Incorporating patient self-testing into your practice.

Patient self-testing (PST) of the INR is still in its infancy in the United States compared to our European colleagues. Information gathered from the four major third-party suppliers of point of care (POC) devices (Quality Assured Services, Reliant, Raytel and Tapestry Medical) estimates the total number of patients performing PST in the United States to be about 20,000, compared to 130,000 in Germany alone. Currently, only about 1% of all warfarin patients in the United States are self-testing. In a survey conducted by Wittkowsky in 2005, 60% of the United States anticoagulation clinics that responded had policies that prohibited self-testing [1]. An informal survey of clinics that have ‡50 patients self-testing revealed that all had certain criteria to be considered when patients are to self-test. Establishing guidelines for PST is crucial for success. The first hurdle a provider must pass before prescribing PST is to make sure that the patient has the motor dexterity to perform the test or a committed caregiver to perform the test. If the patient meets this criterion, the next step is to establish an acceptable method of communication of results to the healthcare provider. It is important to have more than one phone number in your medical record to reach the patient, or, if the patient prefers, email can be a viable alternative. The third hurdle is the most problematic—the financial aspect of PST. Third party companies, Independent Diagnostic Testing Facilities (IDTFs), will process the 2 to 3-page application and determine if your patient has the necessary financial resources for purchasing the monitor and supplies. Medicare has specific criteria for their patient population. Medicare will pay for patients with mechanical heart valves to perform PST. Eligibility requires the patient to have been on anticoagulation for 3 months and to have documented education on the use of the prescribed POC device. Medicare will cover up to one INR test per week, but does not mandate that the patient test weekly. Incorporating patient self-testing into a practice is not difficult. The key is to have a plan for communicating, documenting and scheduling so that patients do not slip through the cracks. The clinics surveyed all have the patient directly communicate with the clinic for INR reporting and dosage adjustments. It is considered a phone management visit. Under Medicare guidelines a physician can bill for every four INR’s that are interpreted/managed using the G2050 code which currently applies a $9.33 charge. The provider of the instrument and supplies is entitled to bill a G2049 for every four INR tests reported which generates a $146.36 charge. Patients may also be responsible to report test results to the third party suppliers in order to assure that they receive supplies in a timely manner and for the companies to recap their cost of supplies. To help the workflow of self-testing patients in our clinic, we devised a questionnaire with all the information we would normally ask at our face-to-face visit. If a health care professional is not available when the patient calls, the clerical staff ask the questions which are all yes and no answers and get a phone number and time that the patient would like to be reached. The message is then given to the professional staff and the visit is completed and the patient scheduled for the next INR check. If the patient does not phone results in on the date scheduled, the nurse in the Disclosure: Trainer for PST for Tapestry Medical.