Order Sets, Pharmacist Protocols Target Iron Deficiency Gaps in HF

Iron deficiency affects as many as half of patients with heart failure (HF), yet only about 1 in 4 are tested for it despite guidelines calling for ferritin and transferrin saturation (TSAT) testing in every patient with HF.^1,2 Clinicians in Washington, DC, agreed the evidence was not the main obstacle. The gap, they said, lies in who orders the labs, who gives the iron, and who makes sure the patient comes back. They shared the protocols and workflows their institutions have built at a Population Health Roundtable held by The American Journal of Managed Care^® on July 21, 2026.

The discussion was moderated by Katherine Di Palo, PharmD, MBA, MS, senior director of transitional care excellence at Montefiore Medical Center and associate professor of medicine at Albert Einstein College of Medicine in New York. Participants included HF cardiologists, nurse practitioners, and pharmacy leaders from George Washington University, Georgetown University/MedStar Washington Hospital Center, the University of Maryland Medical System, and Luminis Health.

Building Screening Into Default Care

Panelists said inpatient testing was more reliable. At the George Washington University Heart and Vascular Institute, any patient hospitalized for HF who has not had iron studies in the past year gets them, said Gurusher Panjrath, MD, professor of medicine and director of the institute and its heart failure section.

"The handoffs between inpatient and outpatient teams, that's kind of where it fails," he said.

Richa Gupta, MD, MPH, an advanced HF and transplant cardiologist at Georgetown University/MedStar Washington Hospital Center, added that iron deficiency "gets underrecognized when the hemoglobin is normal." Cynthia Bither, ACNP, ANP, chief nurse practitioner for the hospital's Advanced Heart Failure Program, said overnight admitting hospitalists rarely stop to consider iron studies. "I can tell you that if it's not prechecked, it won't get checked," she said.

Panjrath said order sets that require clinicians to uncheck a box force them to think about why it is there, and that involving an HF expert in order set design "was very helpful." Jee Young Choi, ACNPC-AG, a pulmonary hypertension nurse practitioner at MedStar Washington Hospital Center, described an electronic medical record dot phrase, or shortcut text command, her team built for outpatients with pulmonary arterial hypertension that pulls a patient's most recent hemoglobin and iron studies and prompts new orders if none are on file.

Pharmacists Take Ownership of Dosing

Several institutions have shifted the iron decision to pharmacy. The University of Maryland Medical Center uses a pharmacy-to-dose intravenous (IV) iron order with HF-specific TSAT and ferritin cutoffs, which lets Lexi Lahey, PharmD, clinical pharmacy specialist in advanced HF, order labs at admission rather than rely on rotating house staff. "I think you're always going to have variability in clinicians, and so it all makes sense to take it out of the hands of the clinician and to follow a protocol," Lahey said.

Sahil Sheth, PharmD, BCCCP, senior director of pharmacy services at Luminis Health, said a medication use evaluation by his pharmacy residents found that about 20% of patients whose labs qualified them for IV iron did not receive it. The system is now revising its HF order set and exploring automatic iron lab orders. To fit 5- to 6-day HF stays, Luminis gives ferric gluconate 250 mg daily, increasing to twice daily in the final 48 to 72 hours if needed.

Andre Harvin, PharmD, MS, MBA, chief pharmacy officer at the University of Maryland Medical System, said a dedicated IV iron clinic at his previous health system in North Carolina showed that visit burden drives completion. "We found if patients had to come in more than 3 visits for IV iron, they just weren't doing it," he said.

Infusion Access and Follow-Up Remain Weak Links

Outside the hospital, most panelists routed patients through oncology infusion centers, where hematologists choose the product and sometimes apply general rather than HF-specific diagnostic thresholds. Choi said some hematologists told referred patients, “No, you don't have iron deficiency."

Bither noted that each visit adds cost. "It's $20 of parking besides the co-pay, and they just can't afford it," she said.

Harvin said his system operates an alternate-site infusion business, but referral habits still steer patients toward oncology centers. Follow-up after a first dose was often absent. Di Palo said she often sees discharge instructions telling patients to "go and get a second dose of IV iron with absolutely no instructions on how to do that."

What Panelists Plan to Take Back

Di Palo said she was considering borrowing from her endocrinology colleagues' diabetes care journeys by automatically pending iron study orders at the interval a protocol sets and pushing them to patients to schedule before visits. Panjrath suggested using artificial intelligence to flag when a patient was last tested and dosed, although he cautioned that the evidence does not yet support making iron treatment a quality metric.

"Our average time to [give] IV iron inpatient was 22 hours, and I'd like it to be the next 7:00 AM that our team sees," Sheth said.

Harvin, who was scheduled to meet with Epic the following morning about clinical pathway design, said he would bring the discussion with him. "Hearing everyone talk about the same kind of care coordination issues that have existed for decades in 2026 is something that a partner like Epic should hear," he said, "because they really are supposed to be someone in the driver's seat of helping us deliver on more effective and safer care."

References

1. Klip IT, Comin-Colet J, Voors AA, et al. Iron deficiency in chronic heart failure: an international pooled analysis. Am Heart J. 2013;165(4):575-582.e3. doi:10.1016/j.ahj.2013.01.017
2. Becher PM, Schrage B, Benson L, et al. Phenotyping heart failure patients for iron deficiency and use of intravenous iron therapy: data from the Swedish Heart Failure Registry. Eur J Heart Fail. 2021;23(11):1844-1854. doi:10.1002/ejhf.2338