US Pharm. 2015;40(2)58-60.
Health information technology (HIT) is opening many new frontiers and possibilities in cardiology and pharmacy. Revolutionary advances have been fueled by the widespread adoption of mobile technology, the availability of home diagnostic devices, and the widespread use of electronic prescribing. This article presents an overview of each of these major developments.
Mobile Device Applications in Cardiology and Pharmacy
Mobile devices are becoming nearly universally available. In 2012 alone, there were more than 6 billion mobile subscriptions, and 1.7 billion mobile phones were sold. About 700 million of these were smartphones. The Apple App Store has approximately 20,000 applications (apps) in the category of health and fitness and 14,000 in the category of medicine. Android’s Google Play has 11,000 apps in the health and fitness category and 5,000 medical apps.1-3
In the past several years, a wide variety of apps relevant to cardiology practice have been developed for mobile devices, including smartphones and tablets. There are apps available for both Apple iOperating Systems (iPhone and iPad devices) and Android devices. These apps generally fall into four groups as described below.4
Patient aids: The first group includes patient education apps such as the American College of Cardiology CardioSmart Explorer app, which features graphics and animation illustrating common heart problems.5 There are also apps that can be recommended to patients to help them with lifestyle changes. These include calorie counters, daily calorie trackers, weight-loss trackers, fitness trackers, and apps that help patients choose a healthier diet. Of special interest to pharmacists are apps that provide patients with instructions and information about their medications. Pharmaceutical manufacturers are now gearing up to develop such apps for specific drugs.6 One aim of this effort will be to improve medication adherence in patients with chronic conditions, such as cardiac disease and diabetes.6
A wide variety of patient-friendly apps for cardiology are now in the marketplace.7 For example, the company FitLinxx provides many apps for monitoring health and wellness, including the AmpStrip, which can monitor heart rate around the clock.8 The company also provides activity trackers, wireless weight scales and wireless blood pressure monitors. Some pharmacies have developed apps that allow patients to request a refill; in addition, there is a pharmacy app that provides a digital health advisor to help with smoking cessation, weight management, nutrition, exercise, and emotional health.9
Reference data: The second group includes apps that provide reference data regarding drugs, tests, treatments, and devices. These apps include information about appropriate drug dosing, indications, warnings, and potential drug-drug interactions. This information can help busy pharmacists and other clinicians keep up with new agents as they are introduced on the market. Patients with cardiovascular diseases are particularly vulnerable to drug interactions owing to polypharmacy, general fragility associated with aging, and underlying cardiovascular illness. For example, in one study of 400 heart failure patients, a total of 863 potential drug-drug interactions were identified.10
New noncardiac agents might have the potential to interact with cardiac medications; hence, an app that provides the most up-to-date information is invaluable to the pharmacist and the prescribing clinician. For example, patients with type 2 diabetes often have comorbid cardiac disease and may be managed with multiple agents including antidiabetes drugs, lipid-lowering therapy, and medications for hypertension. Patients with diabetes are at significant risk for drug interactions.11 A case in point: The new antidiabetes drug, canagliflozin can increase the plasma level of circulating digoxin; thus, the patient’s clinicians must be alerted that frequent monitoring of the digoxin level should be considered in a patient taking both agents. A mobile app can immediately flag such potential interactions and provide literature references if desired.
Remote access to patient EHR: The third group includes apps that allow the clinician to remotely access a patient record. This type of app can be invaluable to pharmacists who are performing medication therapy management (MTM) services.12 These apps generally are web-based tools that interface with the office EHR. In a common scenario, when a pharmacist is consulting with the patient in the pharmacy, he or she can conveniently access the patient’s ambulatory record over such an app. This can be helpful, for example, in reconciling the patient’s medication list upon discharge from the hospital. The pharmacist can retrieve information about diagnoses and laboratory data that could be relevant for checking drug indications and dosage adjustments. Instant access to such information via the pharmacist’s tablet or smartphone can be invaluable during the MTM evaluation or medication reconciliation service.
Patient engagement: The fourth group includes apps that increase patient engagement. One example includes secure e-mail for communication with patients. This is usually a web-based service that encrypts the e-mail messages to protect their content. There are also patient portals that allow patients to access laboratory and other test results from their EHR record. For instance, patients can use a computer or tablet to securely retrieve radiology reports or actual images that they can then share with their pharmacist or other clinicians. The pharmacist who is providing MTM services can use a patient portal to annotate laboratory results with messages to the patient. If the patient’s potassium is low, for example, the results can be conveyed to the patient and also to the prescribing clinician to coordinate an appropriate therapeutic response for managing the potassium level. The patient can be notified by text message and/or e-mail that a communication has been sent on the secure portal. Patient engagement in this manner will help with care coordination and with improving the quality of patient outcomes.
Patient portals can also be used by the patient to send the results of self-monitoring data to their EHR and to the pharmacy. Data such as daily blood pressure, daily weight, oxygen saturation, pulse, and blood glucose can be transmitted via the patient portal to the EHR and the pharmacy computer. This type of patient-generated data can be used by both the MTM pharmacist and other clinicians to monitor the patient’s response to treatment.
Comprehensive systems for monitoring of the cardiac patient at home are now available.13 There are myriad apps for iPhone/iPad or Android devices that can monitor the patient’s heart rate, as well as perform more sophisticated patient monitoring.7 For example, patients who suffer from cardiac rhythm disturbances or chest pain can use a smartphone app to record an ECG on the spot when they experience symptoms.14-16
One such app, AliveECG for the iPhone or Android operating system, can detect a possible finding of atrial fibrillation.16 Runs of atrial fibrillation, the most common arrhythmia, can cause palpitations and also put the patient at risk for stroke.17 To use the AliveECG, the patient must purchase an attachment for the iPhone or Android device called the AliveCor heart monitor, which is an FDA-cleared ECG monitoring device.18 The software app on the iPhone or Android device then analyzes ECG tracings to detect occurrences of atrial fibrillation. The suspected arrhythmia recording is captured by the phone and can be transmitted via a patient portal to the cloud; a cardiologist can then review the tracing for confirmation of the finding. The cardiologist will often call the patient to confirm symptoms and, if necessary, direct the patient to the emergency room for additional evaluation.19 The patient can also share this information with the MTM pharmacist so that the condition can be closely followed, especially if anti-arrhythmic drugs and/or anticoagulants are to be administered.
Home Anticoagulant Management
Home monitoring of anticoagulation therapy for patients with atrial fibrillation is an important area where HIT, in conjunction with point-of-care analytics, can have a major impact.20 It is critically important for such patients to maintain therapeutic levels of the anticoagulant warfarin, as measured by the prothrombin time and international normalized ratio (PT/INR). Careful management is necessary to prevent stroke and also to prevent hemorrhage caused by excessive anticoagulation.
Home devices now exist for rapid determination of the PT/INR.21 The majority of patients with atrial fibrillation can learn to use these devices with minimal coaching, thereby providing valuable opportunities to self-manage care.22 Research studies suggest that patient home monitoring of the PT/INR can improve the quality of anticoagulation management by maintaining the PT/INR more often in the normal range and thereby reducing complications including hemorrhage and thromboembolic events.23,24 Patients using home PT/INR devices can transmit their readings directly to their clinician team over the cloud using software that will interface with the prescriber’s EHR and pharmacy computer, thereby keeping the cardiology team and MTM pharmacist up-to-date with the patient’s progress.20 Medicare and other insurers provide coverage for home PT/INR monitoring for a number of indications, including atrial fibrillation.
Electronic Prescribing and Decision Support
As previously reviewed in this Tech Rx series, e-prescribing offers the potential opportunity for many safety checks, including drug-drug interactions, drug-laboratory interactions, and drug–patient condition interactions.25 Safety checks can occur in both the prescriber’s system and in the receiving pharmacy's system, providing a backup layer of redundancy. Drug–laboratory result interactions can be critical; for example, if a cardiac patient with diabetes is on metformin and the serum creatinine level is significantly elevated, it might be necessary to discontinue the patient’s metformin. If a patient with hypertension and diabetes is on an ACE inhibitor and the potassium is significantly elevated, it might be necessary to adjust the patient’s antihypertension regimen. Pharmacists can assist with these types of safety checks if the pharmacy software also has access to the patient’s current laboratory results. The prescriber’s software and the pharmacy’s software can assist with or verify appropriate patient dosing (based on age, sex, indication, body weight, body surface area, and renal and hepatic function) and can flag patients who require ongoing laboratory monitoring.
Many EHR packages offer e-prescribing; however, the actual level of available decision support varies. Most packages offer basic checking for drug-drug interactions. As more sophisticated decision support becomes available on mobile devices, EHRs, and pharmacy systems, e-prescribing will have the potential to greatly assist the cardiology and pharmacy team and improve patient safety and care.
The introduction of HIT advances into the marketplace, including the mobile technology revolution, promises to open many new opportunities to improve the care of cardiac patients. Pharmacists have a number of opportunities to become involved in these advances, especially through the MTM model. HIT will help cardiac patients monitor their own condition (weight, blood pressure, pulse, oxygen saturation, ECG, PT/INR, blood glucose) and transmit the data back to their team of clinicians, including the pharmacist, cardiologist, and primary care clinician. The ability of the entire healthcare team to seamlessly share data in real time and communicate will greatly improve care coordination and enhance the quality of care. E-prescribing and software decision-support packages for both the prescriber and the pharmacist have the potential to improve patient safety, particularly if they incorporate clinically relevant information about drug-drug interactions as well as patient-specific information such as diagnoses and laboratory results.
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