Interviews
Q&A with Lynn B. Oertel
PTINR.com Staff
Q&A with Lynn B. Oertel
Lynn B. Oertel, MS, ANP, CACP received her Masters Degree in Nursing from Boston University and is certified by the American Nurse"s Credentialing Center as an adult nurse practitioner. She is also a Certified Anticoagulation Care Provider (CACP) and is recognized as an expert nurse clinician in anticoagulation therapy management. Lynn has accumulated over 25 years of clinical and research experience (notably the BAATAF and WARSS trials for stroke prevention) associated with anticoagulant therapy management.
Currently, she is a Clinical Nurse Specialist with the Anticoagulation Management Service at the Massachusetts General Hospital in Boston; one of the largest and oldest warfarin (Coumadin ®) management clinics in the country. She is a board member of the Anticoagulation Forum and is also a founding board member of the National Certification Board for Anticoagulation Providers, the only multi-disciplinary national certification for anticoagulation care providers. She is a co-editor and chapter author of the textbook: Managing Oral Anticoagulation Therapy: Clinical and Operational Guidelines, 3rd Edition, Ansell J, Oertel L, Wittkowsky A, Eds., Wolters Kluwer 2009 and has published a number of other articles.
Q: Can you share with us a little about your facility's model of anticoagulation?
A: We support a primary nurse model of care, underscoring the importance of the nurse-patient relationship and collaboration with other providers. This nurse clinic operates using approved protocols, guidelines and electronic dose suggestions, etc. We have a physician as medical director (not physically in clinic day-to-day but very involved with management issues, long-range planning, etc.), a full-time nurse director and .8 FTE Clinical nurse specialist. We have budgeted 9.1 FTEs (full time equivalents) of RN nurse positions. Additionally, and importantly, we have 4 administrative full-time support staff.
Q: How do you measure "success" in your facility?
A: Many forms are used to determine "success". Primarily, a monthly dashboard is produced that includes: time in therapeutic range (TTR) using exact outside limits and applying Rosendaal's methodology, number of INRs outside of "safety limits" according to designated INR range (on high side we count # INRS 5 or greater and 7.5 or greater, on low side, generally count # INRs 1.3 or lower), number of major hemorrhagic and thromboembolic events, and number of patients who exceeded minimum 4 week interval between INR testing. We consistently achieve 70% TTR for INR range 2 3.
We strive to be responsive to our patient needs. For example, at the request of patients we instituted a process to automatically send dosing information via email. Currently, all of our email communication with patients and other health care providers outside the hospital system is encrypted.
Q: How have patient needs changed over the last 5 years?
A: Communication many want email, simply fast communication. Patients are more mobile and travel more often either long vacations or spend part of the year at a different residence. This creates a need to be creative in communication methods, arranging lab orders and procurement of results. We've all experienced the necessity to pro-actively address the diverse culture and language needs of our patients.
Q: Are dietary supplements a concern? How do you counsel your patients for
A: Yes, but our consistent message to patients in general after making a general dietary assessment is "keep diet consistent, moderate portion size of Vitamin K containing foods". Our standard warfarin guide (educational booklet used across the institution) has several reference lists for Vit K containing foods. Additionally, we emphasize the importance of informing the warfarin manager of any and all changes pertaining to dietary intake as well as several other important variables such as drugs, health status changes, etc.
Q: Aside from greater reimbursement what resources remain to improve the warfarin patient management?
A: Promotion and embracement of patient self-testing -- and then expanding to patient self-management for appropriate patients. POC testing in clinics along with administrative support for increased staffing needs could also improve management. We also have a need for better materials for patients who have low health literacy and limited English proficiency. This is important not only for drug information but for disease knowledge as well, focusing on what is means in clear language for patients (or even general public's health).
Q: Medicare's national coverage expansion for home INR testing 19 months ago opened the door for, up to and including weekly testing. What has been your experience with home testing?
A: It's slowly but surely catching on! The changes to the CMS regulations have made a difference and has helped. Fostering PST can be a huge drain on personal resources in a clinic so more needs to be done to collaborate with IDTFs. Of course, expectations for customer service needs to be high whenever collaborative relationships are established.
Q: What is your selection process for home INR testing?
A: Either a patient expressed an interest or it is suggested to a patient by his/her nurse. We assess current compliance with therapy and if not compliant with lab testing, what is the root cause? Perhaps PST will be the "fix" to that. We also consider: is patient willing, able and reliable? We also assess dexterity and visual acuity and ease of using technology. Are they prepared to test weekly and following INR communication strategies we have devised? We utilize a Patient Agreement (patient contract) for self-testers. Is patient aware of and willing to pay out-of pocket expenses associated with this?
Q: A common barrier to home INR testing includes loss of patient control is there an argument for increased control?
A: I don't view it as loss of control. In fact, home INR testing gives patient more control (empowers the patient to take an active role) with testing and testing at regular, more frequent intervals. (that should theoretically lead to increased time in range and ultimately less potential for adverse outcomes)
Q: Do you see the evolution of patient self-testing (PST) evolving to patient self-management? (provided the healthcare professional provides the instruction)
A: Absolutely for some patients, certainly not for all. However, careful consideration for expectations, actions to take, communication of same, etc. needs to be well understood and agreed upon by both parties from the very start.
Q: From what you've learned can you suggest any tips on implementing patient home monitoring for a practice new to PST?
A: The IDTFs offer an opportunity to "fill in resource" gaps for small or new practices even large practices that may not have the ability to increase personnel. It's important to support PST as a testing option and pass this benefit to patients we just need to be creative and work out the details with an IDTF. Of course, it is important to note that a number of successful business plan models for AMS clinics have incorporated PST and its ability to generate revenue when not working with an IDTF.
Q: New anticoagulation agents under development work without monitoring share with us how compliance breeches for a shorter half-life of drug may weigh against warfarin replacement drugs and how the professional to patient dialogue may go.
A: Tough question hard to carve out a role for these new drugs that won't require routine monitoring typically assumed by many anticoag clinics today. We need to identify what it is the AMS clinic would do that is, if anything. How would revenue be generated? It really falls into hands of the prescriber at the present time. Unfortunately, that opens up lots of room for a lack of thoughtful oversight and follow-up which we typically find in well-run AMS clinics. We already know the non-compliance issues and rates associated with hypertension and diabetes. I see the potential for non-compliance with these new agents in a similar vein.
IDTF = Independent Diagnostic Testing Facility