Improving Transitions of Care for Hospitalized Patients on Warfarin

Transitions in care create challenges for warfarin management, including dosing errors, medication nonadherence, and/or insufficient monitoring. Adverse drug events from warfarin following transitions have been found to have serious consequences. Before the intervention, at the time of hospital discharge, individual physicians identified warfarin management plans on paper forms on the basis of their personal practice preferences. With the implementation of a computerized physician order entry in the electronic health record (EHR) in November 2010, the paper form became obsolete. A modification to the EHR created an order prompting physicians to include five key elements for warfarin management on discharge. A study was conducted to assess the impact of this intervention as a communication tool for patients and health care providers.

Discharge documentation was retrospectively reviewed for warfarin patients discharged from University of Missouri (MU) Health Care (Columbia). Frequencies of documentation in the EHR of five key elements of warfarin management were calculated (indication for anticoagulation, target International Normalized Ratio (INR) range, anticipated duration of therapy, date of next INR, and posthospital provider to manage warfarin therapy) pre- and post-EHR modification.

All five key elements were included in the discharge documents for 268 (42%) of the charts for 633 patients in the preintevention (baseline) period, for 297 (78%) of the 382 charts in the first postintervention period (September 15, 2013-March 15, 2014) and for 574 (61%) of the 943 charts in the second postintervention period (March 16, 2014-August 5, 2015).

Although limited to one health care system's experience, this study demonstrates the EHR's potential value in assisting with anticoagulation therapy between outpatient and inpatient settings and across multiple providers.