the thinking," she adds.
Martin's Point has realized some dramatic improvements in patient care since implementing the module. Overall, the vast majority of patients are staying within acceptable INR ranges. The initial pilot group of physicians went from a collective 64 percent acceptable range to 90 percent among their patients. That means fewer visits to the ED, says Brooks. Communication with patients has also greatly improved. The turnaround time for patients to receive their Coumadin instructions dropped from 9 hours to 30 minutes. That's because, under the old set-up, physicians would receive the lab scores in the EHR, then wait for the nurse to load the results into a generic form that was part of Centricity. The physician would then analyze the results, and then give directions to the nurse, who would work with the patient. Often, the patient had returned home.