HI510 Unit 4 Ancillary Systems Review Example

An INR of 4.2 That Stopped Being Data at 10:05: A Unit 4 Ancillary Systems Review Following One Result Through a Laboratory, a Facility Record, a Pharmacy and an Administration Screen

[Student Name]

Purdue University Global

HI510: Health Information Applications and Systems

Unit 4 Ancillary Systems Review

[Instructor Name]

[Date]

The resident, Ostervale Health and every time and value are composite; the studies cited are real.

The Case

Mrs. L., a composite 79-year-old resident of Ostervale's skilled nursing facility, takes warfarin for atrial fibrillation, 5 milligrams each evening. Her INR is checked weekly by a mobile phlebotomist, and the sample is run in the Ostervale hospital laboratory. On a Tuesday, her INR was 4.2, above her target range of 2.0 to 3.0 but below the laboratory's critical value of 5.0, which is the threshold for a telephone call. She received her usual evening dose. The facility's nurse practitioner saw the result the next morning and held warfarin. Mrs. L. had no bleeding, but the dose she received should have been held, and nothing in the four systems was broken.

The Four Systems

1. Laboratory information system, at the hospital: receives the order, tracks the specimen, runs the test and verifies the result.

2. Facility record, the skilled nursing facility's application: holds orders, notes and results for residents.

3. Long-term care pharmacy dispensing system, run by a contracted pharmacy: receives medication orders and dispenses the facility's medication carts.

4. Medication administration record, a module of the facility record: lists each dose due and records administration.

The Path, Handoff by Handoff

1. 06:10, phlebotomist draws the sample at the facility and labels it. Format: specimen with a barcode label. Discrete result or document: not applicable.

2. 07:25, the sample arrives at the hospital laboratory by courier and is received into the laboratory system. Elapsed: 75 minutes.

3. 09:40, the result is verified by a technologist: INR 4.2, flagged high. The value exists as discrete data with units, reference range and flag. Elapsed: 135 minutes.

4. 10:05, the laboratory system sends the result to the facility. The facility record is not interfaced to the laboratory for discrete results, so the result travels as a PDF report through the outreach portal and is filed under Documents, Outside Results. Elapsed: 25 minutes. From this point, the value is a picture of a number.

5. 10:05 onward, the pharmacy dispensing system receives nothing. Its interface with the facility carries medication orders only, not laboratory results.

6. 21:00, the evening nurse opens the administration record, which shows warfarin 5 milligrams due. No INR appears on the screen, and the nurse gives the dose. Elapsed since verification: 11 hours and 20 minutes.

7. 08:30 the next day, the nurse practitioner, reviewing documents, opens the PDF, sees 4.2 and writes an order to hold warfarin and recheck in two days.

The value left the laboratory as data and arrived at the facility as a document, and from that moment no system could raise an alert, draw a trend or apply a rule to it.

Where the Number Stopped Being Data

At handoff 3, the INR was a discrete result: a number, a unit, a range and a flag, readable by any rule. At handoff 4, it became a document. The facility record could not trend it beside earlier values, could not display it on the administration screen and could not fire the facility's own warfarin rule, which checks the most recent INR before each dose. That rule exists and works; it simply had no discrete INR to read. The pharmacy, which would normally review an anticoagulant against a new INR, never received the result at all. None of the four systems malfunctioned. The path between them failed. Studies of missed test results in hospitals have found that a meaningful share of results are not followed up, and that the gaps cluster at transitions between settings and systems (Callen et al., 2011). Health information exchange research has long described the same pattern: data moves easily inside one system and badly between organizations or applications that were not built to share it (Vest & Gamm, 2010).

Obligations at Each Crossing

The laboratory met its obligation: it verified and reported the result promptly and called nothing because the value was below its critical limit. The facility met its documented process: outside results are filed and reviewed by the practitioner each morning. The pharmacy met its contract, which covers orders. And the nurse followed the administration record. The gap is that no obligation, in any of the four organizations' processes, required a value above a patient's target range but below a critical limit to reach the person giving the next dose.

Why the Critical Value Did Not Help

A tempting conclusion is that the laboratory's critical limit is set too high, and that lowering it to 4.0 would have produced a phone call. That change would help Mrs. L. but would push many more calls to the laboratory's technologists for values that are high but rarely dangerous, and in a hospital those calls go to a nurse who already sees the result on screen. The critical value system was designed for the hospital, where discrete results already reach the people giving doses. The facility's problem is different: it has no discrete result at all, so a value of 4.2 is invisible until someone opens a file. Fixing the path solves the facility's problem without adding noise to the hospital's.

Recommendations

1. Build a discrete results interface from the hospital laboratory to the facility record for a defined set of tests, starting with INR, potassium, glucose, creatinine and drug levels, so that results arrive as data and can trigger the facility's existing rules.

2. Until the interface is live, route outside INR results above a resident's target range to the charge nurse's task list on arrival, not to the documents folder.

3. Extend the pharmacy interface to carry INR results for residents on warfarin, so the dispensing pharmacist can review them.

4. Add the most recent INR, with its date, to the warfarin line on the administration screen.

5. Measure the time from INR verification to practitioner review for facility residents, aiming for under four hours.

Limits

This review follows one result for one resident. It shows how the path can fail but not how often it does. A three-month audit of facility INR results, comparing verification time with practitioner review time and with the next scheduled dose, would show the size of the problem and give a baseline for the interface. Transfers between hospitals and nursing facilities are already known to lose information (Adler-Milstein et al., 2021), and this case shows that the loss continues long after the transfer, every time a result crosses the same boundary.

References

Adler-Milstein, J., Raphael, K., O'Malley, T. A., & Cross, D. A. (2021). Information sharing practices between US hospitals and skilled nursing facilities to support care transitions. JAMA Network Open, 4(1), Article e2033980. https://doi.org/10.1001/jamanetworkopen.2020.33980

Callen, J., Georgiou, A., Li, J., & Westbrook, J. I. (2011). The safety implications of missed test results for hospitalised patients: A systematic review. BMJ Quality & Safety, 20(2), 194-199. https://doi.org/10.1136/bmjqs.2010.044339

Vest, J. R., & Gamm, L. D. (2010). Health information exchange: Persistent challenges and new strategies. Journal of the American Medical Informatics Association, 17(3), 288-294. https://doi.org/10.1136/jamia.2010.003673