“Mobilizing a Million Hearts” Through SMART on FHIR

Kevin Chaney; Kristen Miller and Allison Dennis | November 30, 2020

Estimating risks and weighing the benefits of health interventions is a challenge for patients and their providers. Patients may wonder if they should be thinking twice before having that second portion of desert. Doctors may consider recommending a daily aspirin. Both may know that smoking poses a higher risk, but by how much? While the medical differences between these choices and factors may be nuanced, there are many different software systems, apps, and online platforms that can help providers deliver better care for patients to understand and improve their health. Employing these tools at the right time and setting by integrating them into clinical workflows and leveraging patient data in real time is critical for their impact. With this challenge in mind, MedStar Health Research Institute has been designing risk calculators that fit seamlessly into a physician’s workflow. Now publically available, and built with interoperability in mind, one of these risk calculators, The Mobilizing a Million Hearts app, is ready to be used by other providers and health care systems.

Enhancing Health IT to Improve Clinical Workflow and Patient Care

In 2018, MedStar Health Research Institute (MHRI) received a two-year award under the ONC Leading Edge Acceleration Project (LEAP) in Health Information Technology (IT) funding opportunity to advance clinical knowledge at the point of care. The MHRI project team proposed to transform an isolated risk calculator into an open standards-based application that seamlessly and securely run across health IT platforms and provider organizations to optimize clinical workflow, improve care coordination, and support patient engagement.  Specifically, they set out to create a Substitutable Medical Applications and Reusable Technologies on Fast Healthcare Interoperability Resources (SMART on FHIR) app called “Mobilizing a Million Hearts,” which integrates the Million Hearts Longitudinal Atherosclerotic Cardiovascular Disease (ASCVD) risk calculator into the MedStar Health electronic health record (EHR) system.

The American College of Cardiology’s (ACC) Million Hearts Longitudinal ASCVD risk estimator is a validated tool that calculates a person’s 10-year risk for ASCVD. The risk calculator uses various measurements and criteria, such as blood pressure, cholesterol, and history of smoking. While this risk estimator is very useful, providers need to go to the ACC website to access the calculator and manually enter a patient’s vitals and medical history. The manual process for providers to enter patient data from their EHR system to the ACC website takes more time and increases the risk for error, which can discourage providers from using this tool. Providers may also have a hard time deciding which patients to assess using the risk calculator, particularly those who may seem at lower risk for ASCVD.

To better harness the power of ASCVD risk calculator, the MedStar Health team set out to streamline how clinicians use the tool and communicate its findings with their patients with an EHR integrated app. The Mobilizing a Million Hearts app has two components: the risk calculator (clinicians-facing) and the risk educator (both patient and clinician-facing). The risk estimator is the validated tool from the ACC, now integrated into the EHR system to automatically input a patient’s vitals and medical history into the calculator. These features allow the app to be easily integrated into the clinical workflow to help providers quickly assess their patients, without disruptive alerts or the distraction of visiting website. The app also features an interactive risk educator, which presents the results on a clear, colorful display to help patients understand how various factors contribute to their overall risk for ASCVD. By clicking certain buttons or adjusting a dial one way or the other, such as those indicating cholesterol level or smoking history, doctors can use the risk educator to help patients visualize how taking a medication or making a lifestyle modification could lower their risk for ASCVD.

Providers can also benefit from changing the values for different risk factors to find which has the greatest impact on a patient’s ASCVD risk. Some reported using the app to help with clinical decision making, such as whether to put the patient on a statin. The interactive app allows providers to target a specific modifiable risk factor and customize a patient’s treatment plan.

The Current and Potential Impact of Mobilizing a Million Hearts

The Mobilizing a Million Hearts app was initially launched to 600 users in the cardiology and primary care departments within the MedStar Health system, which includes 10 hospitals and more than 300 outpatient clinical centers. Based on interest from other providers, the MHRI research team quickly launched the app in the family medicine and endocrinology departments. Medical residents also were included in the user base, demonstrating the app’s value as a training tool. In all more than 1,600 providers can currently access the app to better understand patient ASCVD risk. In the seven months since its launch, the calculator has been automatically deployed nearly 400,000 times, providing risk scores for almost 200,000 patients it determined to be in the target population.

Overall, this LEAP Health IT project is a proof of concept to test the app’s ability to improve clinical workflow and advance knowledge at the point-of-care; however, future efforts could focus on whether the app has an impact on patients’ health outcomes. The research team is also interested in using the app to assess a panel of patients and identify those who are at risk for ASCVD, but may not have the typical signs associated with increased risk for which providers look.

The MHRI project team hopes the app will be used by other providers and health care systems and has already received national and international interest in the tool. Because the app was built using SMART on FHIR technology and open standards it can be configured to work at any healthcare organization, regardless of which EHR system they use. ONC is excited to host the necessary source code and implementation guidance on our GitHub Page.

One goal of LEAP in Health IT is to advance the development and interoperability of health IT. The Mobilizing a Million Hearts app enhances a trusted tool for both providers and patients. As a result, providers can make informed decisions about their patients’ care and educate them about reducing their risk for ASCVD. This approach can be used to integrate other validated tools into clinical workflows and improve provider and patient experiences.

Learn more about other LEAP in Health IT projects at HealthIT.gov