Computer protocol cuts unneeded cardiology tests
Program helps doctors act like specialists
In one examination room sits a woman who's eight months pregnant. In the next, a boy with a sprained ankle. And in another, a man with chest pain. "Each one of those people is expecting Marcus Welby to walk in and treat them," says Kevin Graham, MD, a cardiologist at the Minneapolis Heart Institute. "The truth is, the primary care physician just can't do that."
As medicine's knowledge base has exploded, it has become increasingly difficult for specialists, let alone primary care physicians, to keep up with the latest information. There are guidelines upon guidelines out there, but when the waiting room is full, there isn't any time to read them. And with the onslaught of managed care auditing that forces doctors to justify their practices, Graham and his colleague John Lesser, MD, decided there needed to be a systematic way to help physicians make decisions and to record the outcomes at the same time.
System analyzes patients' needs
The result: A computer-based protocol based on national guidelines, medical literature, and the cardiologists' own experience that has cut the rate of unnecessary angiograms at the Minneapolis Heart Institute in half, to about 14%. The point-and-click system, which takes about 90 seconds, asks physicians a series of questions such as whether patients smoke or have a history of heart disease and whether the chest pain is typical or atypical of heart disease. Based on those answers, the chest pain is quantified according to levels from one (chest pain at high levels of exertion) to four (resting chest pain). The computer analyzes the responses and immediately recommends that the patient needs a catheterization or other less invasive test or that the patient can be sent home without any diagnostic procedures.
"It allows someone who maybe only sees chest pain once a week or once a month to treat it in a rigorous fashion the same way a cardiologist would do it. Then it makes a recommendation on what to do," Graham says. "You've given a knowledge base of what would be a reasonable cardiac work-up to somebody who may otherwise be basing their treatment of chest pain on information they learned in their residency 15 years ago."
The computerized decision support system was tested for one year at Abbott Northwestern Hospital in Minneapolis to see how it performed technically, whether physicians used it and accepted it, and how it affected delivery of appropriate care. The "best practice" model for the treatment of chest pain developed by Graham and Lesser had been previously paper-tested for validity.
Training time just 20 minutes
The study found that training time for physicians averaged about 20 minutes. All of the 31 physicians who used the system rated it "user friendly." Fifty-six of the 933 patients in the study were sent home without further cardiac evaluation, 368 were given stress testing, and 475 went to angiography (34 patient work-ups were still in progress at the end of the testing period). A six-month follow-up of patients who didn't receive angiography showed no cardiac events.
"As a cardiology center, we see a lot of patients coming in with chest pain. We were trying to triage them in a way to eliminate those patients who really don't need extraneous testing," says Kory Thomas, RN, BSN, director of implementation and development for ProMedicus Systems Inc., the company Graham and Lesser formed to distribute the program. "A lot of times, physicians will just take patients and give them a stress test or take them to angiography right away instead of having a system to eliminate patients who don't need those tests. A 25-year-old patient comes in after playing basketball, and the doctor says take him to the cath lab and give him an angiogram, and it turns out he was just having rib pain. That's probably an unlikely situation, but it shows there was a need to really take a look at the situation."
Thomas says guideline implementation helps physicians make good decisions. "A lot of guidelines are cumbersome. We looked at all of them plus more than 2,000 articles and our own physicians' expertise to pull out what the physician really needs to know to treat the patient," Thomas says. "What's even better is that since the software is available on a restricted Internet site, physicians can download updated versions that address changes in practice."
System allows for immediate updates
Graham says that's important because with the immediate update, physicians can change their practice right away instead of three to five years after new information comes out, which is the usual lag time right now. "This is an educational tool as well as a way to disseminate information," he says. "If the patient can be well-treated in a primary care setting, then we want to empower the primary care physician to do that by giving them the information they need to handle whatever the problem is. Using this allows a primary care physician to ask the initial questions and approach the problem as a specialist would."
Outcomes data is reported back to physicians so they can see how they're doing and how they compare with their peers on a clinical and cost basis, Graham says. The ease of the program makes it possible to track patients wherever they present within a health care system.
The program has been popular enough that it was released commercially in April under the name Medicalmentor. ProMedicus also plans to develop similar guideline-based programs for other heart conditions as well as cancer, neurological conditions, and obstetric and gynecological symptoms.
[For more information, contact Kevin Graham, MD, or Kory Thomas, RN, BSN, at ProMedicus Systems Inc., 10180 Viking Drive, Eden Prairie, MN 55344. Telephone: (612) 914-0353.]
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