1. Massachusetts General Hospital Anticoagulation Management Service Using Dawn AC to Support Safe Management of Anticoagulated Patients Lynn B. Oertel, MS, ANP, CACP Clinical Nurse Specialist Presented November 4, 2008

2. Dawn AC Front Screen

3. Moving into the 21th Century

4. List Views Daily work organized and sorted with use of these lists Daily work organized and sorted with use of these lists Customizable lists and filters determine what patient data is displayed Customizable lists and filters determine what patient data is displayed Bulk messaging can be accomplished Bulk messaging can be accomplished

5. Clinic Diaries Helps manage/direct future daily work Helps manage/direct future daily work Controls INR scheduling for weekends, holidays, days off, etc. Controls INR scheduling for weekends, holidays, days off, etc.

6. Reports Customized reports (data viewed/printed from screen or easily exported into MS Excel for further analysis) Customized reports (data viewed/printed from screen or easily exported into MS Excel for further analysis) Benchmarking option Benchmarking option

7. AMS Note placed in hospital electronic medical record whenever an AMS patient is admitted Key Elements: INR Intensity range Duration of therapy Pill Size Current and last 4 INRs/dose instructions Brief medical details Contact information

8. ADT Interface: Real time update with hospital census & AMS patient population When patient is discharge, patient’s name appear on discharge filter. AMS RN follows standard procedures for follow-up and confirmation of the treatment plan.

9. Lab Results Interface: timely and more accurate INR records

10. Bridging and Induction patients electronic records

11. Facilitate timely hand-off to outside physician Letter confirms follow-up appointment and identifies: pill size, recent dose and INR response history, Lovenox info, need for new warfarin Rx

12. Computerized Dosing Support Dose management settings can be customized to user specifications (system wide and at individual patient level) Dose management settings can be customized to user specifications (system wide and at individual patient level) INR and dose communication primarily done by US Postal Mail via a dose instruction letter (options include email/fax/phone) INR and dose communication primarily done by US Postal Mail via a dose instruction letter (options include email/fax/phone)

13. Treatment Plan

14. Future release of Dawn AC (7.7) Improved presentation Single or multiple tablet strengths or Mg Image or text denotes mg strength Optional calculated total mg Revised INR Hx area – makes better use of space

15. Enhancement of induction or bridge therapy documentation

16. Results with Transition Pathways

17. Transition Pathways (seamless transition from in to out patient world) Consult Referral Order for Anticoagulation Management Services placed in Physician Order Entry system Consult Referral Order for Anticoagulation Management Services placed in Physician Order Entry system Order processed by AMS secretaries and handed off to a nurseOrder processed by AMS secretaries and handed off to a nurse Nurse reviews and makes inpatient visit to patient.Nurse reviews and makes inpatient visit to patient. AMS begins management day after discharge AMS begins management day after discharge Formal face-to-face educational session scheduled with nurse approx. 7 – 10 days after discharge Formal face-to-face educational session scheduled with nurse approx. 7 – 10 days after discharge

18. Impact of transition pathways 95-100% of AMS-referred patients meet ACCP overlap guidelines 95-100% of AMS-referred patients meet ACCP overlap guidelines 70% of INRs measured at first appointment after discharge in therapeutic range 70% of INRs measured at first appointment after discharge in therapeutic range Significant reduction in hospital length of stay (~ 4.63 days) Significant reduction in hospital length of stay (~ 4.63 days) Patients express high satisfaction Patients express high satisfaction MGH/AMS 2005