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Utilization of Electronic Health Record Alerts for Early Identification and Appropriate Treatment of Pulmonary Arterial Hypertension Patients

Olivia Carter

Amanda Carignan

Mary Whittenhall

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Conference: 2017 PH Professional Network Symposium

Release Date: 10.06.2017

Presentation Type: Abstracts

File Download: 2017 PHPN Abstract 1031

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Abstract presented at the 2017 PH Professional Network Symposium held in Bethesda, MD on October 5-7, 2017

Purpose

To employ immediately visible Best Practice Alerts (BPAs) within the Epic Electronic Health Record (EHR) to identify patients with Pulmonary Arterial Hypertension and their specialized medication regimens upon presentation to the emergency room, or other clinical locations within the Lifespan healthcare organization that may be otherwise unfamiliar with the consequences associated with interruption of PAH therapies.

Background

Despite advances in care for PAH patients and the emergence of PH Care Centers in the United States, knowledge gaps remain in appropriate management of PAH patients outside of PAH-centric units and clinics. This can present several risks, particularly for patients receiving continuous prostacyclin therapies. Infused prostacyclins continue to play a vital role in treatment regimens for patients with PAH. PAH patients who present to the emergency room with pump malfunctions or central line complications face risks in receiving appropriate medical care, as interruptions to these infusions or inadvertently administering a prostacyclin bolus could result in life-threatening complications. There is minimal literature to address strategies for utilizing functionality with EHRs to improve the care of high-risk patients. Efforts should be made to easily identify PAH patients with complex treatment regimens, especially if the patient is unable to meaningfully contribute to their care due to illness or injury. As the level of sophistication in EHR functionality improves, many systems now possess the capability to create patient-specific flags with information that is vital to providing appropriate patient care. These flags would be useful to clinicians in areas such as the emergency department where PAH patients may be considered low-volume but high-risk patients for complications.

Methods

Lifespan, a compressive academic healthcare organization affiliated with The Warren Alpert Medical School of Brown University implemented the Epic EHR in early 2015. Since this implementation, there are ongoing initiatives to improve system functionality. In September of 2016, a team of 45 employees (including the Program Coordinator for the RI Hospital Pulmonary Hypertension Center) formed a committee to develop a process for creating high-risk patient alerts within the Epic system. PAH patients were identified as a high-risk population and plans were made to 1) identify patients on intravenous or subcutaneous prostacyclin who are treated at the RI Hospital Pulmonary Hypertension Center (RIHPHC) via EHR query 2) build a “Smart Phrase” that would be entered individually into each patient’s electronic record via a Care Coordination Note (CCN) to identify PAH patients on a prostacyclin infusions and information about where the patient should be admitted if necessary as well as the PH clinician on call cell phone number, and 3) upon saving the “Smart Phrase” documentation, a Best Practice Advisory (BPA) is triggered for any new user who accesses the patient’s clinical data. The user is unable to bypass the BPA without acknowledging that they have reviewed the information. Thirty-seven patients were identified as receiving IV or SC prostacyclin infusions in the Lifespan organization and CCNs were created by the RIHPHC nurse practitioner and two registered nurses from the Respiratory ICU/PH inpatient unit. The functionality was tested to ensure that BPAs were generated after entering this information.
A face-to-face educational in-service was provided for all clinical staff on the PH-centric inpatient units about this functionality and how to edit or add/remove a patient BPA when applicable. A specialized educational in-service was also offered to the emergency room charge nurses and critical care team at their monthly meeting. Reinforcement training and skills assessment was also required via the Net Learning educational module within the organization.

Results

PAH patients require specialized plans of care that are initiated at the time of presentation to the emergency department or other care area to ensure that any risks or delays to appropriate care are mitigated. Upon entry to the emergency department, the BPA alert is generated upon entering the patient’s record with information specific to their PAH management. The clinician acknowledges the alert and an audit trail is generated in Epic. The resource nurse in the emergency department contacts the resource nurse on the PH-specialized critical care unit to determine the best course of assignment and seek additional assistance if warranted. The resource nurse can then contact the provider to expedite the admission process and notify pharmacy of any specialty medications that must be mixed or ordered. Quality measures are currently being developed to monitor the improvement to quality of care that PAH patients receive in the emergency department.

Conclusion

While the PAH patient population within this organization is small in comparison to the population served at large, PAH patients, particularly those receiving infused prostacyclins require specialized care delivered in an expeditious fashion, particularly during an emergent or unexpected hospitalization. The introduction of the BPA alert and detailed CCN, along with education tailored to specific care areas is intended to decrease the risk of adverse events with PAH patients. Ongoing monitoring of the use of these BPAs and CCNs is required to assess their efficacy. The selective nature of this initial program may provide the framework for adoption of this functionality at other PH Centers or to identify needs for other patient populations with a need for delineation and education.