Highlights

Background

  • Electronic health record-based dashboards have the potential to support high quality anticoagulation management for populations of patients

  • A small number of health systems are known to have successfully implemented such dashboards

  • The breadth of published evidence describing the development, implementation, and impact of anticoagulation management dashboards is unknown

Findings

  • Only a small number of centers have published manuscripts describing the use of digital dashboards

  • Preliminary evidence suggests that digital dashboards positively impact care processes and clinical outcomes

  • Prospective research is needed to characterize dashboard implementation and assess their impact on clinical outcomes

Background and significance

Direct oral anticoagulants (DOACs) are the most commonly prescribed oral anticoagulants in the United States, due to their superior efficacy, enhanced safety profile, simpler dosing regimens, and the lack of frequent laboratory monitoring requirements as compared to warfarin [1]. Although approved indications vary by individual agent, multiple DOACs are considered first-line therapy for common thrombotic conditions (e.g., nonvalvular atrial fibrillation [NVAF] and venous thromboembolism [VTE]) [2, 3] and some are recognized as therapy options in clinical scenarios previously limited to injectable anticoagulants (e.g., postsurgical VTE prophylaxis, VTE prophylaxis in the medically ill) [4, 5]. Some are also approved for use in coronary and peripheral artery disease [6], further expanding the use of these agents.

However, anticoagulant use is associated with an increased risk of bleeding. This risk can be magnified in situations of inappropriate prescribing, drug-drug interactions, misuse by patients, and poorly managed care transitions [7]. Likewise, under-prescribing, prescribing inconsistent with FDA-approved labeling, and suboptimal patient adherence may contribute to avoidable thrombotic events, such as stroke [8, 9]. In fact, anticoagulants are the leading cause of adverse drug events in the emergency room [10].

In order to improve the quality, safety, and efficiency of the management of these high-risk agents, some health systems have developed, implemented, and evaluated digital “dashboards” that aggregate and analyze clinical data available for a population of patients prescribed the agents, identify potential clinical problems, and facilitate clinician intervention and tracking [11,12,13,14,15]. However, the breadth of use of such dashboards for the management of anticoagulants is uncertain. This literature review aims to evaluate and characterize the published literature describing the use of digital dashboards as clinical management tools for populations of patients indicated for anticoagulation treatment.

Materials and methods

This scoping review sought to identify published manuscripts describing the development, implementation, and evaluation of digital dashboards for the management of anticoagulants. In the current context, “dashboard” refers to electronic health tools that aggregate digital clinical data, evaluate the data in the context of pre-identified standards, and present the data on multiple patients (i.e., populations) back to clinicians to support surveillance and guide clinical interventions for individual patients, when warranted (Fig. 1). This approach differs from clinical decision support, which generally influences care at the point of order entry, and quality or management reports, which are typically retrospective in nature (Fig. 2).

Fig. 1
figure 1

Dashboard definition. *Figure based on inclusion and exclusion criteria utilized by Tsang et al. [16]

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Fig. 2
figure 2

Comparing and contrasting digital tool characteristics

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Among manuscripts known to the authors prior to performing the review, the terms “population health management tool”, “dashboard”, and others have been used, yet none had been used consistently or been established as the nomenclature standard. Therefore, an initial set of search terms was developed based on manuscripts known to the authors [11,12,13,14,15] and refined through iterative explorations of English language records in PubMed. Given the considerable heterogeneity in terminology and the existence of a prior systematic review that did not capture all papers known to the authors [16], a systematic, three-tiered search strategy was implemented (Appendix A). A search utilizing a narrow set of terms supplemental to the prior systematic review was performed for January 1, 2015 through January 31, 2021, and a search using an expanded term list was performed for manuscripts more recent than that systematic review (January 1, 2021–May 31, 2022). To account for heterogeneity in language, a manual search of tables of contents was also performed on 4 highly rated medical informatics and/or implementation journals for the complete time interval (January 1, 2015–May 31, 2022). Manuscripts that were not written in English, did not focus on the use of dashboards for anticoagulation management, or that described other types of digital tools to improve the quality or safety of anticoagulation management (e.g., electronic order sets, clinical decision support features) were excluded.

Identified records were imported into Rayyan systematic review software [17], after which duplicative and irrelevant records were removed based on evaluation of titles and abstracts by a single reviewer using pre-defined criteria (DMT or ASW). The remaining manuscripts then underwent blinded, 2-reviewer evaluations (DMT and ASW), with conflicts being resolved by a third reviewer (GDB). Retained manuscripts were then further evaluated by care setting (inpatient, outpatient), medications included (warfarin, direct oral anticoagulants (DOACs), or injectable anticoagulants), and whether the dashboard was utilized to intervene in individual patient care in real time. The protocol and search strategy were developed prior to initiating the literature search.

Results

The initial detection phase for published manuscripts returned a total of 753 records (Fig. 3), which were then reduced to 192 records following title/abstract evaluation. The blinded, adjudicated review process resulted in a final total of 12 published manuscripts relating to the use of population health-focused dashboards for the management of patients indicated for anticoagulation therapy (Table 1) [11,12,13,14,15, 18,19,20,21,22,23,24]. The review noted several terms used to describe the tools used for anticoagulation management. These included “population health management tools”, “provider-level dashboards”, “integrated care applications”, “technology-enabled management platforms”, “electronic patient registries”, and “clinical surveillance tools”.

Fig. 3
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Flow diagram summarizing manuscript selection process

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Table 1 Descriptions of included manuscripts
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The 12 retained manuscripts were published by 7 separate organizations, comprising both international (2/12, 16.7%) and US based institutions (10/12, 83.3%). The earliest detected manuscript was published in 2015, coinciding with our literature search cutoff date, though the majority were published from 2019 to present date (10/12, 83.3%). Most of the anticoagulation dashboard reports were used in the ambulatory care settings (9/12, 75.0%), with the remaining being from the acute care setting (3/12, 25.0%). These publications focused on management of DOACs, warfarin, and injectable anticoagulants, with some emphasizing specific anticoagulant agents and others not limiting their anticoagulant management tools to any specific agent. Injectable anticoagulants were discussed in 2 manuscripts (16.7%)—which focused solely on the use of anticoagulation management tools in the inpatient setting. Of the 12 manuscripts, only 7 (58.3%) described tools that were utilized for direct intervention in patient care.

These 7 studies described the significant, positive impact of dashboard use on a range of important care-related processes and clinical outcomes. Dashboard use was associated with a 24.5% relative reduction of questionable DOAC dosing among outpatients within the Veterans Health Administration (VHA) [14], a 9.3% relative improvement in guideline-compliant VTE prophylaxis prescribing in a tertiary care medical center [24], and a 33.3% relative improvement in no-show appointments in an ambulatory care clinic [23]. The use of a dashboard improved patient knowledge by 21.7% [22], improved the efficiency of clinician intervention by 75% [15], and improved clinician experience [20]. Dashboard implementation achieved a 98.4% risk-appropriate VTE risk prophylaxis prescribing rate among house staff at a tertiary care facility [18] and 40.6% relative reduction in anticoagulation-related adverse event rates [19]. One manuscript described the dashboard implementation strategy for an anticoagulation quality improvement initiative that spans the state of Michigan [12].

Discussion

Published manuscripts describing the use of population health-focused anticoagulation management tools are limited but have been increasing in recent years. Overall, the available published literature suggests improved patient care with the use of anticoagulation-focused digital tools. These promising findings are welcomed and much needed, as anticoagulants continue to be among the agents most frequently associated with serious and preventable adverse drug events and the rate of such events is increasing [10]. As the population of patients eligible for anticoagulation continues to grow, impactful and efficient surveillance and clinical management methods are sorely needed.

However, while these early results are promising, the reports available to date are largely based on single center experiences and retrospective assessments whose designs limit their reproducibility and generalizability. For example, the reports include programs that included only medical residents [18], utilize an electronic health record limited in use to a single government agency [11, 13,14,15], focused on only a single agent [21], or characterized the results of a limited pilot [22]. Furthermore, none of the identified manuscripts describe improvement in clinical outcomes (e.g., bleeding, thromboembolic events). Rather, they focus on surrogate markers (e.g., appropriate medication prescribing) or process outcomes (e.g., clinician efficiency).

Prospective, multi-center studies reflecting recognized best practices in implementation science are needed to adequately control for confounding factors and to objectively assess important aspects of both the implementation process and the impact on well-defined process and outcome measures. Future studies of this type will not only add substantively to the evidence base but will also help consolidate the nomenclature used regarding such dashboards. They will also provide the detailed insights needed to guide administrative decision-making regarding investments in staff and necessary technology.

This literature review brings to light the research and practical use of dashboards that have been implemented within the field of anticoagulation management. Organizations such as the VHA and the Michigan Anticoagulation Quality Improvement Initiative (MAQI2) have demonstrated successful use of anticoagulation-focused dashboards [11,12,13,14,15]. The VHA and MAQI2 organizations have each provided in-depth insights into the impact of incorporating an anticoagulation management dashboard tool for managing anticoagulated patients in an outpatient setting. Each organization has equipped clinicians with tools designed to support evidence-based anticoagulation therapy and timely clinical interventions. The VHA data demonstrates that large scale implementation of anticoagulation dashboards is possible, given the successful integration of their anticoagulation-focused dashboard tool throughout the nation [25]. Furthermore, the MAQI2 data emphasize that implementation of dashboard resources has the potential to greatly improve drug management processes.

This literature review, while robust in design, was not without limitations. Despite increased interest in technology-based tools, there remains significant heterogeneity in nomenclature used for these tools within healthcare settings. This inconsistency in terminologies used among research centers may have limited the overall sensitivity of the PubMed queries. Additionally, this review was unable to incorporate information regarding tools that may already be in existence, but which have not yet been described in peer-reviewed medical literature. This limitation is further complicated by our inability to include manuscripts published in non-English languages, grey literature, and additional literature describing proprietary software.

Conclusion

Early reports of initiatives utilizing digital dashboards to support safe and efficient anticoagulation management describe promising results that require validation in larger, prospective studies. Additional research is needed to understand how best to implement these tools within existing information technology systems and care models.