Imagine you’re a busy primary care doctor who’s seeing three or four patients an hour. One of them is Mrs. Jones, who has diabetes and high cholesterol. You’ve prescribed medication for both of these conditions. You’ve also made sure that Mrs. Jones gets an HbA1c test at least twice a year and that she gets her cholesterol checked regularly. She visits you once every three months, and each time you see her, you sift through her chart to find her latest lab results and to see which medications she’s currently taking and at what dosage.
Is this a bit difficult to do in a 15-minute visit that may involve other medical problems as well? You bet. Could you miss an out-of-range lab result? It’s possible.
Of course, if you have an electronic health record, it would be easier to locate the information you need. But even then, it could be difficult to track the medications you’re giving Mrs. Jones against her lab results. So, even though you probably have a drug interaction checker in your EHR, you’re missing an important component of decision support that could improve patient safety.
A web-based “integrated health record” (IHR) with real-time decision support could help you meet this challenge, whether or not you have an EHR. An IHR is a patient-centered, multi-sourced record that shares a common platform for lab and radiology ordering and results, electronic prescribing, and hospital results and documentation, making it easier to correlate a patient’s data and present it in a comprehensive central view at the point of care. By using an IHR for test ordering and prescribing, a physician would have all the data needed to plot the longitudinal progress of lab results against prescribed medications.
Here’s how it works: The doctor creates a data set that includes up to four different medications or dosages of the same drug, as well as up to four different lab tests. The data set may be related to a specific disease or risk factors. For example, if the physician is trying to reduce a patient’s blood pressure, he or she might look at the patient’s cholesterol level, as well.
By graphing this data over time, the physician can see – at a glance – any trends in lab results that may be related to the medications. For example, the doctor might include a thyroid medication in the dataset to find out how that drug affects TSH on three consecutive tests. The clinician can then change the drug or modify its dosage to improve the patient’s condition.
The key element of this application is its built-in alerts. If a new lab value comes into the IHR and it’s out of the normal range—for example, an abnormal INR value for a patient on Coumadin—the system will automatically alert the doctor that an action needs to be taken. The alert might be transmitted to the physician via secure e-mail, smartphone, or pager. To make sure the doctor sees it, a note is also added to the printed lab report, recommending that because of changes in the patient’s lab values, the doctor might want to review the patient’s medications. Because physicians must sign lab reports within 24 hours, they’re bound to see that note.
Another advantage of this approach is that it can include data from outside of the physician’s practice. Most patients with chronic conditions see multiple doctors, yet those physicians don’t necessarily communicate with one another about the patient’s care. Even if they do, it’s highly unlikely they are exchanging up-to-date medication lists and lab results.
The IHR, as part of its e-prescribing module, includes a connection to Surescripts, the company that transmits prescription data between medical offices and pharmacies. Surescripts, which has access to data from nearly 85% of U.S. pharmacies, can send e-prescribing clinicians a community medication history that displays most drugs prescribed for a particular patient.
On the lab side, an IHR can serve as a hub for ordering and results from community hospitals and reference labs. When the IHR achieves that degree of connectivity, physicians who have a patient’s permission can view all the results of all the tests that have been ordered for that patient. A master patient index ensures that all data is related to the correct patients.
By combining the community prescription and lab data, physicians can build a much more comprehensive picture of patient care than they could from their own data alone. When combined with in-patient lab and medication information, this patient-centered approach provides physicians with the complete data in one place that they need to make the best medical decisions at the point of care.
Oddly enough, the drug-lab decision support application described in this article does not exist in most EHRs. In theory, the EHR vendors could install such a module in their applications. But in reality, it wouldn’t work very well because EHRs lack the level of connectivity of an IHR. Physicians must establish interfaces with each participating lab, often at a high cost. And unless they have a sizable or strategically important practice, their hospital might prefer not to create an interface with their EHR. The IHR cuts through this obstacle by providing a central point to which all local labs and imaging centers can connect.
We are rapidly moving into an era when the bar for patient safety will be dramatically raised. Drug-lab decision support is an essential tool that will help physicians meet those expectations. At the same, it can help improve the quality of care by helping patients recover more quickly. And finally, who would want to waste minutes thumbing through a patient chart when the necessary information is attainable at their fingertips on a secure web site?
The time for 21st century medicine has arrived, and none too soon.
