A Perfect Storm: IT Innovation in Cardiac Care

As a high-cost, high-revenue environment, cardiovascular patient management is fertile ground for a range of improvements driven through IT innovations. Advances in electronic tools, increasing focus on patient engagement, improvements in information sharing, financial incentives and more are converging to set the scene for a perfect storm of innovation in cardiac care.

Cardiovascular disease is probably the perfect disease for this convergence of IT-driven technology, says Sean Collins, MD, MSc, of Vanderbilt University’s emergency department (ED) in Nashville, because there are so many contributing factors that all result in abnormalities, fluid collection and retention. Tracking diet, medications and warning signs are vital to successfully managing heart failure, so tools that can help assess outcomes and symptoms are valuable.

“Heart failure is always present. It’s just a question of symptom severity,” Collins says. Technological advances are leading to a source of information that can address those symptoms earlier and more appropriately.

Cardiac care represents at least 45 percent of inpatient revenue for most healthcare delivery systems, says Michael J. Mirro, MD, cardiologist at Parkview Physicians Group (PPG) in Fort Wayne, Ind. Plus, cardiovascular care encompasses primary, secondary and tertiary services that have a huge impact on healthcare costs, individual disability and survival, says Phillip D. Levy, MD, MPH, assistant director of clinical research for both Wayne State Detroit Receiving Hospital’s Cardiovascular Research Institute and its emergency medicine department.

“We’re definitely in a new era,” Mirro says. Most large healthcare systems with advanced heart failure programs are using telehealth, personal health records and other electronic tools.

More sophisticated EHRS

Advances in EHR systems pave the way for more sophisticated use of data analytics. Wayne State Detroit Receiving Hospital, for example, is developing a fuzzy logic program for its EHR that identifies patients with certain risk criteria. “In real time, you can get information on patients’ risk and see how that may be modified,” explains Levy.

Information is constantly added to EHRs making it the perfect environment for fuzzy logic, which allows for approximate values and inferences as well as incomplete or ambiguous data, he says. “We often approach risk and assessment of patients’ potential outcomes as static phenomena and it’s not,” says Levy.

He works with the Society of Cardiovascular Patient Care which is in the early stages of developing the EHR as a living document. The society is developing a new accreditation process and working with vendors to better track patient outcomes and autopopulate EHR data fields. “This is high-level stuff, but if we’re able to use automated time inputs and HIPAA-compliant patient identification, then we can really track issues like hospital readmissions much more intelligently than we can now.”

Reminders distributed via the EHR also should help improve outcomes, says Levy. That, combined with the ability to see trending information, such as blood pressure, weight and biomarkers that can indicate risk, creates new opportunities for care. For example, computer algorithms can detect subtle patterns in patients’ lab or radiographic workup that a clinician might not notice in individual pieces, he says. That could work toward primary intervention “by providing reminders of evidence-based medicine pattern recognition of dangerous trends that are not obvious.”

The PINNACLE registry, the largest in the American College of Cardiology's (ACC) National Cardiovascular Data Registry's suite of registries, tracks coronary artery disease, hypertension, heart failure and atrial fibrillation in the outpatient setting. Mirro’s practice has been a part of ACC’s effort to use PINNACLE to look at guideline adherence. PPG has been using PINNACLE since 2009 as a clinical decision support tool.

There always are going to be exceptions to the guidelines, Mirro says, but those “exceptions have always been the problem with cardiovascular care. At the point of care, you can see where you’ve deviated from the guidelines.” That forces clinicians to document why a patient is not receiving, for example, a beta-blocker. PPG worked with its EHR vendor to pull from structured data fields to autopopulate the registry. “That’s the value and the innovation taking place with EHRs.”

PPG has improved its anticoagulation guideline compliance to 99 percent across its physicians. As both a decision support and registry collection tool, “PINNACLE has been incredibly valuable. We think that is the future of care.”

Most vendor solutions are focused on charge capture, not clinical care, which has slowed down physician adoption, Mirro says. "Usability at the point of care is limited but it is improving."

PPG provides physician feedback on a quarterly basis. “We’re now putting targets on blood pressure control, so that physician compensation is not just about entering process measures and adhering to guidelines but actually looking at intermediate outcomes.” The system allows clinicians to track such intermediate outcomes as blood pressure and low-density lipid levels, so the entire care team has feedback on how it’s doing to achieve those targets on important outcome measures.
PPG physicians are very focused on their data quality because it impacts their bonus compensation, says Mirro. “There’s no better way to get physicians focused on data quality than to tie money to it. That gets their attention.” Nurses help by serving as data editors during each patient encounter, which takes no more than 30 to 60 seconds per patient.

Improvements in info sharing

Accurately collecting data allows for information sharing which is increasingly improving within organizations, says Beverly B. Green, MD, MPH, physician scientist at Group Health Research Institute in Seattle. She has focused her research on developing and implementing evidence-based medicine and studying how systems of care can be improved. Information sharing between organizations is an ongoing issue but “we’re chipping away at it. Compared with five years ago, we’ve seen amazing improvement.”
EHRs foster collaboration among providers and patients by allowing them to see and share information and improve access to care. Patients can log into the EHR system at Vanderbilt, My Health at Vanderbilt, to access a physician or nurse. Clinicians can use the system to see previous communications and stay in the loop. “They can see what’s been done and what needs to be done going forward,” says Collins.

Expect to see futuristic developments and soon. Patient data increasingly are coming from, for example, mobile and wearable devices and then stored in this virtual memory—iCloud—that physicians can tap into to see how their patients are doing relative to their baseline, says Collins. Recent heart failure studies stemmed from how much fluid patients have in their system and whether that leads to symptoms. “Not everybody can have devices implanted, so we’re looking for other devices that can be applied externally. Advances in wearable devices allow for alerts that a patient is getting into trouble before he or she is experiencing any symptoms.”

Use of some of these tools to facilitate better information sharing should help reduce the rate of rehospitalization—a major concern now that hospitals are facing penalties for readmissions within 30 days that are deemed unnecessary. “Historically, we’ve seen high rates of readmission for heart failure patients because if patients are unclear on taking their medications, their options are penetrating a complicated phone tree at their physician’s office or going to the ED,” says Mirro. A personal health record (PHR) can allow patients to electronically message their physician, or someone familiar with their case. Traditionally, patients who undergo cardiac stenting and bypass are bombarded with information at discharge, and they just want to go home. Unfortunately, that often results in confusion about medication and questions about symptoms. “We’re working to determine whether use of the PHR reduces the readmission rate.”

In Detroit, Levy has a grant in review designed to use the southeast Michigan health information exchange (HIE) to link ED patients with their primary care practice. “We can look at the capability of that information exchange to track ongoing patient management for high blood pressure and heart failure patients,” he says. “That will measure whether patients make it to follow-up care appointments, which could reduce unnecessary testing and duplicative orders.”

Cardiovascular care tends to involve multiple physicians, Levy says. “It creates a world of problems when the right hand doesn’t know what the left hand is doing. Cardiologists and primary care providers might communicate but the norm is not to.” Everyone expects the patient to be the bearer of information even though that doesn’t work very well. “We need a combination of better information for providers and better use of all these available tools through the EHR and HIE to set patients up for success.”

Increasing patient engagement

The increase and improvements in information sharing are working to create more activated, involved patients. “Engagement is key,” says Green. “If a patient is willing and able to engage, that goes a long way to improving health.” All the elements can come together, allowing for written, common goals that everybody is sharing, she says.

Green and her colleagues have learned the importance of finding the patients best suited for team-based care and the best way to engage them efficiently. She wants to figure out who benefits from phone and web communication efforts, along with who doesn’t and why. Her organization also has learned that patients don’t always need to come into a physician office for a face-to-face visit. “We can use asynchronous communication, which we have fully embraced,” allowing for a back and forth that can happen through any mode of communication.

“We can develop all the technology we want, but if the patient is not engaged and does not take a proactive role, it’s difficult to use these devices” to improve outcomes, says Collins. He, too, mentions the need to find a motivated group of patients who want to act on available information.
Mirro’s practice currently has a challenge grant from the Office of the National Coordinator of Health IT to look at PHR use. His study provides a PHR to post-procedural stent patients, and those who have undergone revascularization. They fill out a questionnaire to determine their patient activation measure (PAM) and technology assessment measure (TAM)—the latter being their ability to use technology.

“We’re trying to prove that these electronic tools work and it appears that they do,” Mirro says. PAM scores have improved in patients using the PHR, suggesting that the electronic tools enhance patient engagement. All data are entered into a secure system, called No More Clipboard, which interfaces with the practice’s EHR, creating a secure electronic feedback loop. The site stores their records and can compare baseline measures for such factors as blood pressure, with data collected at six and 12 months. Important changes trigger appointment alerts or other appropriate follow-up.

There is some patient responsibility for follow-up care, says Levy. Improvements in information sharing offer a “huge potential boon” to improve care transitions. For example, access to the latest medical information should help primary care providers feel more confident about accepting responsibility for patient care after a hospital discharge. And, patient access to their medical information can help patients better understand their condition and, in turn, become more active participants in their care.

Social media and text message reminders also could play a role in improving outcomes, Levy says. His colleague has a grant to assess text messaging to help remind hypertension patients to better self-manage. They added an arm to the study for discharged ED patients who are particularly vulnerable. “We’re trying to understand if text message-based intervention is useful. The problem for now is that the messages are generic.”

A thorough information exchange would allow for tailored text messages, he says. “Not everybody needs the same message and not everyone has the same barriers.” He predicts more of these individualized outreach efforts “that help us best respond to patients’ individual needs.”

What the future holds

It will take more than five years to determine whether the convergence of these efforts and advances will make a dent in cardiovascular disease outcomes and costs, says Green. “The technology is moving so quickly, but it also depends on the appetite of communities and the nation to make resources available to make them scalable. The biggest obstacles for scalability are upfront resources and sustainability.”

Bundled payment and restructuring of the U.S. healthcare system are not far away, says Collins. “Because of that, we’re going to have to get creative taking care of patients.” That includes transitioning patients from the ED to the outpatient setting in the least expensive way with the best results. For example, patients might be best managed in an observation unit which is much less expensive than inpatient care.

Patients who receive follow-up care within a week are much less likely to be readmitted within 30 days. “Follow-up care is crucial in this disease process,” says Collins, “but improvements must come on both ends.” The hospital discharge process needs to ensure a smooth transition and, on the outpatient side, providers must find ways to avoid continually readmitting patients to manage their symptoms.

Because cardiovascular disease ebbs and tides regarding severity of symptoms, advances in mobile monitoring technology are going to be huge in the next 10 years, says Collins. “We can’t manage everybody by hospitalizing them, so a big part of improving outcomes is how well we manage these patients on an outpatient basis.”

Although past studies found patient self-monitoring did not improve outcomes, Levy says “all hope is [not] lost on that.” Advances, such as automated pill-dispensing machines and the capability to deposit data collected by blood pressure cuffs electronically, could help.

“The locus of control can’t always be on physicians,” he says. “Patients need to be actively engaged and respond to information on their own.” Future devices could actually provide them with suggestions. “The sky is the limit for where we can go with this. People need to be supported to be good patients. We want patients to be able to make better decisions in real time or close to it, but without the health information pieces in place, it’s impossible to do that.”