Dr Garry Brown & Richard Kelly Kowhai Health Trust

1. Using IT to Improve
Warfarin Management
in the Hutt Valley
Dr Garry Brown (Clinical Director) &
Richard Kelly (IT Specialist)
www.kowhaihealth.org.nz
Friday, 16th March 2007
In a nutshell…
..................................................................
• Warfarin is one of the 5 highest risk drugs in
clinical use
• Management of warfarin is highly complex
Significant sources of avoidable error arise from
– information flow issues from secondary to
primary care
– practice system issues
– patient compliance issues
• Use the power of IT, and the principles of the
Primary Health Care Strategy to improve
system wide management of warfarin patients
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2. Primary Health Care Strategy
..................................................................
• Co-ordinate care across service areas
• Offer access to comprehensive services
• Continuously improve quality using good
information
• Identify and remove inequalities
• Develop the primary care workforce
• Work with local communities
Warfarin is a High Risk Drug
..................................................................
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3. Warfarin is a High Risk Drug
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• Levels measured by International
Normalised Ratio (INR)
• Levels too low lead to excess blood
clotting eg embolic stroke, DVT
• Levels too high lead to excess bleeding
problems eg haemorrhagic stroke, GI
bleeding
Maintenance Therapy
Risk of Intracranial Hemorrhage in Outpatients
Adapted from: Hylek EM, Singer DE, Ann Int Med 1994;120:897
-902
Hylek, et al, studied the risk of intracranial hemorrhage in out patients treated with warfarin.
They determined that an intensity of anticoagulation expressed as a p rothrombin time ratio
(PTR) above 2.0 (roughly corresponding to an INR of 3.7 to 4.3) resulted in an increase
in the risk of bleeding.
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4. Lowest Effective Intensity for Warfarin Therapy for
Maintenance Therapy
Stroke Prevention in Atrial Fibrillation
INR below 2.0 results in a higher risk of stroke
Hylek EM, et al. NEJM 1996;335:540
-546.
-546.
Whose problem is it?
..................................................................
.
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5. The Solution
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The Solution
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• Address information flow issues via
Concerto, Healthlink
• Address practice system issues using
MedTech template, and additional education
and knowledge resources
• Address patient compliance issues using
Patient Defaulters database from Aotea
Pathology
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6. The Solution
..................................................................
• Hutt Valley
DHB and
Concerto
The Solution
..................................................................
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7. The Solution
..................................................................
• Hutt
Valley
DHB
Discharge
summary
The Solution
..................................................................
• MedTech
screening
template
(at GP
Practice)
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8. The Solution
..................................................................
• Aotea Pathology defaulters database
The Solution
..................................................................
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9. The Solution
..................................................................
• Sample of
fax sent
to Practices
with details
of their
defaulting
patients
Results
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• Reduction in patients defaulting for INR
testing from 8.3 % down to <3% of all
patients (1200 in Hutt Valley area)
• Reliable, accurate, complete, and timely
flow of critical clinical information from
hospital to primary care
• Improved practice systems using
MedTech templates
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10. The Future
..................................................................
• Dealing with patients who have no GP
• Can we extend this systems approach
for other high risk drugs eg: amiodarone
> a pilot is in progress
• Text/email patient INR test reminders
• Linking to Point of Care testing
• Using Web hosted decision support tools
> in development by BPAC
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