Enhancing the EHR to consolidate information for comprehensive immunosuppressive medication review following liver transplant was associated with fewer rejection episodes and fewer toxicity events, and it decreased costs, according to a study published in this month's Journal of American Medical Informatics Association.

Post-transplant immunosuppressive therapy requires meticulous management to avoid drug toxicity or rejection episodes. Researchers investigated whether automated clinical management in the liver transplant program would improve clinical outcomes related to immunosuppressive medication management, explained lead author Esther S. Park, MD, of University of Washington School of Medicine in Seattle.

The before/after retrospective study included liver transplant patients from Jan. 1, 2004 to April 1, 2008, who survived to discharge and received tacrolimus for outpatient immunosuppressive therapy.

The 301 patients transplanted from Jan. 1, 2004 to Nov. 30, 2006 were managed via paper charting systems. “Several steps in the process could be problematic,” wrote the authors, “including a delay in knowing when laboratory results were ready for review, not finding the satellite chart and difficulty in finding a physician to review the laboratory results and prescribe medication changes.”

The second patient cohort of 127 patients transplanted from Dec. 1, 2006 to April 1, 2008  were followed with an automated system that consolidates all clinical information to expedite immunosuppressive medication review into three EHR screens.

The second cohort, the automated chart cohort, experienced fewer rejection and toxicity episodes. Rejection episodes occurred in 22 percent of the paper chart cohort compared to six percent in the automated cohort, and toxicity occurred in 31 percent of the paper chart cohort and 18 percent of the automated cohort.

Formal cost-effectiveness analysis showed that the annual monitoring cost of the automated system was $197 with 0.96 quality life year, compared with an annual paper charting cost of $1,703 with 0.86 quality life year.

The automated system also improved clinician response time, reducing response time for adjusting medication from one to three days to a few hours.

The research builds on previous studies that established the value of clinical automation. While earlier studies showed that electronic viewing improved care quality in a non-transplant ambulatory setting and computerized alerts improved efficiency in immunosuppressive care, the authors demonstrated that “use of an automated clinical management system is associated with improved immunosuppressive care following transplantation in an outpatient setting and is cost effective.”

Noting the similarities between chronic immunosuppressive management for liver transplant patients and chronic management of diabetes and congestive heart failure patients, Park suggested the lessons learned from the automated system might be useful to wider chronic medical care management.