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An Anticoagulation Stewardship Director on why RPM enables long-term patient care, early intervention, and system cost savings.

About the Expert

Michael P. Gulseth, Pharm.D., BCPS, FASHP is widely regarded as an international expert on the safe and appropriate use of anticoagulants. As an active author of authoritative texts on anticoagulation therapy guides, he possesses deep knowledge in designing and implementing inpatient and outpatient programs, with a special focus on patient care. He is an active member of many renowned pharmacy organizations, including the American Society of Health-System Pharmacists (ASHP) – where is he also a Fellow, the Minnesota Society of Health-System Pharmacists (MSHP), the South Dakota Society of Health-System Pharmacists, and the American College of Clinical Pharmacy.

As the Anticoagulation Stewardship Director at Sanford USD Medical Center, Dr. Michael Gulseth oversees a critical team of pharmacists and nurses that safely manage all patients on anticoagulation medication through transitions of care. On the outpatient side, his team is responsible for over 2,000 patients on warfarin.

The Challenge/Background: Sanford USD Medical Center needed a holistic remote patient monitoring solution that could seamlessly integrate with its Epic EHR and extend their ability to care for patients living in remote areas. With the onset of the pandemic, they needed to safely and efficiently onboard dozens of patients quickly.

Challenges with outpatient oversight

Striking a delicate balance with anticoagulants is extremely important. Their benefits are clear – preventing thrombosis – yet continued use without proper monitoring can result in both the thrombotic events they are supposed to prevent, and in major bleeding.  Both of those outcomes may lead to death. Unless patients are involved in regular check-ups or monitoring programs, the risk of adverse and potentially life-threatening side effects are too high. There are a number of quality measures we check to ensure quality care and safety, and they in turn help us identify areas for improvement and intervention.

Prior to partnering with WebCareHealth, we allowed patients to conduct home INR monitoring through multiple vendors, which created difficulty standardizing their approach. When the COVID-19 pandemic started, it became increasingly difficult to ask patients to go into facilities for their regular blood testing. Expanding access to home testing to our patients with the assistance of WebCareHealth was one of the best solutions for this issue.

The evolving role of the hospital pharmacist

Early on, our role within the broader hospital ecosystem was more undefined. Over time, it became clear that hospital pharmacists were a natural advocate for ongoing, effective patient care, both inside and outside the hospital walls. With understanding of all the factors involved in monitoring and providing long-term care, we can more easily innovate to provide new guidelines and standards to improve the health of broader patient populations.

Eliminating gaps in care with remote patient monitoring

Remote patient monitoring is revolutionary for us, because it allows us to provide a continuum of care for patients who live in remote areas or facility deserts. We have a large patient population in Minnesota, South Dakota and Iowa without easy access to our facility in Sioux Falls or even their local facilities, but they need routine check-ups and care.

We are a progressive service – we are always working to make protocol improvements that positively impact the health and well-being of our patients. WebCareHealth allows us to collect data that tracks these improvements over time, which contributes to our quality metrics. As WCH integrates with our systems, including our EHR for updated patient records, we know the data is reliable. We capture, analyze and can present these metrics internally.

Foster partnership for RPM anticoagulant programs

We administer anticoagulant therapies routinely. Hospital administrators need to understand the importance of active monitoring for patients on anticoagulants – otherwise, the risks are too great, both for the patient and for the system. The incidence of emergency care and hospitalization associated with unmonitored or misuse of anticoagulants, including warfarin, is high.

Continuous dose adjustment and routing INR monitoring are key to ensuring ongoing safety of anticoagulant administration and avoiding serious complications. Mismanagement can result in bleeding. Major bleeding rates are found to range from 0.4% to 7.2% per year – while minor rates have been as high as 15% of all patients.

Without routine monitoring, other complications are often noted, including deep vein thrombosis (DVT) or pulmonary embolism (PE), both of which are highly fatal. The CDC notes the fatality rate of DVT/PE is between 10 and 30% within one month of diagnosis, and 25% of individuals with PE suffer sudden death. If INR rates are not maintained within a narrow optimal window of 2-3, warfarin patients with deep vein thrombosis (DVT) are at risk of recurrent venous thromboembolism (VTE). A recent retrospective noted that 8% of patients on warfarin experienced a recurrent VTE during follow-up; when INR rates were measured at subtherapeutic levels (below 2), the risk of recurrence increased three-fold.

Physicians and administrations should encourage active partnership with their pharmacy departments. Together, we can create standardized protocols and set up programs that build long-term success – better safety and care for our patients, along with improving hospital quality metrics and overall financial health.

Conclusion

Hospital pharmacists and remote patient monitoring can help extend the systems’ ability to care for patients outside of the hospital walls. With benefits including billing resources, possible integration of external data with your EHR, ongoing and consistent patient monitoring, a variety of devices and hardware included with partnership, reduced emergency care and hospital readmissions, and increased patient satisfaction and long-term loyalty, RPM delivers clear value for all healthcare industry stakeholders.

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