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 Introduction • Topic: • Advantages of fully integrated, fully installed IT • Scenario: • A simple, very commonly occurring ED Visit involving a 28 year old female patient 2 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 Attending Patient Pharmacist Patient Physician in the ER Enters ED Formulates Reviews Participates Handles with diagnosis and prescription in care at follow-up symptoms care plan order home care 3 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
Attending in the Emergency Room 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 4 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)
Attending in the Emergency Room 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. 5 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…
iTriage: Diagnostic Tool 6 Patient Keeper: ER labs 7
Attending and Pharmacist 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 8 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.
Attending in the Emergency Room 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 9 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.
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