STEMI & Heart Failure: How the EMR Tracks & Improves Care
The promise of EMRs to improve the efficiency and quality of care makes their universal adoption a matter of when, rather than if.

From EMS to EMR

For the most fortunate STEMI and heart failure (HF) patients, the EMR is being deployed to catalyze their care beginning with the arrival of emergency medical services (EMS). At select heart centers, upon STEMI patient arrival, EMRs are opened and the hospitals’ cath lab teams are activated by EMS’s electronic transmission of ECGs, which are added to EMRs as PDF files.

“Electronic transmission of data is very effective in enabling us to achieve 90-minute door-to-balloon times on a regular basis,” says Craig S. Smith, MD, director of the coronary care clinic at the University of Massachusetts (UMass) Heart and Vascular Center of Excellence in Worcester, Mass. “We’ve driven down hospital heart attack mortality rates and improved compliance with our overall quality metrics.”

Ambulance call reports, including everything from blood pressure and initial exam results, drugs administered in the field, patient history and critical time intervals may be uploaded electronically into the EMR at certain institutions. But with 50 or more ambulance companies serving a single hospital, standardization has lagged.

Improving documentation

“Once patients hit the emergency department (ED), just about everything gets entered into the EMR,” explains Smith. The process, however, is not immediate. ED doctors quickly confirm the paramedics’ diagnosis of STEMI and jot down notes in the patient’s chart. As with the cardiologists’ progress notes that are dictated post-procedurally, these data also are entered into the EMR only after it has been scanned by medical records—sometimes weeks later.

When it matters most, the EMR turns out important advantages. With lab and test results, pressure readouts, medications and allergies immediately accessible to cardiologists alongside the patient’s history, “patient care is improved,” according to Timothy Henry, MD, director of research at the Minneapolis Heart Institute in Minneapolis.

In some cath labs, entire reports are completed electronically, including information on blockages, lesions, blood pressure and heart rate, as well as test results and procedure details and outcomes. Medications, stents and other equipment may be scanned straight into the EMR via barcodes or noted by physicians and nurses for direct post-procedure entry.

At Ottawa Heart Institute, the EMR and cath reports have been customized and integrated so cardiologists cannot sign off without entering “many details and completing many mandatory fields,” says Michel Le May, MD, director of the coronary care unit and regional STEMI program at Ottawa. Whereas reports would previously consist of short and commonly illegible notes, and could sit for months unsigned with important details omitted, due to their use of the EMR, “you just don’t see that anymore.”

Patient monitoring

The EMR is beginning to transform how STEMI and HF patients are monitored by making information more accessible and better communicated, even with small changes. Attending physicians bring computers on wheels to patients’ bedsides, where they can more quickly access patient information. Meanwhile, UMass has begun round-the-clock monitoring of cardiac intensive care patients. The critical care specialists and physicians have remote access to patients’ EMRs, including real-time updates of ECG, labs and medications.  

As payors become increasingly unwilling to reimburse for HF readmissions within 30 days, home monitoring of HF patients is becoming more sophisticated. HF patients referred to SunCrest Home Health in Madison, Tenn., are equipped with devices to measure their blood pressure, oxygen saturation and heartbeat for arrhythmia, as well as smart scales, according to Karen M. Garfield, RN, director of clinical development for SunCrest. “These devices transmit patient information wirelessly or via phone lines to SunCrest, where 180 telehealth patients are monitored by a staff of critical care nurses.” Garfield says the program has reduced HF readmissions by 50 percent.

The EMR costs, but does it pay?

A host of obstacles stand in the way of tailoring the EMR to reach its potential or even to exploit the above uses on a broader scale. “Cost is an issue that needs to be answered in a very serious and rigorous way,” says Clyde W. Yancy, MD, immediate past president of the American Heart Association and medical director of the Baylor Heart and Vascular Institute in Dallas. “Most of the systems are quite expensive, and we don’t yet know if they are cost effective.”

Henry and Smith also express doubts about EMRs’ cost-effectiveness. Smith says, “Ironically, by reducing length of stay and redundant labs and procedures, the amount of revenue the hospital takes in also decreases.” He notes, however, studies that have found diminished costs and revenue associated with EMR quality initiatives amount to roughly a wash for hospitals.

UMass has used the EMR to track numerous quality indicators. The use of boluses instead of IVs to administer meds, for example, enables nurses to transfer patients quicker. However, Yancy is less confident in this aspect. In his opinion, the promise of the EMR depends on its being deployed as a “dynamic patient management tool,” rather than a passive repository meant to trigger quality improvements.

“There is a paucity of available programs to provide decision support,” says Yancy. He says two fundamental details must be addressed before the EMR can meet the efficiency and quality improvement dreams of clinicians: more robust data points, upon which accurate data and meaningful decision support could hinge, and greater interoperability.

Yancy acknowledges the tantalizing and perhaps imperative benefits of the EMR for the future, but says, “We mustn’t retreat from the quest for evidence that has heralded the dramatic improvements in outcomes for patients with heart disease. Though EMRs are not needles or pills, we still need proof to know that we are providing benefit and that the application of these systems is in fact cost effective. We would be wise to walk, not run, to the EMR trough.”

Timeline for STEMI

  • Acute patient: 10 a.m. EMS arrives at patient location, transmits ECG to hospital, cath team activated, ECG PDF added to patient’s EMR.   
  • Hospital arrival: 11 a.m. Labs, meds and vitals entered into EMR; physician notes later manually uploaded.
  • Cath lab: 1 p.m. Cath report completed electronically, mandatory fields ensure completeness. Barcoded meds and equipment scanned and uploaded straight to EMR. Computerized physician order entry (CPOE) alerts for drug contraindications.
  • Post-op: In-hospital stay Bedside carts on wheels enable physician access to comprehensive patient history. Cardiologist can flag patient's EMR for monitoring unstable conditions.
  • After discharge: Several days later Remaining progress notes and ambulance call report uploaded to EMR. EMR parameters reviewed for quality assurance and improvement initiatives.

Timeline for Heart Failure

  • Acute patient: 10 a.m. Patient arrives at ER, EMR accessed.
  • Labs: 10:15 a.m. Vitals such as blood pressure, heart rate, lung function and ECG entered into EMR.
  • Imaging: 10:45 a.m. Echocardiography, chest x-ray and angiography if coronary disease is suspected. Results imported directly into EMR.
  • Treatment: 3 p.m. CPOE alerts for drug contraindications.
  • At home: Several days later - Weight, blood pressure, oxygen saturation and heartbeat wirelessly monitored and updated to EMR.
  • Office visit: Several weeks later - Primary care physician or cardiologist has access to all data via the EMR.