By Gail Carey, RN, CACP
Emerson Hospital, a nonprofit, community hospital, founded in 1911, is located in Concord, Massachusetts. Since its early beginnings, it has grown to become a 177-bed facility that efficiently provides high-quality health care to more than 300,000 individuals in 25 surrounding towns.
Prior to the installation of Standing Stone’s CoagClinic program at Emerson Hospital’s Anticoagulation Clinic, we used CoumaCare software to clinically document anticoagulation therapy and track reimbursement issues. At Partners Healthcare Anticoagulation Collaborative meetings (our informal networking meetings to improve the quality of anticoagulation services), we learned from peers that CoumaCare systems had failed catastrophically at a number of clinics, and all data were irretrievably lost. The problem seemed to occur when the database contained more than 1,500 patients. When we first learned of this software flaw in 2002, we had 1,400 patients in our database and were beginning to experience difficulties with the program.
We had received CoumaCare free of charge from DuPont Pharmaceuticals. When DuPont was acquired by Bristol-Myers Squibb, we lost our technical backup support. By then, our database had grown to 1,500 patients, and the program was crashing several times a week. Anxiety was the word of the day at the clinic. In 2003, we learned that Bristol-Myers Squibb would resume backing us up with technical support, and the company was working on a CoumaCare upgrade called CoumaCare Plus. Then the FDA issued regulations prohibiting drug companies from supplying free products to health care providers, and Bristol-Myers Squibb indicated that CoumaCare would no longer be a free service.
In addition to these challenges, we felt two important functions beneficial to our clinic were missing from the CoumaCare software: a drug interaction feature and a scheduling feature. Because CoumaCare was no longer free, we began to actively look for other programs with these capabilities.
We investigated several web-based anticoagulation management programs. With web-based applications, patient data could be accessed from home, from the health care provider’s office, or from the emergency department—a convenient and possibly life-saving resource. We ultimately chose Standing Stone’s CoagClinic because of the company’s willingness to work with our IT staff to address our special security needs. Standing Stone also had several former employees from CoumaCare on board, and we felt confident that they would understand our clinical needs.
In June 2004, we implemented CoagClinic, and Standing Stone provided two sessions of on-site training for the staff. At that time, we wanted to implement an Intranet solution: our goal was to run the application behind our firewall on our own servers. Standing Stone was able to install the software locally on our server to meet this requirement. They worked with us during the installation and database conversion to ensure minimal clinic downtime—no easy task since our clinic is open to patients seven days a week. Not only was our database successfully converted, but representatives of Standing Stone also helped us develop customized reports to improve our productivity such as a customized clinic schedule.
CoagClinic software offers health level 7 (HL7) interfaces with electronic medical record (EMR), billing, laboratory, and registration systems. When we converted to the application, these interfaces were not available, so we currently “cut and paste” our narrative notes from CoagClinic into the EMR. We are investigating the potential usefulness of the interfaces available for our Meditech system. CoagClinic software will soon be adding a “view only” feature that will allow other providers to view our database, which will eliminate the need for cutting and pasting until the HL7 interface is live. The program interfaces with all the leading point-of-care (POC) instruments with the exception of I-Stat. Since we use I-Stat at Emerson, we cannot take advantage of the feature at this time.
The reporting features offered through Standing Stone’s CoagClinic are numerous. Daily patient schedules and patient instruction sheets in both English and Spanish are available. Summary reports provide sequential international normalized ratio (INR) with doses and narrative notes as well as percentage of INR in range. Revenue estimates, patient census reports, and number of patients with specific diagnoses are tallied. Quality assurance reports that track number of visits and percent of INR in range are produced. The adverse event feature is limited, however, and does not calculate event rates.
Patient safety has improved at Emerson since the initiation of CoagClinic. The software provides an organized display of data that facilitates clinical decision-making. A dosing support function allows scheduling patient follow-up visits before exiting the patient record, thus reducing the chance of patients being lost to follow-up and identifying those who are overdue. A printed patient instruction sheet provides dose instructions in milligrams and number of tablets needed. Known drug interactions are flagged. When Medicare or other payers request additional information before processing a claim, it becomes a simple procedure to print a patient visit report containing lab results, dosage instructions, narrative notes, and vital signs. CoagClinic software has improved the quality of anticoagulation therapy offered at Emerson Hospital and increased the clinic’s efficiency and profitability.
Gail Carey, RN, CACP, received her BSN degree in 1980 from the University of Massachusetts in Lowell. She has been a critical staff nurse and educator for 15 years and an anticoagulation provider for ten. She is manager of the Anticoagulation Clinic at Emerson Hospital in Concord, Massachusetts.
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