Outside the Cath Lab

Innovating the Anticoagulation Clinic

Kirk Raboin, Director, Cardiovascular Services and CV Imaging, St. John Medical Center, Longview, Washington
Kirk Raboin, Director, Cardiovascular Services and CV Imaging, St. John Medical Center, Longview, Washington

Reams of Data Spanning Months, Years, Decades – Managing Patient Information for Anticoagulation Therapy Is the Final Frontier in Multidisciplinary CV Solutions

When Cardiovascular Services, the Pharmacy and the HealthCare Improvement Division (HID) at PeaceHealth-St. John Medical Center implemented an electronic information system in our Anticoagulation Clinic in 2007, we did more than consolidate patient data. We enabled better clinical care by making a conscious effort to institute a coordinated, collaborative delivery model. Now our clinicians spend less time on administrative tasks and more time accurately tracking patients’ therapy — INR levels, diet changes, missed appointments — and communicating this information to other providers. Innovation at St. John, we have been pleased to learn, is contagious. Instituting a Continuum of Cardiac and Vascular Care The Anticoagulation Clinic arose from what we at PeaceHealth describe as our “quality journey,” an effort to improve care continuously by “innovating to achieve superior clinical and operational outcomes,” and a stated commitment to disease management and evidence-based medicine. This means, of course, treating cardiac and vascular disease at all points: in the catheterization laboratory, in surgery, in cardiac rehabilitation, and in the anticoagulation clinic. Like most treatments in the CV service line, anticoagulation therapy produces a nearly overwhelming amount of data. Because the goal of therapy is to administer the lowest dose possible of warfarin, the patient’s INR, changes in dosages and other contributing factors must be tracked carefully. The result is a far-reaching, highly complex web of data that clinical staff must manage scrupulously to ensure an effective therapy program. Our cardiovascular service line first started to focus on anticoagulation because we noticed what we considered a high rate of bleeding complications. Together, a group of physicians, administrators and staff members determined that a dedicated anticoagulation clinic would allow us to control patients’ post-procedure therapy more closely. Cath lab, thoracic surgery and other appropriate patients could then benefit from a true continuum of care. We opened both a Family Practice Clinic and a Specialty/Internal Medicine Clinic. However, like most hospitals today, St. John is constantly evolving, and the two clinics merged in 2006. “This took the number of patients we had (at the Specialty Clinic) from 300–400 to the nearly 1,000 we have now. It became apparent at that time that we needed a better tool to track our patients,” says Gretchen Vandenberg, Specialty Clinic Manager. “We needed to find a system that would accommodate all the records.” Defining Clinical Goals Because no clinical area exists in a vacuum, a multidisciplinary team was formed to address the technical needs of the newly-consolidated Clinic. This team included Dr. Noel Santo-Domingo, MD, Medical Director of Cardiovascular Services; myself, the CV Service Line Director; Suzi Parker, PharmD, Anticoagulation Lead; Gretchen Vandenberg, Specialty Clinic Manager; Heidi Immel, Cardiovascular IT Manager; Patty Pfeifer and Janet Franklin, both Cardiovascular Information Systems Analysts; and nurses and medical assistants from the Anticoagulation Clinic. After analyzing both workflow and data flow, our goals became clear. Our objective was to develop a system-wide solution for the management of anticoagulation patients through more effective tracking, compliance monitoring, therapeutic dose management and improved education. More specifically, we developed a number of clinical benefits that we expected an information system would help us achieve: • A coordinated care delivery model for all anticoagulation patients referred to the Anticoagulation Clinic; • Improved patient time in targeting the INR range; • Improved patient tracking system for referred patients; • Reduced rate of emergency visits and hospitalizations for anticoagulation-related major bleeding and clot events after referral to the Anticoagulation Clinic compared to before the referral process; • A high level of patient satisfaction with services; • A high level of referring physician satisfaction with services; • Improved collaborative patient care. Reducing the Reliance on Paper Our first step was relatively straightforward: ridding the clinic of its reliance on paper records. An electronic system would make patient information immediately and easily available to caregivers, supporting more fully coordinated care delivery. “Currently we have about 1,000 patients, so there are 13,500–14,000 visits or adjustments a year,” says Gretchen. With a paper system in place and 14,000 visits a year, nurses and medical assistants were spending an inordinate amount of time chasing records. Gretchen describes clinic workflow prior to implementing an electronic information system: “We used notebooks with paper worksheets; all patient records were in these notebooks in alphabetical order. They all had the same type of information: date, INR, old dose, new dose. We had one on every patient. We also had a very basic Excel spreadsheet, and we would have to go look through the entire spreadsheet to see who was overdue and then reference that with the EMR, because you have to keep track of that constantly with anticoagulation therapy.” “We all knew going electronic was going to make a vast improvement,” says CVIS Analyst, Patty Pfeifer. “Having all the needed information online in one place so everyone can look it up is important. We didn’t want patient information in someone’s office somewhere where no one could find it. Even with a well-organized paper system, when a patient shows up, you have to pull all the records. Even if you go straight to the ‘C’ file, you’re still going to have to flip past Carlson, past Carter, etc. That requires a lot of time — imagine doing that all day long.” After months of product review and modifications, we chose the Apollo™ Anticoagulation Module from LUMEDX because it supported the larger CV goals at St. John. The module aligned nicely with our Cardiovascular Information System program for data, patients and outcomes management for this population of patients. Implementation went smoothly thanks to a customized version of the module that was developed in partnership with the vendor. Access and Efficiency Improve Accuracy Now that the clinic stores data electronically, nurses and staff have patient information at their fingertips. Catheterization and other relevant data is already in the Apollo data repository, so our nurses do not have to re-enter it each time there is a new patient event (visit, call, letter, etc.). This is particularly helpful for what was once a burdensome task: tracking patients overdue for visits or adjustments. The nurses and medical assistants spend far less time searching for records and generating letters. Because the new system is highly query-able, clinic staff can find what they need quickly and effortlessly. “In the past, we had to use our eyes to scan through more than 900 patients to find who was due for a visit and who was overdue. We needed to go through those records visually every day. It was very hard on the eyes, scanning over 900 records and trying to be accurate. Now the computer figures it out for us,” Gretchen says. “The new system enables us to look at a patient’s record to see what he or she has undergone over the course of the treatment,” explains Gretchen. “We have all the information we need as we treat our patients. It’s more efficient and helps us with accuracy.” Clinic staff still maintains paper records as back-ups, but they don’t need to rely on these for their daily work. Additionally, clinic nurses use the software’s reporting capabilities, running reports about reminder letters, patients due for treatment and overdue patients daily. These reports give nurses a cue to check whether patients have shown up for appointments, whether they have responded to an overdue letter or call, and so forth, over the course of the day. Supporting Best Practices Medicine Improved access to patient records, increased efficiency and robust reporting have helped us reach other goals. Information flows more smoothly within the clinic and between the clinic and other providers, ensuring the best possible care for cardiac and vascular patients. Patient and referring physician satisfaction are high, resulting in more fully realized collaborative care. The Cardiovascular Services Department at St. John is moving down the path of patient management. Introducing software to manage data at the Anticoagulation Clinic supports this goal. Because of the nature of anticoagulation therapy, we knew that we would have to find a different way of managing these patients. The module is a tool to track and manage the trending of their results — efficiently and accurately. Ultimately, this helps us provide a safer level of care with a dangerous drug. Plans are now underway to allocate additional resources to the clinic and build on its success. A lead pharmacist will be coming to the clinic soon, and the nurses and medical assistants are looking forward to adding more interfaces to streamline workflow even further. Implementing the Anticoagulation Module has also reinforced the forward-thinking ideas behind our CVIS platform. For example, many of our patients today have vascular disease, so we have felt a growing need to address that population too. The module helps us reach across clinical areas and treat all those who need care; we see it as another form of best-practices medicine. Because whether it’s a cardiac patient or a peripheral vascular patient, we are committed to providing comprehensive care and therapy, from the cath lab to the clinic.