BlueBayCT - Warfarin User Guide December 2012 Help Desk 0845 5211241
Contents Getting Started... 1 Before you start... 1 About this guide... 1 Conventions... 1 Notes... 1 Warfarin Management... 2 New INR/Warfarin Diagnosis Screen... 4 Current INR/Warfarin Diagnosis Screen... 6 Practice Defaults... 7 Warfarin Adjustment Algorithm (Maintenance Period)... 7 INR (Maintenance Period)... 7 Tablet Strength... 8 Clinic Days... 8 Recalls Tab... 8 References Tab... 8 Warfarin Dose... 9 Warfarin Dose Screen... 9 INR & Dose Tab... 9 Treatment & Advice Tab... 11 Information... 12 History Tab... 12 Trends Tab... 13 Using the Warfarin Dose... 14 Warfarin Dose History... 16 Warfarin Monitor... 17 Patient Name Column... 17 Sex Column... 17 Active Column... 17 Abnormal Column... 18 Recall Column... 18 i
Due Column... 18 INR Date Column... 18 INR Column... 18 Warfarin Date Column... 18 Warfarin Column... 18 Diagnosis Column... 18 Hospital Column... 18 Accessing Warfarin Monitor... 19 Dosing from the Warfarin Monitor Screen... 20 Mail Merging letters to patients... 20 Scanning for Patients on Warfarin... 21 Patient Settings... 23 Patient Settings Screen... 23 INR... 23 Tablet Strength... 24 Hospital... 24 ii
Getting Started Before you start This User Guide is in PDF format and is best viewed using Adobe Reader X version 10.1.1 or above. Please click here to download the most recent version of Adobe Reader X. About this guide Welcome to the BlueBayCT Warfarin User Guide. This guide can be printed out in its entirety or the relevant sections can be directly accessed by clicking on the help icon from within the software. Embedded within this User Guide are Hyperlinks, which are in blue and look like this, and will take you to the topic relevant area within this User Guide. Conventions The following conventions are used throughout this guide:- Notational Conventions The term Click is used throughout this document to describe the pressing of the left-hand mouse button. The term Right-click is used to describe the pressing of the right mouse button, which commonly displays a menu. Names of files and folders appear in TITLE CAPS, except when you are to type them directly. Unless otherwise indicated, you can use all lowercase letters when you type a file name in a dialog box or at a command prompt. Diagrams & Illustrations All illustrations and example screens, including images of buttons or screen areas have been captured from a Windows XP Professional operating system. There may be slight differences between screens on older operating systems. All screens are produced using the standard Office Silver theme. Notes Several types of Notes appear throughout this guide:- Tips contain explanations of possible results or alternative methods. Notes contain supplemental information. Cautions contain warnings about possible errors or problems. 1
Warfarin Management The Warfarin Management module is a powerful tool for monitoring INR results and advising on the dosing regime. The Warfarin module can be accessed in two ways, firstly from within a patient record in your Clinical System via a single left click on the floating toolbar, as shown in the diagram below. Secondly, the Warfarin module can also accessed without the need to go into individual patients records in the clinical system. This is done by selecting the patient in Warfarin Monitor, and makes it very quick, easy and straight forward to manage patients in a Warfarin clinic environment. Before the Warfarin Dose screen can be accessed, each patient must have a new Diagnosis Indication recorded through the New INR/Warfarin Diagnosis screen in the Warfarin management module. If something other than New Diagnosis is selected prior to a new Diagnosis Indication being added for the patient then they will be directed to the New INR/Warfarin Diagnosis screen for on to be added. If this is the first time you are using BlueBayCT Warfarin Management then it is best to start by looking at the Warfarin Getting Started Guide. The Warfarin Getting Started Guide is a step by step guide to identifying and setting up patients so they can be managed using the Warfarin management tool. Once the patient has a Diagnosis Indication then the Warfarin Dose History screen appears and can be used to record Historical INR results and Warfarin Dose values. Once the patient is set up to use Warfarin monitor, a popup appears when the patient record is opened if a recall has been set. The popup is displayed as "Warfarin Adjustment" along with the recall date, as shown in the diagram below. Double clicking takes the user directly to Warfarin Dose screen. The Warfarin monitoring popup appears on the "Others" part of the floating toolbar but can be disabled or amalgamated with the QOF button by altering the settings on the Options tab in the BlueBayCT Settings screen. 2
3 BlueBayCT Warfarin User Guide
New INR/Warfarin Diagnosis Screen Before patients can have their INR monitored and Warfarin dose adjustment calculated by the software they must first have a current Diagnosis Indication. This is done on the New INR/Warfarin Diagnosis screen. Any diagnosis Read codes on the patients record are displayed in the History column on the line of the relevant Indication. These Read codes displayed can be selected to be used as the Diagnosis Indication. If a Diagnosis Read code does not exist in the patients clinical record then this column will be empty, and a Diagnosis Read code can be added very easily. To add a new Diagnosis Indication from an existing Diagnosis Read code, do the following:- 1. Click on the History button ( ) alongside the chosen Diagnosis Read code you wish to use. 2. Double click on the relevant Read code in the box that is presented. The corresponding indicator will then appear in the Indication section at the bottom of the screen with the Start Date set to that of the Diagnosis Read code. 3. Where the treatment period is known, an end date can be entered onto the End Date box by clicking on the down arrow and selecting it from the calendar. If there is no End Date then it can be left blank (this will be the case for the majority of patients). 4. Click OK. 4
If a Diagnosis Read code does not exist in the patients clinical record the History column will be empty. However, a new Diagnosis Read code can be added at this point to allow a Diagnosis Indication to be used. To add a New Diagnosis Read code and related Diagnosis Indication, do the following:- 1. Double click on the line of the relevant Indication or click the Code set Button ( ). The Read Code Data Entry screen is displayed, as below. 2. Place a tick in the Apply column. If necessary change the Priority, Episode Type and Date Recorded. 3. Click on the OK button. The relevant Indication is placed in the Indication area which is towards the bottom of the screen. 4. The Start Date will default to the date of the Read code entered but can be backdated if necessary by clicking in the down arrow and selecting it from the calendar. 5. Where the treatment period is known, an end date can be entered onto the End Date box by clicking the down arrow and selecting it from the calendar. If there is no End Date then it can be left blank. 6. Click OK. Left click on the expand button ( each of the Indications. ) to view the description and details from 5
Current INR/Warfarin Diagnosis Screen The Current INR/Warfarin Diagnosis screen is the same layout as the New INR/Warfarin Diagnosis. They differ slightly in the way that they are used. During a treatment period the New Diagnosis option on the menu will be unavailable, instead the Current INR/Warfarin Diagnosis option will be displayed. From this screen the Current Indication can be changed if necessary. This screen also shows the most recent diagnosis where the treatment period has ended. It may be necessary to extend the treatment period by altering the End Date. If the End Date entered has passed, End Date will appear in Red text to notify that the treatment period is complete and any additional dosing data entered today will not fall into the current dosing period. When the end date does appear in red (e.g. the treatment period has ended) then a New Diagnosis option will be available on the Warfarin menu. 6
Practice Defaults The default settings for the whole practice are stored in the Practice Defaults screen. The Practice Defaults screen allows you to configure a number of settings for patients who are newly monitored by the Warfarin management software. Changes made to these settings will not affect patients who are currently being monitored. Warfarin Adjustment Algorithm (Maintenance Period) This area of the Practice defaults screen contains configuration parameters that will affect how the software calculates the Warfarin adjustment. The Warfarin adjustment algorithm used during the calculation can be either set to Hillingdon or Coventry/Warwickshire method. INR (Maintenance Period) The INR Target range is a range that if the INR value falls inside, then no change to the dose will be made. This INR Target range has a default value of 2 to 3 but can be altered if necessary. The INR adjustment range is the range which the adjustment algorithm will hold true and recommend a dose. If the INR value falls outside of this range then a dosing regime will not be calculated. If the Hillingdon Warfarin adjustment algorithm is selected above then the Hillingdon coefficient can be changed from the default value. If the Coventry / Warwickshire adjustment algorithm is used then this option will be greyed out. 7
Tablet Strength The tablet strengths that are available to the patient can be selected under the Tablet strength area, so consideration can be taken so that the daily dosing value can be achieved from the tablet combinations available. Where the weekly dosing regime is not possible the user will have a choice to round up or down when choosing the dosing regime. The 1mg tablet strength cannot be made unavailable to the practice as this is a most unlikely scenario. Clinic Days The Clinic Days are used to record the days of the week that the practice holds Warfarin clinics, and can be chosen by checking the relevant box. This is relevant to the recall date given to the patient during the calculating of the dosing regime. If the recall date is on a day that the Warfarin clinic does run on, then the Recall Date appears in Red. This alerts the clinician that the patient is due to be recalled on a day when the Warfarin clinic is not run so the clinician can take the necessary steps to either bring the recall date forward or delay it to a suitable Warfarin clinic day. Recalls Tab The Recalls tab on the Practice Defaults screen contains the recall periods used by the Induction and Maintenance periods. This tab is for illustrative purposes only and cannot be changed by the user. References Tab The References tab on the Practice Defaults screen contains the list of references cited during the development of this module. During the development and testing of this module the papers listed here were referenced and the methodologies used were taken into consideration when developing the software. 8
Warfarin Dose The Warfarin Dose screen is the primary screen used by the clinician. It is looks at the previous INR and dose history and calculates the new weekly dose. It is split into four tabs. The main INR & Dose tab is the one from where the calculation is performed. Warfarin Dose Screen INR & Dose Tab Current INR and Dose New INR and Dose Current INR and Dose This area of the Warfarin Dose screen gives details of the current Diagnosis Indication, previous INR value and previous weekly dosing regime, along with the relevant dates. The Information in this section of the screen is used for reference purposes only and cannot be changed from within this screen. If INR values are automatically added to the patients notes, or input by the nurse as a Read code when the blood test is performed i.e. before the patient sees the Doctor, then the INR value will be displayed in this area. In this case the clinician in the Warfarin clinic will not need to re-enter this value again, as the Use Button should be available below. If the patient is under hospital management then Managed By the Hospital will be displayed in Red, which is specified in the Patient Settings. New INR and Dose The New INR value can be recorded by entering it into the INR box. The date displayed is the date that will be recorded with the INR value and will always be the date of input. Should the INR values need to be backdated then this can be done by entering them through the Warfarin Dose History screen. 9
Advised Warfarin Adjustment The Advised Warfarin Adjustment weekly dose is displayed in this area of the screen once an INR value has been entered New INR box. The Warfarin Dose value is shown in mg's per week. The method used to calculate the dose is also shown. If the weekly dose suggested cannot be produced from the available tablets then there will be an option available to either round the weekly dose up or down as the clinician sees fit. If a tick is placed in the Same Daily Dose box, the Round Up and Round Down values will reflect this. By clicking on the Use button the recommended weekly Warfarin amount will be split into a day-byday weekly dosing regime and displayed directly below. Warfarin Dose Within this area of the Warfarin dose screen the New Warfarin Dose is displayed and broken down on a day-to-day basis. The date displayed is the date that will be recorded with the weekly Warfarin value and will always be the date of input. Should the weekly Warfarin values need to be backdated then this can be done by entering them through the Warfarin Dose History screen. The date which the patient should next be seen in the clinic, the recall date, is also shown. If the recall date is on a day that the Warfarin clinic does run on, then the Recall Date appears in Red. This alerts the clinician that the patient is due to be recalled on a day when the Warfarin clinic is not run so the clinician can take the necessary steps to either bring the recall date forward or delay it to a suitable Warfarin clinic day. The Clinic Days can be specified in the Practice Defaults. Print Preview The Print Preview button displays a print preview of a report that can be printed to the default Scripts printer. The report contains information on the patients dosing regime, including which colour tablets they need to take on which days. The weekly Warfarin dose history is also displayed from the previous 5 values. Contained within the report is also information regarding taking Warfarin. The report is designed to be printed out so that it can be given to the patient or any other clinician who may potentially need an overview e.g. If the patient changes practice. Print The Print button prints of a report to the printer which the default Scripts printer. The report contains information on the patients dosing regime, including which colour tablets they need to take on which days. The weekly Warfarin dose history is also displayed for the previous 5 values. Contained within the report is general information regarding taking Warfarin. The report is designed to be printed out so that it can be given to the patient or any other clinician who may potentially need an overview e.g. If the patient changes practice. Print A4 Report The Print A4 Report button prints a copy of the report on A4 paper. Settings The Settings button opens the Patient Settings screen which allows the settings for the individual patient to be changed. 10
Treatment & Advice Tab Locus of Care, Patient Informed of Result & Home visit by Healthcare Professional This area of the screen records the Locus of Care, how the patient is informed of their result and any home visits they receive. The last relevant Read code is displayed in the history column, but a full history can be viewed by clicking on the history down arrow ( ) tools. To record a new Read code click on the Codeset button ( ). Read codes can be entered by placing a tick in the Apply column alongside the Read code, and if necessary changing the Priority, Episode Type and Date Recorded, and then clicking on the OK button. After a Read code has been added it can be removed by clicking on the Undo Last Entry button ( ) which is not available until a Read code has been added. 11
Information The Information section provides an area where details of whether a Warfarin booklet and card have been given to the patient, along with the date they were provided. The possible options are YES, NO, DECLINED or UNKNOWN. Prescriptions The most recent prescription for Warfarin is displayed along with the date prescribed. A full history of Warfarin prescriptions issued can be viewed by using the drop down history arrow ( ). History Tab Diagnosis Information Displayed in this area of the screen is a history of Diagnosis Indications along with their start date and their end date if applicable. INR History This section of the screen displays a full list of INR Read codes held in the patients record along with their values and date recorded. 12
Warfarin History This section of the screen displays a full list of weekly Warfarin dose Read codes held in the patients record. The Warfarin dose values shown are in mg's per week and are shown along with their values and date recorded. Trends Tab Diagnosis Information Displayed in this area of the screen is a history of Diagnosis Indications along with their start date and their end date if applicable. By default the data shown in the INR and Warfarin Graphs is the current Diagnosis Indication. To see the Graphs of other Diagnosis Indications highlight it by clicking on it. INR Graph The graph displayed is a plot of INR with respect to time. This is a good visual aid when looking at the INR history. 13
Warfarin Weekly Dose Graph The graph displayed is a plot of weekly Warfarin dose with respect to time. This is a good visual aid when looking at the Warfarin dose history. Using the Warfarin Dose The Warfarin Dose screen can only be accessed when a New Diagnosis has been entered through Warfarin Monitor. The Warfarin Dose screen makes it very easy to monitor and calculate INR and Warfarin dosing respectively. It is important that you enter the last five historical INR results and Warfarin doses (if they exist, in the Warfarin Dose History screen) to ensure that the new Warfarin dose is calculated correctly. If these have been previously recorded in the patients notes then they should appear on the History and Trend Tabs. If not, they may need to be entered via the Warfarin Dose History screen. The INR & Dose Tab is split into two sections. The top half of the screen displays information about the Current INR and Dose and the bottom half of the screen allows the user to enter a new INR value and suggests the New Dosing regime. To record a New INR value and allow BlueBayCT Warfarin Management to recommend a dosing regime, do the following:- 1. Type directly into the INR box the new INR value. 14
2. To prescribe the same Warfarin dose for each of the days make sure a tick is placed in the Same Daily Dose box. Clearing this will allow the software to calculate a Warfarin dose that may be different from day to day in order to allow the exact weekly Warfarin dose to be prescribed. This check box will affect the Round Up and/or Round Down warfarin dose values. 3. Select either Round Up or Round Down if displayed. (If the dose cannot be achieved with the tablet strengths available then the option to round the weekly dose Up or Down will become available and must be selected before clicking on Use.) 4. The Advised Warfarin Adjustment is shown. If correct, click on the Use button to allow the regime to be calculated. To save time, if the relevant INR value has already been entered into the clinical system (e.g. by a nurse or automatically from the lab), then there is no need to reenter it in the INR box, and the Use button will be available in this case. This misses out the step of having to enter the INR value into the INR box. 5. The weekly dosing regime will then be shown, and can be printed out and given/posted to the patient by clicking on Print A4 Report. 6. The recommended Recall date will be shown. If the recall date appears in red it means the patient is due to be recalled on a day when the Warfarin clinic is not run so the clinician can take the necessary steps to either bring the recall date forward or delay it to a suitable Warfarin clinic day. Warfarin clinic days can be defined in Practice Defaults. 7. Additional information can be recorded on the Treatment and Advice Tab if necessary. 8. If necessary all the INR and Warfarin Dose data can be viewed on the History and Trends Tab. 9. Click OK to save the changes in Warfarin Dose. 15
If Warfarin Dose is being accessed through the patients individual record in the clinical system, rather than through Warfarin Monitor, then the encounter should also be saved as normal from within the clinical system. Warfarin Dose History The Warfarin Dose History can be accessed by Right Clicking on the patient in Warfarin Monitor, and selecting Warfarin Dose History. Alternatively it can be accessed from the Warfarin Monitor menu on the floating toolbar. The Warfarin Dose History screen makes it easy to backdate any previous Warfarin dose and INR values. This is done on the Enter History tab by clicking on the Value button ( ) and filling in the value and date on the screen that follows. Corresponding pairs of weekly INR values and Warfarin doses should be entered. When entering the warfarin dose, use Warfarin dose changed if the weekly dose being entered is different from the previous weekly dose, and Warfarin dose unchanged if it is the same as the previous weekly dose. The new warfarin dose is calculated based on a maximum of 5 previous weekly doses and INR values. 16
Warfarin Monitor Warfarin Monitor displays a list of all patients who are currently having their Warfarin dose managed by the practice. At a glance the clinicians can see information such as the patients are due to be recalled, the patients who have an abnormal INR result, and other useful details. As the list is interactive, clinicians can view and record data to patient s individual Warfarin record without the need to open the patient in the clinical system. To appear on the Warfarin Monitor list the patient must have an Indication recorded via the New INR/Warfarin Diagnosis screen. From the Warfarin Monitor screen the patients details can be mail merged into letter templates to be sent to selected patients in the list. In addition a scan can be performed to produce a list of all patients who are currently being prescribed Warfarin but do not appear on the Warfarin Monitor list as they do not have a current Indication recorded. The patient data displayed in the Warfarin Monitor screen is:- Patient Name Column The patients name and date of birth is displayed here. Sex Column The sex of the patient is displayed here. Active Column If the patient has a current Indication then the patient is Active and a tick is shown. 17
Abnormal Column When the INR value falls inside the Target Range the INR result is said to be Normal. Likewise if the INR result is outside of the Target Range then it is said to Abnormal and red flag ( Recall Column The Recall column displays the date the patient is to be recalled to have a new INR reading. ) is displayed. Due Column A tick appears in the Due column if the Recall date is due or has passed. Those patients who are due also appear in Black as opposed to those who are not due appearing in green. INR Date Column The INR Date column displays the date of the patients most recent INR result. INR Column The INR column displays the patients most recent INR result. Warfarin Date Column The Warfarin column displays the date of the patients most recent Weekly Warfarin dose. Warfarin Column The Warfarin column displays the patients most recent Weekly Warfarin dose. Diagnosis Column The Diagnosis Indication is shown in the Diagnosis column. Hospital Column The Hospital column shows whether the patient is currently being managed by the hospital. This can be set/unset from the Settings screen which can be accessed through the Warfarin Dose screen. The area which displays the Column Headings can be used to manipulate the data stored within the columns. When a column heading is clicked, the displayed data is ordered by that column e.g. text data is ordered alphabetically/reversealphabetically, numerical data is ordered ascending/descending. Clicking again on the column heading will reverse the order, which is displayed by a small up ( ) or down ( ) arrow. Some column headers also have a drop down filter arrow ( ). Clicking on this arrow provides filter choices (e.g. all, male, female etc). Once a filter has been applied to a column then the filter arrow changes from black to grey ( ). 18
Accessing Warfarin Monitor To open Warfarin Monitor, do the following:- 1. Log into the Clinical System in the normal way, but do not open any patient records. 2. Right click on the BlueBayCT light bulb icon ( ) in the Notification area of your Windows Taskbar, and select Practice Reports from the menu. 3. Select Warfarin from the toolbar and select Warfarin Monitor from below. Select Warfarin from the toolbar...... and select Warfarin Monitor The patient list will be empty if you are running Warfarin Monitor for the first time as only the patients who are currently being monitored and hence have a current Diagnosis Indication are shown. 19
Dosing from the Warfarin Monitor Screen The Warfarin Monitor screen makes it easy to access the Warfarin Dosing and other screens. To access the Warfarin dose screen, do the following: 1. Left-click a patient to highlight. 2. Select Warfarin Monitor on the toolbar. 3. Select Warfarin Dose from the drop down menu. The Warfarin Dose screen is then displayed. Alternatively, right click on a patient and select Warfarin Dose from the menu. Mail Merging letters to patients Letters can be sent to patients very easily using a standard letter template and then mail merging the patient details in. The letter may be calling patients into the surgery, or providing information to them. The information contained in the letter is completely user definable. Letter templates are created in the same way as you would any other letter in BlueBayCT. This is done by clicking Templates on the Practice Reports screen, as shown below. Click Templates to create and edit mail merge templates For more information see designing patient recall letter templates in BlueBayCT Help. To Mail Merge patients from the Warfarin Monitor screen, do the following:- 1. Select the Mail checkbox for each patient to be sent a letter. 20
If you want to select or clear all the checkboxes, toggle Select All on the toolbar. This is useful for managing larger lists. 2. From the Letter Template list on the toolbar, choose the required template. 3. Click the Mail button on the toolbar. The letters will open in a single Microsoft Word document, ready to be printed. BlueBayCT will also add an appropriate Read code into the patient's medical record to help manage the recall status. If you want to check the letter before your mail merge, click the Preview Letter button on the toolbar. 4. Print the recall letters and close Microsoft Word. Scanning for Patients on Warfarin Patients taking Warfarin either appear on the Warfarin Monitor list or a list produced when Scan Patients is selected. The Scan Patients function produces a list of all patients who are prescribed Warfarin, but do not appear on the Warfarin Monitor list, because they do not have a current Diagnosis Indication. When patients on the Scan Patients list have a Diagnosis Indication added they are moved to the Warfarin Monitor list instead. To perform a Scan, do the following:- 1. Click Scan Patients on the toolbar. (This will take a few minutes to run through depending on the size of the practice. The window is then populated with patients who are currently taking Warfarin. The list excludes patients who have a Diagnosis Indication that is current as they are displayed initially when Warfarin Monitor is opened.) 21
To go back to the list of patients who have a current Diagnoses Indication and are being monitored by the practice, close Warfarin Monitor and reopen it. 22
Patient Settings The Patient INR Settings can be accessed from the Settings button on the Warfarin Dose screen. Alternatively, the patient Settings can be accessed by selecting the required patient from the Warfarin Monitor list and selecting Display from the Warfarin Monitor drop down menu. Two tabs are displayed. On the Patient Tab, the patients personal details which are taken straight from the clinical system are displayed. They cannot be changed from this screen and should be up edited in the usual way through the clinical system. On the Settings Tab the settings for the individual patient can be changed from those defined in the Practice Defaults. Changing the settings within the Patient Settings screen is not the same as changing settings in the Practice Defaults. Changes made to each individual patient through the Patient Settings screen will only affect the current patient. Patient Settings Screen INR This section of the Settings screen specifies the INR target range and the Hillingdon coefficient. When a patient is first managed via the BlueBay Warfarin management software, the individual patient settings 23
reflect those stored within the Practice Defaults at the time. Changes to this Settings screen will only affect the current patient. If the Hillingdon Warfarin adjustment algorithm is selected in Practice defaults then the Hillingdon coefficient can be changed from the default for each individual patient from within this screen. The INR Target range is a range which if the INR value falls inside it, then no change to the dose will be made. This INR Target range has a default value of 2 to 3 but can be altered if necessary. Tablet Strength The tablet strengths that are available to the patient can be selected under the Tablet strength area, so consideration can be taken to enable the daily dosing value to be achieved from the tablet combinations available. Where the weekly dosing regime is not possible, the user will have a choice to round up or down. The 1mg tablet strength cannot be made unavailable to the practice as this is a most unlikely scenario. The Practice Defaults screen allows you to configure a number of settings for any new patients who are monitored by the Warfarin management software. Any changes made to these settings will not affect the existing patients but will apply to any new patients who are monitored. Hospital The Hospital Managed box should be checked if the patient is under hospital care e.g. admitted. A marker is placed alongside the patient, which can be seen in Hospital column of the Warfarin Monitor screen. 24