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New Office Procedure/System Changes Increase Lipid Screening
  By Chris Kaiser, Cardiology Editor, MedPage Today
Published: April 13, 2012
Action Points
· Note that this study was published as an abstract and presented at a conference. These data and conclusions should be considered to be preliminary until published in a peer-reviewed journal.
· Explain that a Kaiser Permanente performance improvement project found that the percentage of members with a Framingham risk score increased because of a team-based approach that resulted in more lipid screening.
· Note that nurses were able to order a lipid profile, tests were performed without fasting, and alerts were programmed into the EMR to facilitate identifying more at-risk plan members.
Having nurses order cholesterol tests, using nonfasting testing, and creating alerts in the electronic medical record (EMR) system to identify missing data helped primary care physicians increase the number of patients undergoing lipid screening, a performance improvement project showed.
A year after the program was initiated, the percentage of completed lipid profiles for Kaiser Permanente Colorado members between the ages of 40 and 80 increased from 77.3% to 83.3%, according to Sally S. Foland, RN, and colleagues. In absolute numbers, physicians were able to calculate the Framingham risk score for 15,000 more members in the first year of the program because of the completed lipid profiles, Foland reported at the annual meeting of the Preventive Cardiovascular Nurses Association in National Harbor, Md.
The project to increase lipid screening began as an integrated cardiovascular health initiative, which ultimately became a collaboration between cardiology, primary care, and population and preventive services.
"Over the past 15 years, we had implemented many changes to help reduce recurrent cardiovascular events," Foland told MedPage Today. "The next step was to look at primary prevention."
In 2010, Foland and colleagues noticed that 25% of their adult members did not have an up-to-date Framingham risk score -- mostly because their lipid profile was missing.
So they initiated several system-wide, patient-centered and technology-supported team strategies to help gather the missing data and enhance preventive screening.
Foland, who is a business analyst in the clinical informatics department, and her colleagues began by implementing changes to the EMR system. This entailed having alerts for missing cardiovascular risk data and acting upon those alerts when lipids hadn't been checked in 5 years.
Next, to make cholesterol testing more patient-friendly, the team promoted nonfasting testing. Historically, it was thought that nonfasting cholesterol testing would elevate triglycerides, which would then have an overall impact on LDL cholesterol.
"The most recent literature, however, suggests that the changes seen in nonfasting cholesterol testing are minimal in most people such that the lipid profile components, along with the Framingham risk score, can still be used to determine one's risk of heart attack," Foland said.
A study published last year suggested the small differences in cholesterol values between fasting and nonfasting children were "unlikely to result in important clinical changes in the results of screening for cholesterol abnormalities."
The next step for Foland and her group was to create guidelines that would allow nurses to order a lipid test without consulting a physician. Each of the physicians signed the new guidelines.
"The physicians were enthusiastic about this change," Foland said. "They are happy to have population strategies such as this. We try to do everything we can to help each member of the healthcare team work to the full limits of their scope of practice."
Foland reported that the number of lipid profile tests that were nonfasting increased from 4% to 15% during the year in question.
Kaiser Permanente Colorado has a fairly sophisticated EMR system and whether this approach would work for smaller practices remains to be seen. However, all practices have to adopt EMRs in the near future to either receive bonus incentives from the government or be penalized.
Foland recommended that practices ensure their EMR system can be programmed to have such alerts.
"These results show that by putting a system of support into place, we were able to get many more adult members to undergo their lipid screening so that our computer system could calculate the Framingham risk score and report that result in the medical record for the physician and healthcare team," Foland concluded.
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