CEO SUMMARY: It was six years ago when Geisinger Health System pushed laboratory testing and pharmacy services closer to the patients and referring physicians. By establishing coagulation clinics in six multi-specialty clinic sites, Geisinger has allowed pharmacists to use point-of-care testing to provide coag consults, therapy, and patient counseling in real time–often in as little as 30 minutes from a physician’s order.
KEEPING UP WITH COAGULATION MANAGEMENT is presenting new challenges for clinicians—and new opportunities for laboratories. One such opportunity is to more closely integrate pharmacy services with laboratory testing.
This is happening at Geisinger Health System (GHS) in Danville, Pennsylvania, where pharmacist- staffed coagulation clinics have been established throughout the Geisinger service area. The laboratory division’s ability to support these coagulation clinics is a direct consequence of its integrated informatics capability, along with its rigorous program to connect all point-of-care testing devices to the LIS (laboratory information system). (See TDR, November 14, 2005.)
Close interaction and cooperation between pharmacy and laboratory has made a significant difference in patient care. One example of clinical improvement involves patients on anticoagulation therapy. For these patients, there has been a relative reduction in bleeding episodes of 79% during the six years that Geisinger Health System has operated its coagulation clinics. Another example of improved clinical outcomes is the relative reduction in recurrent thrombotic events of 89%.
Doing More With Lab Results
These two examples show how close interaction and collaboration between pharmacy and laboratory is making a big difference at Geisinger Health System. These coagulation clinics pro- vide a powerful example of how laboratory test results can be used to significantly improve clinical outcomes even as the cost per healthcare encounter is reduced.
In such situations, everyone is a winner. Physicians see their efforts produce higher-quality outcomes. Patients benefit from more accurate care, delivered in a timely fashion. The health system enjoys a reduction in the cost per healthcare encounter, along with the long-term benefits that accrue from improved patient satisfaction.
Geisinger established these coagulation clinics in recognition of the complexity of treating patients with bleeding problems. “It’s becoming increasingly difficult for clinicians to manage coagulation issues,” stated Dean Parry, R.Ph., Director of Pharmacy Utilization Management for Geisinger. “The current armamentarium of anti-coagulants requires close management of the patient. Patients must be monitored frequently and dosages of anti-coagulant drugs adjusted immediately when indicated. Failure to appropriately monitor could expose patients to serious risks.”
Integrated Health System
Geisinger is a physician-led, integrated health system. It serves 40 counties spanning 20,000 square miles in northeastern and central Pennsylvania. Approximately 2.5 million people live in Geisinger’s service area.
“We’re fortunate to have a stable, rural population as our service market,” observed Dr. Parry. “It creates three interesting advantages to our healthcare system. First, we can more easily translate discoveries through research into actual patient care. Second, it allows us to more easily monitor patients. Third, these prior two advantages better allow us to improve patient care.
Models Of Care
“This fortunate set of circumstances creates benefits that extend beyond our system,” said Parry. “We are able to create models of care that can be replicated nationwide, particularly in other rural areas.”
That’s exactly what GHS is doing with its pharmacist-run coag clinics. “Maintaining this vital interaction with patients is time-consuming for physicians,” commented Parry. “Pharmacists can bring special expertise to drug therapy management.
“At Geisinger, we saw that, with the capabilities presented through our integrated POCT and informatics system, we could improve drug therapy management and reduce costs by setting up coagulation sites at multi-specialty clinics located throughout our service area,” he explained.
Geisinger’s goal was to bring pharmacists closer to the referring physicians by establishing coagulation clinics at key locations within the health system. Geisinger operates a hospital-based clinic in Danville, along with another 50 ambulatory clinics within its 40-county service area.
“We have six coag clinics,” noted Parry. “These are located in Danville and five of the largest primary practice sites. Each Geisinger clinic site that includes a coagulation clinic also has a CLIA laboratory. Any testing performed by the coagulation clinic is integrated with the on-site laboratory and the lab owns all the testing equipment used in a coagulation clinic.
Managing Coag Therapies
“At these locations, pharmacists actively manage drug therapy,” he explained. “Further, we use these clinic sites as hubs to serve anti-coagulation patients in the surrounding areas. Our staff includes 10 pharmacists and five clerical support personnel.
“Our coagulation clinics operate in a straight-forward manner,” Parry noted. “The physician refers the patient to the pharmacist with three specific objectives: 1) drug therapy management; 2) patient education; and, 3) drug dosage adjustment.
“Additionally, the pharmacist— working in collaboration with the laboratory—provides two valuable services to the clinician,” he explained. “One, the pharmacist makes recommendations to the clinician for the laboratory testing necessary for evaluation of ongoing concerns, for example, coagulopathy. Two, the pharmacist coordinates and helps interpret laboratory test results for appropriate therapeutic interventions.
“Currently our coag staff is man- aging care for over 5,000 patients at our coag clinics,” stated Parry. “These patients fall into three basic categories. In the first category are patients with atrial fibrillation. Blood clots are a big risk factor for atrial fibrillation. These patients are pre- scribed an anticoagulant—a blood thinner, such as Coumadin. In the second category are patients who have already had a clot.
Patients At Risk For Clots
“The third category includes patients who’ve had surgical procedures that put them at risk for a clot,” stated Parry. “These are patients who had orthopedic surgery, spine surgery, hip or heart valve replacement, as well as pregnant women who are at high risk for clots. These women may be on Coumadin or heparin or low-molecular heparin. There is a constant process of dosage adjustment due to the ongoing weight gain during pregnancy. Age is another factor in coag management, since risk of a clot increases with age.
“Another significant risk group is the diabetic population,” stated Parry. “About 30% of our coagulation patients are diabetic. One pharmacist now serves in the additional role of managing the medication of diabetic patients for physicians within the region of the health system for which she is responsible.
Diabetes And Heart Disease
“Diabetics must deal with a variety of crossover risk factors,” he said. “For example, there is a tie between diabetes and heart disease. Physicians at Geisinger are taking a more proactive approach to evaluate diabetic patients for all these risk factors.
“Each of the six multi-specialty clinic sites where we operate a coagulation clinic has three to 10 physicians and one pharmacist,” explained Parry. “The coag clinic is located in a standard examination room, which houses the pharmacist’s desk and computer. This exam room is large enough to accommodate the patient and one or two family members.
“Our coag clinics perform certain point-of-care testing (POCT) on site” he noted. “These include INRs (inter-national normalized ratios) and nor- mal monitoring tests. We use i-STAT instruments for Prothrombin time, for example. Lab test results are fed into the LIS and Geisinger’s EMR (electronic medical records) system.
“Our pharmacist-run coag clinics bring added value to patients, clinicians and the healthcare system,” observed Parry. “Patients receive more rapid and personalized care. Clinicians save time. The health system reduces costs through improved outcomes.
“At a minimum, the pharmacist meets personally with the patient for at least the first visit to provide education and start therapy,” he continued. “Some patients are always seen in person by the pharmacist, others are then managed via the telephone. A stable patient is checked every four to six weeks.
“New patients are checked every few days until their levels are stable,” noted Parry. “Each dosage adjustment does not require the prior consent of the physician. Part of the initial consultation request from the physician establishes parameters for dosing and authorizes the pharmacist to make adjustments. The physician receives an e-mail report of every encounter.”
At three of the six coag sites, the pharmacist does the fingerstick. “This depends on whether the pharmacist has the time and capacity to take the specimen and phlebotomy doesn’t,” stated Parry. “It depends on the site, volume, and who has the time. At the hospital-based coag clinic, the pharmacist’s office is located right next to phlebotomy. In this situation, it saves time for phlebotomy to do the sticks. It’s very much a cooperative process.”
Special pharmacological expertise puts the pharmacist in a position to stay abreast of current guidelines and to manage patients accordingly. The pharmacist’s role includes identifying
patients with coagulopathies and making recommendations for therapy and follow up tests.
“To come up with the best therapy, our pharmacists work with hematologists in the laboratory,” observed Parry. “We then consult directly with the referring physician and recommend short-term therapy.
“The objective is to recognize coagulopathy and start therapy before the patient has a clot,” stated Parry. “The pharmacists work with hematologists in the laboratory and recommend a short-term therapy to the clinician. Prior to our coag clinic program, 80% of the patients who did not have a clear reason for their clot, were not evaluated for the possible underlying causative factors. As a result of the closer cooperation with our pharmacists through the coag clinics, there is a greater awareness of coagulopathy among our physicians.
“The major advantage of the pharmacist-run clinic is the ability to respond quickly and to immediately adjust dosage,” stated Parry. “The critical objective in anticoagulation is to make the dosage adjustment proactively, before a high-risk scenario develops. As part of our monitoring strategy, the laboratory reports any unexpected values to the pharmacist around the clock. This allows for rapid response dosage adjustment.
Doing Lab Tests On Site
“Our coagulation clinics are able to perform about 85% of the need laboratory tests on-site,” Parry noted. “Because some patients live as far as 220 miles from the Medical Center (up to 100 miles from the nearest coag clinic), their tests are sent to our main laboratory,” he said. “As appropriate, all our clinics are able to send patients to the lab for venipuncture or POCT.
“On-site testing is an essential to the success of our coag clinics,” Parry noted. “Typically, elapsed time from draw to a face-to-face consultation between patient and pharmacist is less than thirty minutes. For telephone encounters it’s within twenty-four hours.
“By contrast, the lag time with physicians managing dosage can be as much as three to seven days,” he added. “Effective use of POCT and pharmacists has allowed us to cut out all the middlemen and provide faster, more effective treatment to patients.”
Lab administrators and pathologists should pay particularly close attention to the substantial outcomes this six-year effort has generated. Here’s a partial list:
•Relative reduction in recurrent thrombotic events by 89%.
•Relative reduction in bleeding episodes for patients on anticoagulation therapy by 79%.
•Comparative data shows that the percentage of INR’s within the therapeutic range for the coag clinic is twice that of the rate prior to implementation of the clinics.
•Positive patient satisfaction ratings for the coag. clinic exceed 96%.
•The monitoring and followup provided by the coag clinic has allowed the average length of stay for patients with a DVT (deep vein thrombosis) to decrease from just under six days to about two days.
•Stable patients without significant co-morbidities can often be man- aged as an outpatient.
•This decreased length of stay has been accompanied by a reduction in cost of care for these patients of about 50%.
As these impressive results demonstrate, the effort to bring laboratory testing into the pharmacy at Geisinger Health System has contributed to significant improvements in patient care. The laboratory is supporting testing which is done closer to the patient and is producing lab test results in real time. Pharmacists are using this information to improve their patient’s outcomes.
THE DARK REPORT predicts that this type of close interaction between the laboratory and clinicians will become more common in future years. Coagulation is just one clinical area where faster access to relevant test results can trigger major improvements in patient outcomes.
United Kingdom Has Lab Testing in Pharmacies
IN THE UNITED KINGDOM,the National Health Service (NHS) has a pilot project under way to provide laboratory testing services in pharmacies. The goal is to provide pharmacists with real-time laboratory test results that allow them to better match the appropriate prescription to the clinical needs of the patient.
This pilot project is taking place in Manchester, England. The NHS has remodeled several pharmacies to include a phlebotomy drawing station and an on-site laboratory. The remodeled pharmacies have been in operation for more than a year, and the results have been favorable.
“I am aware of the ongoing project in Great Britain with regard to anticoagulation services by pharmacists,” Dean Parry, R.Ph., Director of Pharmacy Utilization Management for Geisinger Health Systems, based in Danville, Pennsylvania. “I believe that the benefits of such a program have been clearly established in the literature and it is only a matter of time until this process becomes the standard of care.”