Epic Integration: Enhancing Care for Heart Failure Patients

A UHN-created tool that supports Emergency Department (ED) physicians in deciding whether to admit or discharge a heart failure patient is now available in Epic, UHN’s electronic patient record system.

The Emergency Heart Failure Mortality Risk Grade (EHMRG) calculator estimates the risk of a heart failure patient dying within one week, and over the course 30 days, based on 13 key metrics calculated in the ED.

Based on the score, different courses of action are recommended depending on a patient’s risk
category.

The Epic integration at UHN is the first in Canada for this decision-support tool.

The EHMRG calculator, which was created by Dr. Douglas Lee, a cardiologist at UHN’s Peter Munk Cardiac Centre where he is Ted Rogers Chair in Heart Failure Outcomes, was validated in a clinical trial – “Comparison of Outcomes and Access to Care for Heart Failure (COACH)” – at 10 hospitals across Ontario. The results were in a study published in the New England Journal of Medicine in 2023.

“UHN Emergency Department clinicians enrolled patients into the COACH trial and contributed to the development and validation of the score,” says Dr. Sam Sabbah, Chief of Emergency Medicine at UHN.

“Fast forward, and it’s now becoming a best practice and is integrated into our workflow in Epic – let’s take a moment to celebrate that.”

The EMHRG calculator provides a low-risk, intermediate-risk, or high-risk score based on the patient’s presenting metrics at the ED, such as age, blood pressure, creatinine and potassium levels, and whether they arrived by ambulance.

Low-risk patients can be safely discharged from the hospital and given a follow-up appointment with a heart function clinic within two weeks. High-risk individuals should be admitted from the ED for immediate care and ongoing monitoring.

An intermediate-risk score prompts further consultations with hospital specialists to determine if the patient can be discharged with a follow-up appointment within a few days, or should be admitted for monitoring.

The EHMRG calculator’s benefits extend beyond individual patients, however.

It supports clinical decision-making with an objective and evidence-based score – generated automatically and quickly – to help ensure the safety of patients and efficiency of the workflow in a busy ED. This improves patient quality of life, ensures allocation of hospital resources to those in most critical need and reduces health care expenses.

“In the fast-paced environment of Emergency Departments, where decisions can mean the difference between life and death, the Emergency Heart Failure Mortality Risk Grade (EHMRG) score provides timely insights to help make the right decision,” says Dr. Lee, whose work on the project was funded by the Ted Rogers Centre for Heart Research and Institute for Clinical and Evaluative Sciences (ICES).

“Heart failure is complex, and objective measures like the EHMRG score can complement physician clinical judgment.”

Before receiving the greenlight for integration into Epic, the EHMRG calculator was first validated in the COACH trial.

The trial at 10 Ontario hospitals saw more than 5,000 patients who came into the ED with acute heart failure divided into two groups. One received usual care, and the other received a special hospital-based strategy using the EHMRG calculator to help physicians determine which patients were able to be safely discharged with follow-up.

The results showed that within 30 days of receiving treatment, the group using the EHMRG calculator had a lower rate of either dying from any cause or being hospitalized again for heart problems compared to the group that received usual care. Over 20 months, the difference in health outcomes between the two groups continued to be better for the EHMRG care group.

Specifically, only the patients in the EHMRG calculator group experienced a statistically significant reduction in death or repeat hospitalization for cardiovascular reasons compared to the control group.

The study concluded that for patients with acute heart failure, receiving care informed by their individual risk level determined with the EHMRG calculator score in tandem with rapid follow-up at a heart function clinic resulted in a lower risk of mortality or re-hospitalization.

It was this promising result that led the Epic and UHN teams to design an integrated care pathway for the ED that incorporated the EHMRG calculator score and integrated it into Epic at multiple UHN sites.

This is the latest tool from the Ted Rogers Centre for Heart Research to be integrated for wide-scale use across Ontario hospitals, showcasing the incredible impact of both the research and translational work being done by its scientists and clinicians.

“By integrating this calculator into the Epic system at UHN, we’re not just enhancing the decision-making process, we’re helping to transform the way heart failure is managed in the Emergency Department,” says Dr. Lee. “It’s a step forward in our mission to improve the quality of care for heart failure patients across the province.”