E-Iron: Rethinking the Way We Deliver Intravenous Iron. Report of a Pilot Telemedicine Initiative

Introduction

Iron deficiency is common in the community, affecting upwards of a third of females in their childbearing years. The majority of patients with iron deficiency anemia (IDA) will be successfully managed with simple oral iron supplementation. However, a substantial proportion will only achieve normal hematocrits after protracted courses of treatment, often entailing significant GI toxicity. In recent years, with the availability of formulations that allow for total dose infusion, the role of intravenous iron (IVI) has become increasingly appreciated as a rapid, reliable, and safe strategy in addressing IDA.

Historically, at our institution and at many others, the path to IVI treatment entails initial referral to hematology, a face-to-face evaluation at a hematology clinic, followed by scheduling for infusion on another visit. The median time from referral to infusion is approximately 35 days, with timing of infusions determined not by clinical considerations, but by chair availability and the whims of non-clinical personnel entrusted with the scheduling. Inappropriate delays are common, and of practical import when occurring, say, in pregnant women approaching their due dates, or patients scheduled for surgery.

With the purpose of expediting the above process, capitalizing on a robust e-consult platform already operational at our institution, e-IRON was made available to referring providers as a function in the EPIC EMR, that facilitates an ‘electronic’ referral to hematology, for consideration for IVI. A template-based design ensures that all information required (indication, experience with oral iron, current lab-work, etc.) is included. Following the institutional protocol for e-consults, e-IRON referrals are ‘chart-reviewed’ by a specialist hematologist within 3 business days, and a determination regarding IVI is made. If deemed appropriate, the patient is scheduled for infusion within 10 business days. The specialist also specifies whether a face-to-face hematology appointment is required, and in cases where IVI is not deemed appropriate, will provide guidance as to alternate management.

Results

During the initial 75 day evaluation period 81 e-IRON referral were received. Indications are listed in table 1, and responses in table 2. The largest subgroup of referrals was from the prenatal clinics, likely as a result of a proactive protocol for management of IDA in pregnancy adopted by the department of obstetrics in conjunction with hematology. Of note, IVI was approved and scheduled for 60 of 81 (74%) patients, of which only 2 were required to be seen by hematology. Reasons for non-approval of IVI varied, but the most common reason cited was an inadequate trial of oral iron, in which case specific instructions were provided for oral iron supplementation. In one notable case, wherein a referred patient’s anemia was felt to be discordant with his degree of iron deficiency, a more extensive workup was recommended resulting in a diagnosis of previously unsuspected myeloma.

Recommendations were generated within 3 business days for 77 (95%) consults and in 1 day for 47 (58%). Recommended IVI regimens all entailed 1 or 2 infusion days, depending on the estimated iron deficit, and all first infusions were scheduled within 2 weeks of the request.

Conclusion

The e-IRON pilot project demonstrates the feasibility and efficacy of a telemedicine approach in triaging, and expediting the management of patients requiring IVI. Using a template-based e-consult platform, reviewing hematologists are in the vast majority of cases able to rapidly determine appropriate management, and facilitate IVI when appropriate. The platform ensures effective supervision by specialist hematologists, but dispenses with the laborious, costly, and time consuming traditional requirement of a face-to-face visit to the hematology clinic. The value of this paradigm shift in patient care is underscored by lessons learned during the ongoing COVID19 pandemic.