enabling safe prescribing of toxic drugs and blood test monitoring (including PSA) for GPs
In a shared care environment the monitoring of patients is usually shared between secondary care specialists and GPs. Initiation and titration of medication (and associated monitoring) is the responsibility of specialists. However once stabilised, responsibility for patients’ ongoing prescribing transfers to GPs.
Safe prescribing: many drugs like Disease Modifying Anti-Rheumatic Drugs (DMARDs) can have serious side effects and patients who take them should be regularly monitored. To prescribe these drugs safely it’s vital to know that a patient is stable by checking their recent blood results. This is known as safe prescribing. It may be difficult for GPs to know how stable patients are. That’s usually because they don’t have specialist knowledge as to what constitutes stability for patients on complex and possibly combination therapies.
Blood-test monitoring (including PSA): around 80% of regular blood tests that GPs order for their patients are normal and require no further action. Yet GPs routinely and rightly check all incoming test results. This may be subject to clinical risk and takes time – as much as half a day per week per GP.
Safe prescribing: collect electronic copy of blood test results and check them for abnormalities or deteriorating trends that may indicate instability. If a patient’s results are normal (they are stable) automatically produce an electronic certificate and send it to the relevant GP’s electronic patient record system to confirm it’s safe to prescribe. If any results are abnormal the certificate isn’t renewed and the abnormals are escalated to specialists for review. Certificates are time-limited. When the relevant GP needs to prescribe a simple check for a valid (in-date) certificate provides reassurance to go ahead with safe prescribing. This solution can be used with existing (or new) beetrootDMARD installations in secondary care, or independently.
Blood test monitoring (including PSA, lithium, vitamin D): collect any or all blood tests from local pathology electronically and check the results against rules set up within the practice, PCN or CCG. Alert GPs only to abnormals, deteriorating trends, and patients for who a test has not been received when expected. Provide an automated reminder service to go for tests via SMS, and use the same to follow up DNAs. File results and actions direct into the patients’ records in the GP system. Save time and effort and reduce clinical risk.
The Rheumatology team at Warwick Hospital, a part of the South Warwickshire NHS Foundation Trust has used beetrootDMARD (and its predecessors TAMONITOR and RheMOS) for more than 20 years. The system was originally implemented there by Dr Chris Marguerie, a consultant Rheumatologist and current clinical lead. The department’s use of beetrootDMARD has grown over the years and it now has two administrative staff who work with clinicians to use the the system to safely monitor over 3,500 patients who live with auto-immune disease like rheumatoid arthritis. For those patients an important medication is one or more of a number of Disease Modifying Anti-inflammatory Drugs (DMARDs). However these drugs can sometimes have serious side-effects, and they therefore need regular mentoring of their blood test results.
Over the years there have been various attempts to introduce safe shared care prescribing, where patients are started on new medications under the care of the rheumatologists. Once patients are stable on their medication prescribing of repeat medication is done in the community by GPs. However GPs have always been concerned about prescribing potentially toxic drugs without the reassurance that their patient is stable. That reassurance would usually be provided by contacting the relevant specialist and asking them if it’s appropriate to re-prescribe. That clearly presents logistical problems, involving two busy clinicians connecting by phone or email.
The solution appeared to be some kind of traffic light system that indicated it was safe to prescribe. A system that was automatically updated, without costly manual intervention. And that’s when the rheumatologists in the hospital thought of a way of using beetrootDMARD system to generate that green light. In the shared care setting the hospital continued to provide the monitoring of patients, but GPs were to take on responsibility for prescribing. Because patients were still expected to provide blood samples for checking by beetrootDMARD, the specialist would know if they had a problem with any of their bloods. Conversely, if patients were stable, beetrootDMARD could also confirm that by virtue of the absence of any abnormal alerts, or if the patient hadn’t been recently tested.
So we were asked to amend beetrootDMARD to generate a ‘certificate’ for all patients for whom a blood test had been received within the expected monitoring frequency, and didn’t have an abnormal result. The certificate would confirm the patient’s stability, and would be valid for an agreed time period, usually 3 months, but dependent on the actual monitoring frequency in place for the patient and the medication they were on. The certificate would be automatically sent to the GP’s system, and so when the time came to re-prescribe the medication the relevant GP could look on their system for a valid certificate. If the certificate existed and was in date it was safe to prescribe.
If beetrootDMARD identified a problem with the patient’s results that alert would be escalated to the relevant specialist and a decision made whether to generate a new certificate or hold off until the patient’s problem had been rectified.