Clinical protocols are a collection of procedures and medications that have been pre-approved by physicians for patient care. They come in many forms and are created by healthcare organizations under the guide of physicians so that nurses can perform patient care without further physician intervention. I’ve seen protocols most effectively used to allow nurses to triage patients in telephone encounters, prescription refill requests, and treating patients in oncology though these tools are used in many other settings. Clinical protocols are an important tool for managing overall patient care while reducing workload for physicians and variance in care provided.
I’ve broken protocol ordering into two groups:
- If/Then Protocols
- Predefined treatment regimens which can be further Individualized for patient care
If/Then protocols are to treat patients without direct physician intervention. Typically these instructions are written for conditions that can be diagnosed with a few simple questions asked by a nurse and easily answered by a patient. Alternatively they can be utilized to rapidly refill prescriptions without physician intervention. In both cases, the burden on physicians responding to patient messages.
For example: A diabetic patient sends a patient portal message requesting a refill of insulin. The computer can look to see that the patient has had a recent visit with their PCP, updated HgA1C labs, and that their diabetes is being managed well. The computer can go ahead and refill the prescription for the patient without physician or nurse intervention.
To help nurses order patient care from telephone encounters, the best system I’ve seen on the market is Schmitt-Thompson. These protocols have been in use by many of my clients and are vetted by many physicians and through use in patient care throughout the US. The best refill protocol tool I’ve seen used is HealthFinch’s Swoop, which is a software tool that interfaces directly into your Electronic Health Record (EHR). While many of the features of this product are available through EHR systems, the designed protocols are invaluable for a quick and safe implementation.
Predefined treatment regimens are used heavily in Oncology. The concept is pretty similar to the If/Then protocols. An oncologist compares cancer type and stage of cancer against which protocol would best suit the patient. Then the protocol is applied to the patient, and individualized into a treatment plan. Once the treatment plan is setup, the physician then signs the orders. These orders wait signed until the appropriate treatment date. The patient then receives updated labs which are then compared against instructions to the nurse. As long as the lab values check out, the patient can receive chemotherapy and adjuvant care without further intervention by the physician.
In both cases physicians design the protocols in advance for the proper care and treatment for patients. This work saves considerable time for both the provider and the patient receiving care. Refill protocols can save physicians up to 30 minutes a day which allows the physician to be used elsewhere. For oncology, protocols and treatment plan creation is the only reasonable method of managing patient care. By installing a refill protocol system, Kaiser Permanente Northwest directly saved $1.2M per year in staff costs alone, and earned an additional half million through increased prescriptions.
Creating protocols from literature is difficult. It takes several dedicated physicians & pharmacists to produce safe protocols, and even then it takes several rounds of review and needs to be updated annually. For my clients, I recommend purchasing predesigned protocols whenever possible. For Nurse Triage and Refill protocols, this content is readily used in conjunction with your existing EHR. Unfortunately this content does not exist in a readily usable format when implementing oncology protocols.
In the next post I will detail the various methods of structuring chemotherapy protocols with your EHR with pros and cons listed for each. Additionally I will include notes on how to integrate standard of care chemotherapy protocols with your interfaced radiology systems, and tie both of these systems to your clinical research modules.