Nearly two years ago, the Centers for Disease Control and Prevention and the Centers for Medicare & Medicaid Services launched a bold initiative aimed at preventing 1 million heart attacks and strokes in the United States between 2012 and 2017. From the beginning, Million Hearts has formed strong partnerships with such private organizations as the American College of Cardiology, the American Heart Association and the Association of Black Cardiologists, and dozens of other public and private entities have signed on as partners.
Among the private organizations — and the first health system — to join the partnership is MedStar Health, the largest integrated health care system in the Washington, D.C.-Maryland region. MedStar Health comprises 10 hospitals, the MedStar Health Research Institute and a comprehensive array of organizations across the health care continuum. Through the leadership of its board of trustees, MedStar Health is committed to helping achieve Million Hearts' goal.
MedStar's participation is a natural evolution of its board's support of state-of-the-art health information technology and its commitment to continuous improvement of quality of care. With enthusiastic MedStar board endorsement, the system is immersed in a multiyear plan to bring the best of health IT to the bedside and the outpatient setting. The board's focus on improving quality of care has been the hallmark of its stewardship for nearly the past decade.
Primary Care Prevention
Million Hearts entered the health care landscape at a propitious time for MedStar. The initiative and its tactical road map to success resonated deeply with the board's dual focus on health IT and continuous quality improvement.
The initiative has two axes of activity. The first is a public health initiative and the second is a patient-specific educational, screening and treatment approach. Briefly, the public health aim is to foster community-based activities, such as legislation and regulation, to improve the health of the population by reducing sodium intake and by promoting tobacco-control activities. Legislative and regulatory actions in New York are a model for what can be achieved at the population level. The incidence of cigarette smoking among New York citizens has steadily and significantly declined over the past decade. While MedStar Health is fully aligned with Million Hearts in public health activities, most of its current Million Hearts activities center on the patient-specific educational, screening and treatment approach.
At the patient level, Million Hearts seeks to improve compliance with the ABCS of outpatient cardiovascular care: aspirin for patients with appropriate diagnoses, blood pressure screening and control, cholesterol screening and management, and more aggressive smoking cessation for current smokers. These four risk factors have been shown to contribute significantly to the development of atherosclerotic arterial disease and its clinical manifestations of heart attack and stroke.
Appropriate control of these risk factors is the purpose of nearly all outpatient visits to cardiologists and, perhaps more importantly, screening and control of these risk factors in patients without diagnosed cardiovascular disease is a goal of primary care providers. Family medicine specialists, internists, primary care nurse practitioners, primary care obstetricians-gynecologists and pediatricians are all trained to diagnose these risk factors and to treat patients whose values are outside acceptable ranges. The importance of primary care providers to Million Hearts' success cannot be understated because vastly more patients are seen by primary care providers than by cardiologists.
Further, primary care providers have the opportunity for very early improvement of their patients' risk factors and, thus, are able to prevent the first heart attack or stroke. This primary prevention is less under the control of cardiologists who mostly see patients who already have had a manifestation of vascular disease and are in need of secondary prevention.
A Boost for Meaningful Use
The MedStar board of trustees was given a presentation on the goals of Million Hearts in the fall of 2011. The context of the presentation was the annual update on progress of health IT within the system. It became clear that Million Hearts was an ideal focus for MedStar's plan to achieve meaningful use of electronic health records. To qualify for incentives under the second stage of meaningful use, systems and providers must (among other requirements) employ their EHRs to report on several clinical performance measures that could be improved in quality programs — preferably those related to priority health conditions, such as heart disease and stroke. The ABCS of Million Hearts readily meet these criteria.
With board support, the IT professionals at MedStar modified the system's outpatient EHR to provide primary care providers with real-time feedback on the status of each patient's ABCS measures while he or she is being seen.
With this information readily at hand, MedStar's primary care providers can formulate specific plans to improve blood pressure and cholesterol control, to counsel and prescribe tobacco cessation activities for smokers, and to prescribe daily aspirin for patients who will benefit from this treatment.
This information also is used to create a personalized ABCS report card for every adult patient seen by a primary care provider, so that when patients leave their respective doctor's office, they know their specific ABCS goal, if they have met their goal and, if not, what to do to get there.
The ultimate goal is that every adult patient who is seen by a MedStar primary care provider will have his or her ABCS risk factors assessed and, if appropriate, treated over the course of care. Those patients with abnormal risk factors and no history of heart attack or stroke will benefit from the active incorporation of primary prevention into their medical care, and those who have suffered the complications of vascular disease will benefit from secondary prevention activities.
Fewer heart attacks and strokes will occur because of these prevention strategies, and the net result will be improvement in the overall health of the population that is entrusted to the care of MedStar providers.
Million Hearts went live on MedStar outpatient care providers' EHRs on Oct. 1, 2012. Not surprisingly, opportunities for improved care were noted in the initial evaluation of the organization's ABCS. The care quality improvement intervention is ongoing, and follow-up analyses soon will be performed and reported. Board members eagerly await the results of this commitment to IT, improved patient care, meaningful use of EHRs and the prevention goals of Million Hearts.
The Million Hearts collaboration, with the strategic goals of the MedStar Health board of trustees and the enthusiastic support of the American College of Cardiology, is a wonderful example of what can be accomplished when health care institutions and professional organizations seek creative ways to improve the health of those entrusted to their care.
William Oetgen, M.D., M.B.A., F.A.C.C., F.A.C.P (firstname.lastname@example.org), is a member of MedStar Health's board of directors and is senior vice president of science and quality at the American College of Cardiology, Washington, D.C. Peter Basch, M.D., F.A.C.P. (peter.basch@Medstar.net), is medical director of ambulatory electronic health record and health IT policy for MedStar Health Inc., Columbia, Md.