Increased Oversight and Centralization of Immunosuppression Lab Monitoring

From the 2019 HVPAA National Conference

Dr. Meghan Berkenstock (Johns Hopkins), Dr. Ruby Parikh (Johns Hopkins School of Medicine), Dr. Jennifer Thorne (Johns Hopkins School of Medicine)

Immunosuppressive medications are the mainstay of therapy to treat chronic ocular inflammation. If untreated, blindness can result. These medications include antimetabolites, biologics, alkylators, and corticosteroids. Their use is associated with the development of elevated LFTs, malignancies, infections, and death. To monitor for toxicities, patients require lab-monitoring every 1-3 months. Currently, the 6 physicians in the Uveitis Division prescribe and monitor the use of these medications in 269 patients.

Purpose

To create a standardized and central system to track lab results for patients on immunosuppression. Previously, all patients were divided into three groups alphabetically. One technician monitored if labs were up to date for each patient within a group and maintained records independently on an Excel spreadsheet. If deficient, a technician contacted the patient via phone or a letter stating their medication would not be renewed without lab results. Each spreadsheet contained the patient name, medication, last lab result date, prescribing physician; lab monitoring interval. Without a centralized system with oversight, labs were overdue, the ordering physician and interval for labs were not updated; new patients were not added consistently. Results varied among individual technicians.

Methods

A new Excel workbook was created and saved to the Division’s I drive. Using the software, the time interval for lab monitoring is entered and automatically generates a date on which the next labs are due. If the patient is up-to-date, the patient’s row is green. One week prior to lab results coming due, the row turns yellow- prompting technicians to call the patient to remind them to have labs drawn. Once overdue, the patient’s row turns red- a registered letter is sent to the patient with a phone call to state that the medication will not be refilled until labs are received. All physicians, technicians, and the office manager have access to the workbook in real time. Any changes to the workbook are tracked by Excel to evaluate updates made by each user. New patients must be added within one week of medication start, as communicated via email from physician to technician.

Results

After testing the new workbook in a small sample to look for errors, it was introduced Division-wide on 4/1/18.  One faculty member and the office manager track three outcomes monthly:1) time to new patient entry (benchmark= 1 week from immunosuppression start); 2) rate of patients without a lab-monitoring interval (benchmark = less than 5% at end of year 1; 3% at end year 2); and 3) reduction in the percentage of patients with lab deficiencies with 1% reduction/month with less than 25% of patients at any time within 2 years.

Over 10 months there was a 10% drop in overdue labs. Previously, 117 patients (44%) did not have labs drawn within the specified time interval and this was reduced to 92(34%). Patients with an unknown lab monitoring interval decreased from 11-5 %. All new patients were entered in 1 week.

Conclusion

The use of a centralized workbook improves communication between the ordering physicians and technicians obtaining results. Increased oversight decreased the percentage of overdue labs, omissions of lab testing intervals; identification of patients needing closer follow-up for compliance.

Clinical Implication

The project is sustainable; can be used by other uveitis specialists around the world. It decreases the risk of morbidity and mortality associated with high-risk medication use.