By David Bronstein
GRAPEVINE, Texas—Vanderbilt Specialty Pharmacy has harnessed the power of patient monitoring tools for the management of inflammatory bowel disease (IBD), asthma and other challenging chronic conditions. But as with most technology-based interventions, following a few key guiding principles can help smooth the journey, two of the health system’s data management experts noted during the NASP 2023 Annual Meeting & Expo.
To start, “you’re going to want to set your goal and decide how you’re going to measure success,” said Kristen Whelchel, PharmD, CSP, a research and patient care pharmacist at Vanderbilt, in Nashville, Tenn. “Those goals need to be clearly defined on the front end.”
There are several quality improvement frameworks that can be used to guide this process, Dr. Whelchel noted, but the one she and her colleagues have found to be particularly helpful is Plan-Do-Study-Act (PDSA). “It gives us a clear picture of what we are trying to accomplish, how to determine whether the changes we implemented are actually working, and what tweaks are needed to keep on track.”
Dr. Whelchel and her colleague, Bridget Lynch, PharmD, MS, an analytics data management pharmacist at Vanderbilt Specialty Pharmacy, used the PDSA framework to tackle a particularly thorny issue that arose in Vanderbilt’s IBD clinic: patients being denied refill renewals because their lab monitoring was out of date. Without lab tests confirming that the patients were free of tuberculosis or other opportunistic infections that can occur as a result of biologic therapy, the refill requests would be rejected, resulting in delayed patient care.
“When examining this problem, we started by defining our goal, which was to identify this patient population earlier so the specialty pharmacist could intervene before the patients experienced that denied refill renewal,” Dr. Whelchel said. The solution chosen was a laboratory monitoring dashboard that identified patients four weeks before they would need a refill renewal. This approach “allowed that extra time for patients to go and have those labs done so that they could get their new prescription,” she said.
To satisfy the PDSA framework’s “study” component, the team compared the number of IBD patients who experienced treatment gaps before and after implementing the lab monitoring dashboard. “We found that patients with gaps in therapy due to outdated labs dropped from 80% at baseline to 32% post-implementation,” Dr. Whelchel said. Moreover, “the median length of therapy gap went from 21 days to 11 days. So, implementing this dashboard monitoring was successful—so much so, that it has become standard practice in the IBD clinic” (Am J Health Syst Pharm 2023;80[suppl 2]:S55-S61).
Adding a data tracking component may seem fairly straightforward, but its success hinges on a few key factors, not the least of which is engaging key stakeholders from the start.
“When designing this solution, it was critical that we brought in all of the other people who would be involved or impacted by the laboratory monitoring dashboard,” Dr. Whelchel said. “So, we pulled in the clinic nurses because they were the ones who were ordering the lab monitoring and sending the prescriptions. With their input, we were able to shape how the refill messages were sent in the electronic health record [EHR] and what data was included.”
Keeping Asthma Patients Out of the Hospital
The Vanderbilt team also had recent success creating a clinical dashboard for monitoring asthma patients. The dashboard tracks key response indicators, including the respiratory function parameter FEV1%, short-acting beta-agonists and systemic steroid use, and hospital/urgent care visits.
“The purpose of this dashboard is to proactively identify patients who might be at risk for uncontrolled disease,” Dr. Whelchel said. “These are all structured data that can be pulled from the EHR into this dashboard. Our specialty pharmacist in the asthma space set up parameters and receives alerts on patients once they fall into those parameters. That allows her to then go in and review trends for that patient, and then provide the needed interventions to improve disease control.”
Although this particular data analysis has not been published, Dr. Whelchel noted, Vanderbilt researchers recently authored a paper highlighting pharmacists' role in improving specialty medication adherence (Am J Med 2023;136[7]:694-701.e1).
Dr. Lynch emphasized the importance of relying on such structured data as much as possible when building patient monitoring dashboards. She explained that structured data typically includes pull-down menus, clickable boxes and other automated data entry tools. Unstructured data, in contrast, includes free-text fields for entering items such as progress notes.
“There’s certainly a place for unstructured data, but it’s prone to misspellings, it’s not standardized, and so it can make it extremely hard to data-mine and report on,” Dr. Lynch said.
There are several other key steps to include when building a patient monitoring dashboard, such as taking your staff’s workflow into account when setting specific features and tasks, Dr. Lynch noted. She echoed the need to include all key stakeholders in the process. But one of the most important keys to success is having a proactive strategy for periodically assessing whether the monitoring tool actually is working optimally, and if not, making necessary tweaks, she stressed.
“Whatever monitoring tool you build, there is going to be maintenance and documentation and validation,” Dr. Lynch said. “So be prepared to document the logic, track and check what data was being requested, how you’re capturing it, and whether it can be reported in a streamlined fashion.”
Although these dashboard-based projects rely heavily on data set builds and other complex technologies, “it’s really about creating something that helps your team truly impact patient care,” Dr. Lynch said. “That is not a set-and-forget endeavor.”
