Dear Editor,
Untreated or undertreated chronic ocular inflammation can result in blindness. Treatment options limited to the eye include periocular or intravitreal steroid injections and drops. If local side effects develop, there is patient intolerance, or suboptimal inflammation control, oral immunosuppressive agents remain an effective treatment option. These medications include antimetabolites, biologic agents, alkylators, and corticosteroids. While these agents have been shown to effectively control ocular inflammation, they also can cause systemic adverse effects. In a minority of patients, these medications have been associated with the development of hepatic toxicity, malignancies, infections, and rarely, death. To monitor for these toxicities, patients require laboratory monitoring with a complete blood cell count and complete metabolic panel every 1 to 3 months. The 7 physicians in the Ocular Immunology Division of the Wilmer Eye Institute prescribed and monitored the use of these medications in 269 patients with ocular inflammation.
We sought to create a standardized and centralized system to track laboratory test results for patients taking immunosuppressive medications. The Division employs 3 technicians to ensure patients are up to date on laboratory testing and to obtain the results for the prescribing physician for review. Previously, all patients were divided into 3 groups alphabetically. Each technician monitored whether laboratory test results were up to date for each patient within a group. Records were maintained independent of each other on an Excel Workbook (Microsoft, Redmond, Washington) saved to the Ocular Immunology Division's secured, shared drive. If records were deficient, a technician contacted the patient via phone or registered mail stating his or her medication would not be renewed without the receipt of updated laboratory test results. Each spreadsheet contained the patient's name, medication, last laboratory test result date, prescribing physician, and laboratory monitoring interval. This previous protocol lacked a centralized system with oversight. There were lapses in patient laboratory work, the ordering physician and interval for laboratory test results were not updated, and new patients were not added consistently. The percentage of patients with overdue laboratory test results and missing information varied among individual technicians.
A new Excel Workbook was generated that incorporated the spreadsheets from each of the 3 technicians and was saved to the Ocular Immunology Division's secured, shared drive (Figure). Using the software, the 1- to 3-month time interval for laboratory monitoring was entered and automatically generated a date on which the next set of laboratory test results was due. If the patient was up to date, the patient's row would be shaded green. One week prior to laboratory test result due date, the row would turn yellow, prompting technicians to remind the patient to have laboratory samples drawn. Once overdue, the patient's row would change to red. This would alert the technician to mail a registered letter and call the patient to notify that the medication will not be refilled until laboratory test results are received. All physicians, technicians, and the office manager had access to the workbook in real time. Changes to the workbook were tracked by the Excel program to evaluate updates made by each user. New patients were required to be added within 1 week of the start of the medication, as communicated via electronic medical record message or e-mail from the prescribing physician to technician. After testing the new workbook in a small sample to look for errors, it was introduced Division-wide on April 1, 2018. One faculty member and the office manager (M.K.B. and C.H.) tracked 3 different outcomes monthly: first, the time to new patient entry; second, the rate of patients without a laboratory monitoring interval with a goal of less than 5% by the end of the first 12 months; and finally, a reduction in the percentage of patients with laboratory deficiencies by 1% per month over the next 24 months and with less than 25% of patients deficient at any time.
Nine months after the initiation of the workbook, there was a 10% decrease in overdue laboratory test results. There were no further decreases by 12 months. Previously, 118 patients did not have laboratory samples drawn within the specified time interval and these were reduced to 81 at 9 months (10% reduction). The percentage did not change at the 12-month time point despite 22 fewer patients being followed by the Division for immunosuppression. Of those 22 patients, 8 stopped their immunosuppressant, 11 changed the physician monitoring their laboratory test results to a provider outside of the practice, and 3 were lost to follow-up. Patients with an unknown laboratory monitoring interval decreased from 11% to 5% by month 9 and to 2% by month 12. All new patients were entered into the workbook within 1 week at both time intervals.
The use of a centralized Excel Workbook to track laboratory test results can decrease the risk of morbidity and mortality associated with immunosuppressive medications use. It has also improved communication between the ordering physicians and the technicians obtaining the results. Increased oversight decreased the percentage of overdue laboratory test results and omission of laboratory testing intervals. The software also allowed identification of patients needing closer follow-up to ensure compliance with laboratory testing. After 12 months of use, the project has become a sustainable organizational tool for the Division of Ocular Immunology, which improved patient safety. Since Excel is a readily accessible software, this method of laboratory monitoring could also be used by other ocular inflammation specialists around the world.
Sincerely,
-Ruby A. Parikh, MD
-Isabelle Ann Remolador, BS
-Carolyn Hines
-Meghan K. Berkenstock, MD
Wilmer Eye Institute
Johns Hopkins School of Medicine
Baltimore, Maryland