Introduction Topic: Advantages of fully integrated, fully - - PDF document

Care of a Patient with Pulmonary Embolism: Leveraging HIT

March 7, 2011 402- Introduction to Clinical Thinking

Ahmad Haque, Amanda McCook, Paul Koepke, Priya Krishnamurthy

• Topic:
• Advantages of fully integrated, fully installed IT
• Scenario:
• A simple, very commonly occurring ED Visit involving a

28 year old female patient

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Introduction

Priya: Medical Practice has always relied on technology; whether it is the use of X‐Rays in path physiology or electronic lab assays, technology has played a vital role. But, over the last decade, HIT has revolutionized the health industry in more ways that ever before. The patient population has benefited from increased collaboration between all parties involved in clinical care and IT enhanced decision support. Today through our presentation we want to illustrate the advantages of fully integrated, fully installed IT.

Clinical Process

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Patient Attending in the ER Pharmacist Patient Physician Enters ED with symptoms Formulates diagnosis and care plan Reviews prescription

• rder

Participates in care at home Handles follow-up care

Priya: Our role play is going to take the following course

• 1. We have a 28 year old, female patient sharp chest pain that walks into ED with symptoms of blood in cough,

dyspenea and chest pain.

• 2. The attending in ED formulates a diagnosis and treatment plan.
• 3. Pharmacists consults with the attending
• 4. The patient after being discharged from the ED participates in care at home.
• 5. The Outpatient Physician checks on the patient progress and determines a long term plan for care.

Patient= Priya, Attending= Amanda, Pharmacist= Ahmed, Outpatient = Paul

Records via handheld:

• Key complaints
• Shortness of breath, sharp chest pain, and blood in cough
• Problem list
• Mild alcoholism
• Probable diagnosis
• Suspected deep-vein thrombosis
• Pulmonary Embolism
• Test needed
• D-dimer to rule out a thrombotic disorder (test has high

sensitivity and low specificity) (Philip S. Wells, 2003)

• PT/INR to see how thin the blood is

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Attending in the Emergency Room

Amanda: Hi Priya, I’m Dr. Amanda. I understand you have been experiencing some blood in your cough. Can you tell me a little more about this? Priya: Yes, about 2 days ago I started coughing with a little blood. It’s not consistent, but occurs at least several times a day. I’ve also had some shortness of breath and a chest pain. The chest pain is a sharp intense pain. Amanda: Ok thanks Priya. Anything else? Priya: No, those are my only concerns today. Amanda: Ok I’ve noticed on your chart that you are an occasional drinker. Can you tell me how often? Priya: About every day. Amanda: A glass or more? Priya: Usually bring home a bottle to enjoy with dinner. Amanda: Ok, anything else about your health I should note? Priya: That’s it. Amanda: Ok, I have a couple probable diagnosis including Pulmonary Embolism. I would like to do a test for PE as well as deep‐vein

• thrombosis. The test will not tell us that you necessarily have thrombosis but will tell us that if you do not. It will be helpful for us to

rule that out if possible. The PE test is a PT/INR test that will tell us how thick or thin your blood is. These papers should tell you a little more about the tests. Do you have any questions? Priya: Not at this time. Amanda: Ok, I’m going to bring in a nurse to coordinate the tests. We want to get them started right away. Your chart also says you take aspirin. How often do you take this and are you on any other medications? Priya: No just that and I take it when I’m not feeling well. Friday afternoon was the last time I took some. Amanda: Ok thanks. And we’ll get you taken care of. Just let me or the nurse know if you have any questions. (D‐dimer tests have a 93‐95% sensitivity and about 50% specificity in the diagnosis of thrombotic disease)

Handheld responds off entered data via:

• Natural language translation (compares against

physician entered data)

• Integrated automatic diagnostic tool
• Pulls from outside source of truth
• Sensitivity and specificity of recommended test
• Populates patient probability of diagnoses before and

after test results

• Takes into account factors that would throw results off

(patient use of aspirin)

• Medication alerts (when entered post test results) of

side effects, drug reactions, etc.

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Attending in the Emergency Room

Amanda: Ok, as Priya was talking I was recording key complaints, a problem list, and probable diagnoses on my handheld device. The notes section where I free typed my response was translated via a natural language translator and confirms the same number of key complaints captured. The system has also utilized iTriage automatically off already entered data and recommends other probable diagnoses. I don’t see anything here that jumps out to me as concerning. As I enter the tests I’m recommending, the tools returns the probability that my patient has each diagnoses. It also seems to have picked up that the aspirin could throw off the blood thickness reading. In addition, there is a note at the bottom already alerting me to probable drugs and side effects. This is a great overview of information and perhaps I should ask our pharmacist about what prescriptions he would recommend…

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iTriage: Diagnostic Tool Patient Keeper: ER labs

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Attending begins a chat

• Pharmacist
• Prior note in chart that patient periodically takes aspirin and

alerts patient not to take aspirin or other salicylates while on Coumadin

• Also notes that patient was a mild drinker and alcohol may

interact with Coumadin. Alerts patient.

Once diagnosed, patient admitted to the floor, treated for PE and discharged

• Recommends home INR monitoring/periodic blood checks to

validate prescription dosage

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Attending and Pharmacist

Amanda: Let me ping Dr. Ahmed, our pharmacist, to see what he recommends.

• Dr. Amanda: Hello Dr. Ahmed, I have a patient that I would like to discuss with you, do you have a moment?
• Dr. Ahmed: Yes, Dr. Amanda, I am here.
• Dr. Amanda: Well, I have a patient, female, which I am diagnosing as PE
• Dr. Ahmed: OK. What are her symptoms?
• Dr. Amanda: Shortness of breath, sharp chest pain, blood in cough
• Dr. Ahmed: OK. Is there anything else I should know?
• Dr. Amanda: Yes, she periodically takes Asprin and is a mild drinker.
• Dr. Ahmed: I have a few ideas, but let me check my decision support tool, e‐pocrates. Just a thought, Dr. Amanda, do

you suspect there is a blood clot and are you planning on admitting the patient?

• Dr. Amanda: Yes, if the lab results come back like expected.
• Dr. Ahmed: Alright. I’d like to recommend Urokinase ("yer ‐ oh ‐ KINE ‐ ace") to dissolve the clot, followed by Coumadin

to prevent further clotting. Also, it may be a good idea for the patient to be on a home INR monitoring to check for appropriate dosage of the medication.

• Dr. Amanda: Perfect, that’s what I was thinking as well. Thank you. I will put the order through the POE as soon as

results are back.

• Dr. Ahmed: Great. I will fill the order and message you back through the EMR once the prescription is ready.

Automatic triggers via patient portal

• Posts lab results
• Notes from physician and links to education
• Reminder to patient for follow-up
• Escalation if patient does not schedule follow-up within

recommended time

• Orders Rx online
• Patient receives alert that Coumadin has been added to

prescription list and link to education materials

• Reminds patient via portal of Coumadin interactions with

aspirin and alcohol

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Attending in the Emergency Room

Amanda: Well, Priya’s lab results came back as expected, ruling out deep‐vein thrombosis (with a minimal probability that Priya has this even though tests are negative). She has been admitted to the floor, treated for PE and discharged. I know she signed up for access to our patient portal and PHR so the lab results have been automatically posted with links to education material. I don’t have anything special to add to the material for this patient. I also trust that I will get notified if the patient does not schedule her follow‐up visit in our Ambulatory setting. These alerts really help me to focus on the clinical part of my practice which I really appreciate. I did see the note this morning from Dr. Ahmed letting me know the prescriptions were ordered and information automatically added to the patient portal.

Patient Participation:

• Logs in to Patient Portal
• Views lab results, diagnosis and physician notes
• Views Discharge Instructions
• Patient notes interaction between alcohol and aspirin
• Access the reference material published by physician to learn more

about PE

• Makes a note to schedule follow-up appointment
• Makes a note to check with PCP about stopping aspirin
• Pays bills

Ongoing Tracking:

• Records medication taken
• Inputs additional symptoms and drug reactions

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Patient- Immediately Following the ED Visit

Priya: (Patient Thinking) Well, I was discharged from the hospital yesterday, they did sign me up for their online patient portal, let me log in to see what it is in there. Oh, this is great I can see the lab results and physician notes. I am not even sure what this PE is , may be I should google it. Hold on, what is this, a link to the reference material. This is great and much easier to understand than stuff on the web and after all PE doesn’t sound as bad as I thought. The nurse mentioned something about staying low on alcohol. There I see it, the physician notes that my medication mixes up aspirin and alcohol. I need to talk to my PCP about aspirin and see if he has alternatives. He is the one who asked me to take it. While I am at this let me schedule the follow up appointment and pay the bills. The patient goes on to print the INR worksheet and tracks the medication taken and drug reactions as best as she can.

myChart: Patient Requests Appointment

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Patient – Preparation for Appointment With Outpatient Physician

Online Scheduling

• Schedules follow-up appointment online
• Receives questionnaire from Physician's office
• Registers profile and completes Medical History online

Online Agenda Setting

• Completes the agenda

Priya: A few days before the follow‐up appointment with the outpatient physician, the patient logs into the portal again. This time she registers her profile and completes medical history online. (Patient Thinking) Isn’t this great, Dr.Paul wants me to enter my questions and agenda for the appointment? I have never had this before and always ended up not getting what I wanted from the appointment.

Automated, transparent check-in process at kiosk

• Patient swipes a credit card, verifies insurance details, and

can update history or agenda while checking in

• Card Identifies the patient against MPI (Master Patient Index)
• Kiosk downloads coverage and co-pay information

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Patient – OP Check-In

At the appointment, (Patient) They did tell me that I can check in myself by swiping the credit card. It seems that there is a new technology that will pull my history and insurance information based on a Master Patient Index. [[Kiosk allows automated, transparent check‐in process

• The patient swipes a credit card at a kiosk, which identifies them against the office’s Master Patient

Index.

• The patient could also enter their name, but the credit card makes the process quick, and is

something that many people have available rather than some kind of unique medical identification card.

• The patient verifies that their insurance details and pays the co‐pay at the kiosk. The kiosk downloaded

coverage and co‐pay information from insurer.

• If the patient has questions, the kiosk is next to the check‐in desk so the patient can ask the staff for

help.

• Kiosk verifies that the pre‐visit questionnaire is on‐file, and offers the patient the option of updating

their responses if anything has changed.]]

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PCP – Office processes

Online scheduling kicks off several processes at the office

• Front desk staff notified of appointment
• Confirm appointment details
• Office EMR pulls ED data from a statewide HIE
• Automated, proactive process
• Nurse reviews the patient’s history and agenda submission
• Flags responses for review
• Can message patient with answers or for clarification

Paul: I’m the patient’s primary care physician. The technology in use before the visit makes me more efficient. I can trust that:

• The scheduler was notified of the online appointment, and confirmed that the length of the visit was

appropriate for the reason for visit.

• The scheduled appointment causes the practice’s EMR to proactively pull the ED and inpatient data from the
• HIE. I have the problem list, notes, labs, and meds from the patient’s episode
• I can see the patient’s history questionnaire and agenda so I can plan for the visit. I can see my nurse’s notes and

make my own notes as well.

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PCP – Exam

After the exam, the physician discusses the plan of care and specific goals with the patient:

• Track INR online in PHR via internet-ready device
• Allows automated alerts
• Physician sends instructions to PHR
• Schedule a follow-up visit in 1 month
• Tracked in PHR

E-prescribes the new Coumadin script

• E-prescribing system helps adjust Coumadin dose based on

patient info.

Paul: After the exam and an INR test, the physician discusses the plan of care with the patient and writes up specific goals:

• Your INR test was a little too high, so I’m going to prescribe a lower dose of Coumadin.
• I want you to use a new device to measure your INR at home. This will upload the values to your PHR,

which will remind you if you miss a reading, and I’ll be able to pull these readings into my records here at the office.

• The normal INR range is .8 to 1.2, but we want you to be in the 2.0 to 3.0 range. Call the office if you are
• utside of that range and we’ll adjust your dose.

Patient asks: Why do we want my INR readings to be higher? Physician’s answer: Due to your embolism, we want your blood to be thinner than the average person’s. A higher reading is thinner, so we want you to stay in that higher range.

• Schedule a follow‐up visit in 1 month.

I need to write the patient a new script for a lower dose of Coumadin. Coumadin dosing isn’t always straightforward. Fortunately, the e‐prescribing portion of my EMR has dosing aids, including for Coumadin. Based on the patient’s age, history, and diagnosis, all of which are already in the EMR, I write a new script and send it to the patient’s pharmacy. Coumadin dosing website (from WashU): www.warfarindosing.org

Epic: Physician Enters Notes

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myChart: Patient Enters Data and Tracks Progress

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End of Role Play

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Priya: That brings us to the end of role play. Our scenario was hypothetical, we had ideal physicians (attending and PCP), an ideal pharmacists and a somewhat ideal patient. Each of the players were able to perform at their best with the help

• f HIT:

Attending in the ER evaluated: Problem list, probable diagnoses supported by a diagnostic tool, test sensitivity and specificity populating patient probability of having the diagnoses Knows that results and vital information made transparent to the patient via PHR/patient portal Patient: HIT has created an informed patient who can be advocates for their own health. Pharmacist: Better communication between the clinician and pharmacist and the use of decision support tools in care can help improve the quality of health and healthcare. Physician: Fully integrated HIT systems help the physician plan the patient's long‐term care and enhance the patient's ability to care for themselves with the physician's help.

Healthcare IT of Today:

• Slow Adoption
• Disparate Systems
• Provider Skepticism

Healthcare IT for tomorrow:

• Integrated
• Interconnected
• Prevalent

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Conclusion

Priya: The reality of a system that supports clinical thinking seamlessly is within reach. Current state of HIT has developed and implemented tools for select roles while simultaneously evaluating the effects and anticipated benefits. The technologies are vast but integration is still limited. However, advancements continue to support current state development and as HIT becomes a major focus of health care institutions, we can see where health care information technology is headed. Through our role play, we understand how HIT can transform the way we deliver health care. Although HIT has taken huge strides, it does fall short in delivering the promises of improved quality. The benefits from some applications such as CPOE have been realized quite well, while HIEs and EHRs have areas of

• improvement. It should also be noted that only about 25% percentage of providers even have access to EHR and

associated systems. But there is hope the future of fully integrated and fully installed IT.

Thank You

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Paul: Questions?

References

Casalino, LP (2009). Frequency of Failure to Inform Patients of Clinically Significant Outpatient Test Results. Archives of Internal Medicine. Baldwin, D. M. (2005). Patient preferences for notification of normal laboratory test results: A report from the ASIPS Collaborative. BMC Family Practice. Gold Standard. (n.d.). Warfarin Sodium Oral tablet. Krupa, C. (2011). Referral silence irks specialists, primary care doctors alike. ama-assn.org. McPhee, J. (2011). Health-care gaps worry patient’s son. TheChronicleHerald.ca. Philip S. Wells, M. D. (2003). Evaluation of D-Dimer in the Diagnosis of Suspected Deep-Vein Thrombosis. The New England Journal of Medicine , 349:1227-1235. Soheir S. Adam, N. S. (2009). D-dimer antigen: current concepts and future

• prospects. Blood , Vol. 113, No. 13, pp. 2878-2887.

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