Implementation Tools
and Strategies

Carrie Swihart: Hi, we're live at Becker’s. It's a pleasure to be here on the Becker's podcast. My name is Carrie Swihart, and I lead the health IT strategy team at Amgen. Amgen is sponsoring this podcast, and I am joined by several physicians who I will let introduce themselves.

Gigi Dawood: Hi, I'm Gigi Dawood. I'm an endocrinologist in Madison, Wisconsin.

Lori Siegel: Hi, I'm Lori Siegel. I'm a rheumatologist at Illinois Bone and joint in Gurney, Illinois.

Stephanie Saucier: Good morning. I'm Stephanie Saucier. I'm a non-invasive cardiologist and a lipid specialist with Hartford Healthcare.

Ralph Riello: And I'm Ralph Riello, cardiology pharmacist at Yale School of Medicine.

Carrie Swihart: Thank you all for joining me today to talk about the benefits of electronic health record integration to help improve outcomes for patients, especially for pressing public health issues such as cardiovascular disease and osteoporosis. To help set the stage for our conversation, before diving into each of your projects, can you talk about the benefits of leveraging EHR integration capabilities to improve population health management? Ralph, I'll start with you.

Ralph Riello: Yeah, sure. Thanks, Carrie. So, I mean, I view the EHR as one of the ultimate great equalizers among healthcare systems, where the ability to share evidence based practices via order sets or alert providers attention to particular evidence based treatment strategies with clinical decision support, best practice advisories, really helping to organize care consistent with guidelines, and being able to share that technology scale that across your own system, beyond your community, with other sites as well, really makes for improving population health a little bit easier challenge to take on.

Stephanie Saucier: You know, Ralph, that I think is a great point. And something else I always like to touch base on when we're talking about EHR is that EHR is one of the only things that touches every patient. Right. It's a way that we can look at every single patient because they touch EHR. And so scaling that and utilizing that, it's a huge resource for our teams.

Lori Siegel: I think often, that's a really good point. And I think often patients are overwhelmed when they're trying to think of all the things they need to do. So sometimes they need a very easy reminder to address all the different areas, especially osteoporosis. I work with a bunch of orthopedic surgeons, and they might not be thinking about screening for bone health. And by having the EHR formatted in a certain way, they are ultimately reminded what to do.

Gigi Dawood: Such a great point. I think technology and medical advances are occurring at such a warp speed. So it's hard for clinicians to keep up. One of the things I really love about the EHR is its ability to access patient data in real time, and that helps us facilitate some of those time sensitive decisions and just as quickly intervene. I think we saw some of that during COVID where the healthcare system needed to identify and address the health trends and then just be able to quickly pivot as things changed.

Carrie Swihart: Thank you, Dr. Dawood. We'll go to our next question of how are you leveraging EHR capabilities at your respective organizations? What public health challenge are you addressing with your project? And we'll start with you, Lori.

Lori Siegel: So our public health challenge, as I mentioned, thank you, Carrie, is making awareness of osteoporosis, and we see a ton of fractures in our practice, or the orthopedic surgeons do. And so when someone has a fracture, they're at high risk for having another fracture. So these people need to be screened to prevent the secondary fracture, and it's really important. So that's our goal, is to just make awareness of osteoporosis, getting these patients streamlined into our healthcare, into our bone health team, getting them screened for osteoporosis, and preventing that secondary fracture.

Carrie Swihart: Thank you. Gigi?

Gigi Dawood: I love that. On the same vein, I think our healthcare systems are operating on such a razor thin margin. So I think registries really serve as a cornerstone in leveraging the capabilities of the EHR. It's a structured framework so that we can take and organize patient data. At Northwestern, our project was aiming to quantify the extent of gaps in post fracture care. Despite some really effective treatments, we're still failing in secondary prevention. So our goal was to raise concerns and identify who was slipping through those gaps with a registry.

Carrie Swihart: Great. Thank you. Ralph, we'll pass it to you.

Ralph Riello: Sure. Thanks, Carrie. In my particular system, I mean, we know cardiovascular disease is number one killer globally. However, rapid lowering therapy, which we know evidence based guideline recommended for decades, unfortunately remains woefully underutilized in that patient population, even across my own healthcare system. Among very high risk secondary prevention atherosclerotic cardiovascular disease patients, roughly only half are on a statin, and only about a quarter are on the appropriate high intensity statin. And that leaves a lot of room for quality improvement initiatives. So we designed the PROMPT-Lipid trial to develop clinical student support made by clinicians or clinicians to alert them to these patients, otherwise low hanging fruit who need optimization of their lipid lowering therapy, with the ultimate goal, scaling that across the system to really make a dense in hard cardiovascular outcomes by promoting guideline concordant lipid lowering therapy.

Stephanie Saucier: And Ralph, I have to thank you, because the project that we did here at Hartford Healthcare really was an ode to PROMPT-Lipid. And we took a lot of that feedback from you as a general cardiologist and as a practicing clinician and lipid specialist. You know, we saw those same gaps and we really wanted to identify the patients who we could help better. And we wanted to utilize a BPA that lives within the patient's chart in order to empower the primary care physicians. So our BPAs, we actually made three of them, will identify the appropriate patients that need additional lipid optimization. And not only that, but all of the orders are right within that BPA. The physicians don't need to go outside of it. And it takes away some of that guessing, it takes away some of those, “Hey, I don't know what to do next.” We also even sent within it a consult for our lipid management program just in case the primary care physician needed a little extra help. And so again, you know, really just trying to make strides towards improving cardiovascular health and hopefully preventing disease and recurrent disease.

Carrie Swihart: Thank you, Stephanie. All great points, great projects. To wrap us up. I'd like for each of you to give us your biggest piece of advice for health system practices that are looking to leverage their EHRs to address these care pathways and maybe what really made yours successful.

Lori Siegel: I guess I'll start. Thank you, Carrie. I think the biggest piece of advice is persistence. Don't give up. Don't take no as an answer because it's really a computer system and we can fight that computer system and we can make it easy for the clinicians. So I don't take no as an answer and you shouldn't either.

Gigi Dawood: Thank you, Lori. I absolutely agree. I think we need to surround ourselves by people who are passionate about the same issue and are willing to persevere. Definitely. And I also think we should make friends with the EHR analysts. They are truly magical and we need a lot more of them.

Ralph Riello: Great points. Couldn't agree more. If I had to give one piece of advice, it's to those folks who may have 1 foot on the dock and 1 foot on the boat and acknowledge the health IT AI landscape and healthcare is setting sail soon. Get on that boat now. Reach out to your other healthcare systems, your friends, your colleagues. You're not in this journey alone. And often you don't have to reinvent the wheel as long as you make good friends with those IT analysts. Be able to share that technology and really start from hit the ground running. It's time to start was yesterday.

Stephanie Saucier: All of these points are so empowering. And I think my favorite point would be, you know, if you have this great idea as a clinician, as a pharmacist, as anyone in the healthcare system, I want to make sure that, you know, that you're empowered to make these changes, get in touch with the right people. And if you don't know what you're doing, that's okay. Ask for help. Because, you know, as Ralph mentioned, we are all in this together. We're in this to make patients lives better. And ultimately, at the end of the day, that's what we need to do. And learning in your system, you know, who are some of those key players? Who are your informatics? Who are the people that you need to have that buy in, right? So that when we get told no the first time, we can go back a little bit stronger and not let these things deter us. So fantastic points all around.

Carrie Swihart: Thank you very much. I'd like to thank our panelists for joining us today to talk about how we can really utilize the EHR to optimize patient care and treat our patients the best that we can. Thank you. Live here from Becker’s.

Becker’s Representative: We want to thank our podcast sponsor, Amgen. The projects discussed may have been in full or in part financially supported by Amgen.

Becker’s Representative: Hello everyone. Welcome to the Becker’s Healthcare podcast. Today's episode explores the importance of implementation science and how Amgen is working with others in the healthcare system to highlight the importance of implementation science to test and scale population-level interventions. This episode is sponsored by Amgen. So with that, I'd like to turn the floor over to Christen, who will be moderating this conversation. Thank you so much. Christen, take it away.

Christen Buseman: Thanks so much and hello everyone. It's a pleasure to be back on the Becker’s podcast. My name is Christen Buseman and I lead our health system solutions strategy and marketing team at Amgen, where we focus on identifying care gaps for patient populations and working with health systems to identify opportunities to fill those care gaps and improve population health management. I'm delighted to be joined by my colleague from Amgen, Bethany Kalich, as well as Dr. Francoise Marvel from Johns Hopkins, to talk about the role that implementation science can play in improving population health. I'll turn it over to my colleagues for brief introductions before we jump into the conversation. Bethany, would you like to go first?

Bethany Kalich: Certainly. Hello everyone. I'm Bethany Kalich. I'm the US medical lead for cardiovascular at Amgen. In my current role, I lead our late-stage evidence generation activities, our evidence communication strategy, and our evidence implementation efforts. Prior to joining Amgen, I was a cardiology clinical pharmacist and professor at UT Health, San Antonio and UIW School of Pharmacy. Francoise?

Francoise Marvel: Thanks, Bethany, thanks, Christen. my name is Francoise Marvel. I'm a cardiologist and advanced lipid specialist at Johns Hopkins Hospital. I'm director of education and scholarship for the Ciccarone Center for Prevention of Cardiovascular Disease at Johns Hopkins, and I also co-direct our Johns Hopkins Digital Health Lab. Thanks for inviting me for this podcast.

Christen Buseman: Absolutely. And thank you both again for joining me today on this important conversation around the value of using implementation science to help improve cardiovascular care processes and outcomes for patients. So to set the stage, cardiovascular disease is a leading public health issue in the United States. So I'm going to turn this question to Bethany first. Can you describe some of the key challenges we face in fighting cardiovascular disease today?

Bethany Kalich: Thanks, Christen. As you mentioned, it is a leading public healthcare crisis in the United States and globally. Among U.S. adults, LDL is a key modifiable risk factor for ASCVD, or atherosclerotic cardiovascular disease. So lowering LDL levels is important. We know that lowering those levels is associated with lower rates of major coronary events in patients with ASCVD. But what we continue to see in real world evidence is that the trends in lipid lowering therapy use is underutilized. From a system wide perspective as well, the total cost of cardiovascular disease in the United States are expected to reach 1.1 trillion per year by 2035. And so it's necessary to be able to identify mechanisms to improve the intensification of lipid lowering therapy in patients who are at highest risk, in whom that LDL level remains above the recommended levels. I'd love to hear directly from Francoise from a clinical perspective on these challenges and gaps in care.

Francoise Marvel: Thank you, Bethany. I think you really outlined the importance of achieving these guideline thresholds for LDL-C control. We find that in order to improve population health, it's particularly important for high risk and very high risk ASCVD patient populations. For example, those who've had coronary artery bypass grafting, those who have had a heart attack and have other comorbidities or health conditions like diabetes, hypertension, high cholesterol, and others. It's really important to time the intervention of lowering LDL as early as we can clinically. That makes a lot of sense, because ultimately, what we're trying to do is lower the LDL cholesterol, which is the bad cholesterol that can build up in arteries and cause ASCVD events like a heart attack. And by intervening earlier, we can help prevent those events from occurring or reoccurring in some of our highest risk ASCVD patient populations. A lot of times, that's going to require not just using one medication, but like in many of our cardiovascular health conditions, we need to utilize a combination of lipid lowering therapies, including non-statin therapies, when recommended, to reach LDL cholesterol goals. You know, Bethany, this is really missed opportunities. In fact, I was just on clinical service taking care of these kinds of patients with atherosclerotic cardiovascular disease and heart attacks. And a lot of times, although we can diagnose heart attacks, preventing them, treating atherosclerotic disease really is a missed opportunity that I think we could improve on by finding ways to improve our LDL cholesterol testing through getting regular lipid panels and through utilizing non statin lipid learning therapies more frequently. In addition, some of our patients have genetic dyslipidemias, or they inherited higher levels of cholesterol than people who didn't have those genes. And ultimately, they're at higher risk for having atherosclerotic disease events. So these are another specific population that we could absolutely intervene earlier and do better with. And when you start to think about the newest science, the latest imaging and data that we can use to personalize and manage atherosclerotic vascular disease patients’ risk and intervene early. We have so many tools, for example, coronary artery calcium scoring or coronary CT angiogram, that allows us to identify that risk and start to aggressively lower their LDL cholesterol. And I think, Bethany, what's exciting about the state of the science is that we know that guidelines have a specific goal for LDL-C of less than 70 for ASCVD patients who are at higher risk for an atherosclerotic event. However, more recent data has supported that the lower that LDL-C can be—in fact, the 2022 Expert American College of Cardiology Consensus decision pathway recommends that for patients who have are considered to be very high risk, again, having had ASCVD events and comorbidities that place them at higher risk for having an ASCVD event, we need to go lower, and lower the better. So really aiming and targeting an LDL-C of less than 55 is where we focus in on our latest expert consensus decision pathway for utilization of non-statins to reach those goals. So I think although there are many care gaps and challenges, there are also many opportunities to improve our LDL-C management through optimizing non-statin combination therapy for lowering LDL-C and targeting a lower LDL-C earlier to help really promote health and prevent ASCVD events.

Christen Buseman: Thanks so much to both of you for all that background. It's clear that there's a lot of challenges and care gaps in this patient population. And Francoise, I completely agree with you. It sounds like there's a lot of opportunity here and a lot of tools at our disposal to address those care gaps. Now, let's turn our attention to the role that implementation science can play in helping to bridge the gap between the clinical evidence and putting that evidence into clinical practice. Bethany, do you want to give us a little bit of background on implementation science and how it can help bridge that gap?

Bethany Kalich: Certainly. I think as Francoise has already illuminated so well for us, there's a wealth of clinical research and data out there demonstrating the benefit of lowering LDL-C. Yet, as has been discussed already, we see that those levels remain high. So there's an opportunity to understand, how do we improve the uptake of clinical trial data from research into clinical practice. And so that's where the science of implementation comes into play, because it's the scientific study of methods and strategies that can help ease the uptake of that evidence-based care into practice by regular use by practitioners and policymakers. Put simply, implementation science just wants to take what we know and study how to make it into something that we do in clinical practice. And so with the potential to improve processes and outcomes in the cardiometabolic space by helping facilitate efficient adaption and adoption of evidence based tools and methodologies, we want to understand how to improve that relationship from the data into clinical practice for the system, the HCP, and the patient. And there already have been many studies that have been conducted and demonstrated tools and methods that can support this, such as EHR tools or advanced practice provider care navigators. And as more tools and methods continue to be studied and proven to be useful, the question is, how can we then translate these more broadly? I'd love to hear Francoise's perspectives on this as well.

Francoise Marvel: Thank you, Bethany, for that very eloquent and powerful description of what implementation science is. I think you encapsulate it perfectly by saying, take something that we know and make it something that we do. Ultimately, this very much appeals to clinicians, frontline cardiologists, nurses, advanced practice providers, people who care for patients. We understand that there is a significant gap in care when it comes to modifying and reducing cardiovascular risk through improving our LDL-C testing and improving our LDL-C intensification of therapy, initiation of therapy, and ongoing management to reach the goals that have been set forth through the science that has proven that if we lower LDL-C, the lower we can go. And so I think to highlight what you're mentioning here, Bethany, this is action-oriented science, which very much appeals to the clinical side of those of us on the front lines, taking care of our patients every day, and ultimately relies on opportunities, whether it be innovations or evidence-based practices, and implementing it in a scalable way, so that we're taking this really from the bench to the bedside, and we're taking it from institutions across the country and world. And I think that's the power of implementation science, that this is really driving the outcomes and the performance that we need.

Christen Buseman: Thanks so much to you both. It's really exciting and inspiring to hear about the opportunities that implementation science offer in this space. So, to that end, Amgen and its partners established the LATTICE Consortium last year to help raise awareness on what's being done in the implementation science space to address those clinical care gaps and unmet patient needs for cardiometabolic care. Now, I know you've both played an important role in establishing this consortium, so can you share a little bit more about the genesis of the LATTICE Consortium and how it helps to address some of these challenges for this patient population? Bethany, I'll turn it to you first.

Bethany Kalich: Certainly. So, LATTICE is an abbreviation for Leading Awareness To action Through Implementation of Cardiometabolic Efforts. And we call it the LATTICE Consortium for short. It was established in April of 2023 as a coalition of independent stakeholders with a shared goal to address cardiometabolic patient care through these evidence-based tools and methodologies. To date, the LATTICE Consortium efforts represent over 50 health systems, and the current projects led by the consortium reach over 4 million patients. LATTICE aims to share these evidence-based tools and methodologies that can then be broadly adopted or adapted, and then adopted and integrated to improve the quality of cardiometabolic care across health systems. LATTICE efforts to share and scale implementation with health system support to achieve the ambition to reduce cardiovascular events, and so Amgen has set out with a bold ambition by 2030 to reduce cardiovascular events by half. And to do this, we've set four milestone goals by 2025. The first is to increase the LDL testing rate. We know that, as already mentioned, the LDL testing rate remains low, and so we are hopeful that efforts are able to help increase this from the current average of 27% of patients hospitalized for their first MI having a lipid test within 90 days to we would like to be able to increase that to at least 50%. The second goal is to double the number of patients on target for their LDL. As Francoise already mentioned, we just simply are not seeing the achievement of those guideline-recommended goals of less than 70 or even less than 55. And so we'd like to see what is currently the average of about 25% of the population achieving those levels to more than 50% of the population achieving those levels. We also recognize the importance of quality metrics, both from a national level, but also from an institution level. And so we are excited to be able to support initiatives that help bring quality measures into the front of view for health systems, as well as consideration from a national perspective. And finally, we are committed to help improve patient access to advanced therapies and diagnostics. And so, taken together, those being our four milestone goals by 2025, we're hopeful that we can start to bend the curve in a more favorable direction for cardiovascular disease by 2030.

Christen Buseman: Excellent. Thanks so much for that overview, Bethany, and I was struck by how you mentioned that our current LATTICE Consortium projects in the implementation science space are reaching over 4 million patients. Can you tell us a little bit about those implementation science projects and how they are playing out at health systems to test and scale population level interventions?

Bethany Kalich: Certainly. At a high level, we have categorized these interventions based off of their methods for deployment. So whether that be educational tools for HCPs or patients, whether that be care navigators, whether that be performance dashboards that help clinicians understand where a patient is today versus where they were in the past, or where they would like to get them to in the future. And all of these tools and methodologies that have either been demonstrated in the past or currently in progress are available on the latticeconsortium.com website, and we continue to evaluate strategies that may be added there. I would love to get Francoise’s perspective from a clinician's point of view on a few of these projects that she specifically is involved in and how she's seeing the impact of those in their early phases in her own clinical practice.

Francoise Marvel: Thank you, Bethany and I just want to applaud Amgen and your leadership in bringing together the LATTICE Consortium as really, I think, a historical advancement in taking people who have both, I would say, a perspective in research, science, innovation, preventive cardiology and many different facets within cardiology from potentially siloed projects, innovation and advancement, and synergizing them together through this consortium with a commonality and foundation of actionable goals towards improving LDL testing, making sure that our patients are reaching those LDL-C target guidelines and expert consensus decision pathways that will help to reduce ASCVD events, and making sure that we follow up with quality metrics and improving patient access and equity. I just want to first say thank you for this incredible, really, really impactful consortium and opportunity for us to collaborate as cardiologists, as healthcare providers, as innovators to make a difference and improve these care gaps and improve population health. So I want to thank you for that. And let's go and take a deeper dive into these specific LATTICE projects that will show you how action is being taken to really achieve these goals and milestones that we've set forth to achieve in the coming years. So first is cvMOBIUS2, and what's really fascinating and interesting about this project is it's so critical to set an understanding of where we are today with tracking lipid lowering therapy utilization and LDL-C levels across the country. So I think what's really powerful about this project is they're looking over 25 health systems over five years, and it's so powerful to have this level of longitudinal data that will allow us to gain actionable insights from utilization trends and potentially sites that are doing incredible getting those LDL-C levels down and learning from them. But on the other side of that, learning from care gaps and being able to really synthesize and learn what we can do better from that level of very broad and longitudinal and in-depth health system data around LDL-C levels and lipid lowering therapy utilization. So that's a phenomenal project and that's one way we're going to gain very important insights that will have clinical impact. Now, I am proud to be a PI for LOGAN-CV, which really is a multifaceted site-level intervention that combines both innovative technology with a performance platform and high-level education from preeminent lipid specialists and cardiologists to really engage clinicians who are caring for patients and having a point of care opportunity to improve LDL-C management. And we hope to see that that happens for these very high risk ASCVD patients with optimizing their access to education performance platform and also peer-to-peer opportunities to really get a sense of how other people are managing their LDL -C. So excited to be part of this multi-site study that's engaged with performance platform and education to really enhance clinicians’ adherence to guidelines and expert consensus pathways to improve LDL-C levels for patients with very high risk ASCVD. The third project I want to highlight is called PROMPT-LIPID and this is harnessing the power of our electronic health records, messaging, and alerts. And so this is an implementation of a real-time, tailored, targeted EHR alert that increases lipid lowering therapy prescribing rates and also in intensification of lipid lowering therapy at the point of care. So many of us here maybe listening to this podcast right now have a lot of familiarity with working in tandem with our EHR as we're seeing patients in our clinic or in the inpatient setting. And those messages can be very powerful at engaging us in clinical decision making and support. And so what PROMPT-LIPID has already shown is that there is a chance for these to be tailored to lipid lowering intensification therapy and prescribing rates and really improve our performance there. I had the pleasure of publishing an editorial on PROMPT-LIPID just last week. Feel free, that's hot off the press, to check that out and explore more about PROMPT-LIPID. But Bethany, these projects are the beginning of what is going to be a portfolio of impactful LATTICE projects that are aimed to target those four key milestones you mentioned before, increasing our LDL-C testing rate, increasing the amount of patients who are on guideline, and our expert consensus pathway LDL-C targets to show that we're improving quality and show that we're providing greater access to advanced therapies and diagnostics for our patients and communities.

Christen Buseman: Wow. Thanks for that overview. And it's truly exciting, the amount of work that's being done in this space to address these care gaps and to really identify interventions that work. And I know that the ultimate goal here is not only to test these interventions, but also to scale them. So to that end, what does LATTICE have planned for the rest of the year, right? So where can our listeners go to learn more about LATTICE, to learn more about these projects, and to learn more about how they can be considering implementing some of these types of interventions to improve population health management for their patient populations? Bethany?

Bethany Kalich: Thanks, Christen. As Francoise mentioned, 2023 was just a very exciting year for us. We are very appreciative of her very kind sentiments regarding the pulling together of the lattice consortium and are just thrilled to see the enthusiasm from the researchers, the clinicians, the implementation science experts. And so with what we focused on in 2023 being the establishment of the structure of the LATTICE Consortium and the website, in 2024, we're now focused on the scaling of these tools across health systems and strategically partnering with national health agencies and these efforts. And so, as I previously mentioned, these tools and resources can be found at latticeconsortium.com. And the purpose of this is that we see the enthusiasm across the United States from many clinicians who submit proposals each year to investigate ways to improve care for patients by developing these projects that translate clinical trial data into practice. And we are seeing potential synergy in these efforts. And so we created an opportunity for these like-minded individuals to have a place to go where they could work together and find these resources. And so where best practices already exist, we want to make it possible to share those nationally. On the website, people can find references and publications to some of these methodologies, as well as best practice papers. In future updates, we're also looking forward to adding new tools for systems to just download and apply within their own organization through the EHR. There are also going to be very shortly educational presentations, webinars and podcasts posted to the latticeconsortium.com website, as well as opportunities to learn more about live events that are coming up soon, to sit down in an ask-the-expert type style. Where tools may not exist yet and a new idea is proposed, we do also want to bring those HCPs together to work collaboratively, and so they will also notice that there are contact information for projects that are already in progress where they can recontact for that project. And the LATTICE Consortium is always looking for opportunities to collaborate across institutions in the United States. I'd love to hand it over to Francoise for any of her final thoughts on what she's looking forward to in the future for lattice consortium.

Francoise Marvel: Thank you Bethany. It's just incredibly exciting. I think this is the first time that these types of thought leaders, influencers, cardiologists, healthcare leaders have all been in the same room trying to solve a very important problem that is fixable. And I just again have to say that the vision of bringing us all into the same arena to solve problems together, to address challenges as a team, to bring diversity of thought, and to focus on action, is a profound advancement in improving population health and addressing care gaps. And this, as I mentioned, is just the beginning. And I'm really excited to be a part of the LATTICE Consortium to work with Amgen and collaborators and really improve the health of our community and our world. Thank you. One-take home point for clinicians, cardiologists, innovators, those who are interested in improving the health care of our of our world. It's so important to be a part of this LATTICE Consortium, and there's many different ways that you can do that, through exploring implementation science opportunities to reaching out with your own ideas and proposals, or connecting with the consortium team members and share your ideas. Please be sure to visit latticeconsortium.com and keep in touch. Stay in touch and be sure to follow us in terms of our podcasts and what we're posting so that you can really be part of this important change that's happening for cardiovascular health. Thank you.

Christen Buseman: Thank you both, guys, for this insightful discussion. I think that I certainly walk away from this conversation encouraged and excited for all of the opportunity that lays ahead. And I am certain that our listeners as well will be encouraged and excited about the opportunity that lays ahead and really seeing how implementation science can drive improvement in population health management by really sharing interventions that work to address care gaps. So this episode marks the exciting beginning of a series of discussions that Amgen will be hosting on the Becker’s podcast, where we will continue to delve into this important work. We're certainly excited to share these efforts and to really help figure out how we can scale, and to Francoise's point, work together in new and different ways to drive to action. So stay tuned for our next episode, and be sure to visit latticeconsortium.com to learn more about the LATTICE Consortium and implementation science efforts in the cardiometabolic arena. Thank you again. And with that, I'll turn it back over to Becker’s to close us out.

Becker’s Representative: Thank you, Christen, Francoise, and Bethany for your time and that thought-provoking conversation. Truly appreciate it. We also want to thank our podcast sponsor, Amgen. Dr. Marvel has been compensated for her participation. The projects discussed may have been in full or in part financially supported by Amgen. You can tune to more podcasts from Becker’s Healthcare by visiting the Podcast Page at beckershospitalreview.com/podcasts.

Mariah Muhammad (00:05):

Hello everyone. Thank you for tuning in to the Becker's Healthcare podcast series. My name is Mariah Mohammed, writer at Becker's Healthcare, and today we'll be discussing how alerts in the E H R system may help bridge the 17 year gap between publication of evidence-based guidelines in consistent implementation and practice by healthcare providers. We are thrilled to be joined by Dr. Ralph Riello and Dr. Nihar Desai. Before we get started, Dr. Riello and Dr. Desai, can you please share a bit more about yourself, starting with you, Dr. Riello?

Ralph Riello (00:38):

Certainly. Yeah. So my name is Ralph Riello. I'm a clinical pharmacy specialist that's been working with Yale Health System for over a decade. And, and tr transitioned a few years ago over to the School of Medicine to partner with some wonderful cardiologists like Nihar on, on some exciting trials like Prompt Lipid.

Mariah Muhammad (00:55):

Perfect. Thank you very much. And then Dr. Desai?

Nihar Desai (00:59):

Sure. Nihar Desai. I'm a cardiologist here at the Yale School of Medicine and Vice Chief of Cardiology here. And also very interested in implementation science and doing pragmatic clinical trials, which we're really excited to talk about today.

Mariah Muhammad (01:13):

Yeah, absolutely. Thank you again so much for joining us today to the both of you and Dr. Desai. If I could ask you the first question for those tuning in who may have not seen the featured presentation at the American Heart Association Conference, can you please explain the objective of the Prompt Lipid trial and summarize the key findings for us?

Nihar Desai (01:34):

Sure, I’m delighted too. So, Prompt Lipid was really designed to evaluate whether automated electronic alerts with guideline-based recommendations could help to improve the management of hyperlipidemia among patients with established cardiovascular disease at very high risk for cardiovascular events. And what we were very excited to see in this trial of about 100 providers and over 2000 patients is a significant increase in the use of evidence-based lipid lowering therapies. In fact, we saw that those providers who received this decision alert were about 40% more likely to intensify lipid lowering therapy. And then amongst the subset of providers who sort of more favorably interacted with the alert, we saw a more than two fold increase in the use of evidence-based lipid lowering therapies.

Mariah Muhammad (02:28):

Wonderful. Yeah. Thank you so much for that background information. Now, Dr. Riello, the Prompt lipid research team felt strongly that patients with very high risk atherosclerotic cardiovascular disease would make for a compelling population to test an innovative approach to quality improvement. Can you explain why that is?

Ralph Riello (02:50):

Yes, it certainly can Mariah, and that patients with atheros sclerosis cardiovascular D disease or ASCVD we know that their, their L ldl well L D L cholesterol LDLC has been a critical modifiable risk factor for their disease that, that we as providers can control. And in lipid lowering therapy, particularly intensive lipid lowering therapy for this high risk patient population, you know, it's been recommended by, by clinical practice guidelines for years. However, the evidence practice gap between what the guidelines say we should be doing and the therapies our patients actually receive in, in real world practice is vast. Only about half of patients with ASCVD are actually prescribed any statin whatsoever in the United States. And fewer than a quarter of these patients are, are even prescribed the appropriately recommended high intensity statin. So as it currently stands, sort of passive diffusion of these guidelines to, to our providers and to make sure that these therapies reach patients just really isn't enough. And, and clinical inertia really you know, prevents our providers from, from passing on these therapies to patients. So, so we were hoping that the C H R alert might do something to change that.

Mariah Muhammad (04:04):

Yes. Thank you for those insights. Dr. Riello, Dr. Desai of the many E H R alerts that fire every day for clinicians using the electronic health record system. Very few are ever subject to thorough evaluation after their deployed. What prompted your research team to go through the extra effort?

Nihar Desai (04:23):

Yeah, it's a great question, and I think as you heard from Ralph, that there was a real sense of urgency that our team felt that, you know, patients with high risk atherosclerotic cardiovascular disease really needed intensification of their lipid lowering therapy. We thought that an alert like this that was real time, that was targeted and tailored would be helpful to providers, but we were committed to actually testing it in a very rigorous way to actually define and determine whether an alert like this would actually do the things that we wanted it to do. And, and again, we were very pleased with the results of prompt lipid that really again showed the benefits of an alert like this to improve the quality of care for our patients with very high risk ASCVD.

Ralph Riello (05:07):

Yeah, and to, to dovetail off Nihar's point there as well, I think all too often when health systems look to implement alerts like these in the, in electronic health record very rarely are they ever actually, you know, formally studied in a, in a prospective fashion, let alone even a randomized controlled trial. And, and, you know, I think the consequence of that is, is, you know, contributes to alert fatigue. Many of these alerts, you know, as important as they may be, tend to get ignored. You know, for instance, we're, we're, we're in deep flu season right now. I can even tell you how many charts I've opened up just to get pinged with these alerts that, that I know most of our clinicians click through. So, so it's important to understand in a, in a well controlled setting how these alerts actually perform and, and, you know, do what they're intended to do.

Mariah Muhammad (05:48):

Absolutely. Yeah, I completely agree. And it seems that that ex that really did pay off, thankfully. If I could come back to you actually, Dr. Riello, the providers surveyed in both the Prompt HF and prompt lipid trials seem to view the alert quite favorably and often accepted the recommendations as suggested. What about your team's approach enabled that user finding what you say.

Ralph Riello (06:13):

<Laugh>? Yeah, Maria, that was a really good point. That might've been one of the most surprising things I think that we came away with. Some of the results from our, our various prompt studies for 'em and PROMPT lipid it's certainly notwithstanding I I think it has to do with our secret sauce and, and that's, that's engaging our, you know, highest volume cardiology stakeholders upfront in, in early in that process. You know, give them a seat at the table, listen to them you know, engage them, you know, recruit them for feedback. And, and we actually had a, a couple separate focus groups with, with, you know, the busiest you know, lipid lowering therapy prescribers to make sure, you know, these are the ones in the front lines of healthcare doing the work that, that we think is important and, and that we want to see more of.

(06:52):

So, you know, by asking them for their input on not just the build of the alert, but you know, when it should fire what the order set should look like, what labs should display we felt like, you know, their input was, was incredibly valuable to make sure we designed something that was user-friendly for the people who would actually use it and by the people that used it. Because sure, you know, Nihar and I have, you know, spent our careers caring for cardiovascular patients, but, but we want to ask what others think about that too, to make sure that, you know, it, it, it helps facilitate their clinical workflow rather than hinder it in any way.

Mariah Muhammad (07:25):

Yeah. Yeah, making sure everyone feels heard is definitely essential for these types of trials. And Dr. Desai, if I could ask you, alert fatigue is a pressing concern for many frontline clinicians and may have consequences for patient safety as well as contribute to provider pa burnout. How did the prompt lipid trial help address this barrier?

Nihar Desai (07:48):

Yeah, it's a great question and a great point and I'll, I'll build on much of what Ralph, you know, just started to discuss about the design of the alert. And so alert fatigue is a real concern. I think all of us, you know, practicing on the front lines are, are loath to get additional alerts, you know, especially those that interrupt or interfere you know, with, with direct clinical workflow. And I think one of the things that we did, you heard about from Ralph was we engaged frontline providers and said, Hey, what, what do you want to see? What should the alert look like? What time in your clinical encounter should it fire? I think the other thing that we did was very helpful was we brought and pulled information from the medical record that might otherwise take 2, 3, 4 other clicks and actually brought that into the alert.

(08:34):

And I think the final piece of it is that we made the alert pretty easy to interact with that if you wanted to do the right thing, if you wanted to open the order set, that the orders were actually embedded within the alert itself. And so that, that step from interacting with the alert to then doing the right thing was about as simple and straightforward as could be. And so I think, you know, many of the in secret ingredients as, as Ralph calls them <Laugh>, you know, kind of, you know, get, getting the engagement of, of clinicians upfront really thinking deep about, you know, what the alert itself looks like, pulling information into it and then embedding, ordering capability within the alert to really make it a very seamless experience. So that at least I hope, you know, gives you a sense of what we were trying to do to try and overcome that kind of intrinsic fear that everyone has about alert fatigue.

Ralph Riello (09:24):

Yeah. And, and I think another point to add on there, there near, at least to emphasize again cause I think it's so important, is that the, the alert only fires when the patient has, you know, low hanging fruit, you know, guideline recommended but not yet implemented change with their therapy. So you know, it, the alert's not going to suggest them to do something that would be duplicative or, you know, the patient's already on a statin. Why is this telling me to prescribe another one? It, it's really just a meaningful easy change at the point of care only when it's indicated for the patient.

Mariah Muhammad (09:56):

Yeah. Yeah. Thank you very much to, to both of you for that information. Dr. Riello, before I let you both go, I must ask now that the PROMPT lipid trial is completed, what are the next steps for your research team to further explore opportunities on these findings?

Ralph Riello (10:14):

Yeah, great question, right? We always need to look beyond sort of our own house to, to, to make sure that we can then extrapolate these findings to, to other systems as well. And, and I think the, the, the prompt research team, et cetera, definitely has some big plans for that. For, for one, this the prompt lipid trial was conducted exclusively at Yale New Haven Health System and the outpatient clinic's both cardiology and medicine. But we would certainly like to see, you know, how this, you know, study performs beyond our own, you know, neighborhood beyond our community and expand that to, to other interested sites. A additionally, the, the study only took place on an Epic as our E H R platform across Yale. But certainly wouldn't be nice if, if we could expand that to other E H R platforms as well. It's not sort of pigeonhole ourselves just to one particular, eh, h r platform and make it more interoperable for other sites that that may be using different ones. And, you know, expand it to, to other clinical settings, you know, maybe focus on primary care or endocrine ob. We know a lot of these patients you know, may also frequently see providers as well.

Nihar Desai (11:15):

Yeah. And I, I might just add, you know, I think there's a lot of important work ahead and, and I think we're very excited to build on the results of prompt and prompt lipid to then, you know, think about what else can be done. I mean, I think Mariah, you very nicely kind of said right at the front of, you know, how do we bridge the gap between evidence and practice? How do we shorten that time from when things go into the guidelines and they're actually received by patients? And so I think there's a lot of work to do and we're really excited to build on, you know, the exciting results for prompt lipid.

Mariah Muhammad (11:46):

Absolutely. And I'm also excited to hear back on what you find. And I want to thank both of you, Dr. Riello and Dr. Desai for your time and thought provoking conversation today. We also want to thank our podcast sponsor Amgen. You can tune into more podcasts from Becker's Healthcare by visiting our podcast page at Becker's hospital review.com/podcast. Thank you both again.

Becker’s Representative: Hello everyone. This is Madeline Ashley with Becker's Healthcare Podcast. Today's episode dives into the process of establishing an electronic health record-based initiative and overcoming roadblocks to implementation within a large healthcare system. This episode was sponsored by Amgen. With that, I'll turn the floor over to Amgen's Laney Jones.

Laney Jones: Hello everyone. It's a pleasure to be here on Becker's podcast. My name is Laney Jones and I'm the Implementation Science Medical Director at Amgen, and I'm excited to be joined by Dr. Stephanie Saucier from Hartford Healthcare.

Stephanie Saucier: Hi everyone. My name is Dr. Stephanie Saucier. I'm a cardiologist, a lipid specialist, and the director of the Women's Heart and Wellness Program for Hartford Hospital.

Laney Jones: Thanks, Stephanie, for joining me today to have this important conversation about how implementation of electronic health record-based interventions in complex healthcare systems to bridge gaps in care among cardiovascular patients. First, for those who haven't listened to our previous podcast episode, I'd like to provide some background on implementation science as well as the LATTICE Consortium and its efforts to address cardiometabolic patient needs through implementation science.

Stephanie Saucier: Thanks so much, Laney. So implementation science is basically the scientific study of methods and strategies and tools that ease the uptake or use of evidence-based practice in research into regular use practice by both practitioners as well as the policymakers and leadership. Implementation science really has the potential to improve the processes and the outcomes in the cardiometabolic space by facilitating efficient adaptation and adoption of evidence-based tools across the healthcare systems. The way that we do this is by providing the opportunity to both improve the interrelationship between the system, the healthcare provider, and also the patient. As we often say, the electronic medical record is the only thing or person that sees all patients all of the time. Now, the LATTICE Consortium, LATTICE standing for “Leading Awareness To action Through Implementation of Cardiometabolic Efforts.” Amgen and its experts established the LATTICE Consortium last year to help raise awareness on what is being done to address unmet patient needs in cardiometabolic care. LATTICE experts represent 50 or more healthcare systems, and the current projects led by the consortium collectively reach over an estimated 5.2 million patients. So a really great reach into our community, both from our healthcare system standpoint and also from a patient standpoint. LATTICE shares evidence-based tools and methodologies that can be broadly adopted, adapted, and also integrated to improve the quality of cardiometabolic care to all of our patients.

Laney Jones: Great. Stephanie, thanks for that overview of implementation science and LATTICE. So the question comes, how are you involved with the LATTICE Consortium and how are you using these implementation science methods at your own healthcare system to test and scale population level interventions?

Stephanie Saucier: That is a fantastic question, and as a lipid specialist, it's something that's very passionate that I'm passionate about, is low density lipoprotein cholesterol or LDL-C is one of the most modifiable risk factors for atherosclerotic cardiovascular disease, and yet unfortunately, lipid-lowering therapy is underused among patients who it should be used in, so eligible patients. And unfortunately, there's this gap, right? Not only do we have clinical inertia, but we have this research to implementation gap. And so as a lipid specialist and a cardiologist, I found that there was a gap in our patient care. And so initially what I wanted to do is I wanted to empower PCPs to help patients achieve LDL-C levels that were fitting with the guidelines and really meeting best practice advisory in terms of our goals. And so my idea was to create a BPA, and I know sometimes we think that BPA is one of these evil words, just we worry about it. However, I think that this was the best way that we could utilize our EHR system to really identify three different groups of patients. The first were high risk patients who were not on appropriate lipid lowering therapy such as statins. The second were high risk patients who were on statin therapy or lipid lowering therapy but weren't at goal just yet. And the third were the high-risk patients that were unable to tolerate statins. And so what my initiative was to do is to really look at the patient's chart, and we talked with the primary care providers initially, and we said, okay, well, how can we make it so that it's not burdensome? How can we make it so that it's not something that's going to make more work for you without a good outcome? And so it took a lot of time and effort to really formulate this. And so the way that we created this BPA is not actually to pop up at all, but to live within the patient's chart. And that was to help with avoiding alert fatigue from the primary care providers. And what it does is it basically just lines up based on the guidelines, the lipid guidelines, what the next steps of care are, including options for other lipid lowering therapies, follow up blood work. And if patient providers were uncomfortable, there was even an area where they could just drop in a consult to our cholesterol management program so that if they recognized that a patient needed more help but weren't quite sure which option to choose, that they could easily send their patient to one of us lipid specialists and so that we could help. And so that was really the aim behind the best practice advisory.

Laney Jones: Great. Thanks for that overview. And I know it probably, you just explained it very succinctly what you did, but I'm sure it took a lot of effort navigating your healthcare system to put these projects into place. So where did you start and can you share us, I know you mentioned some of those roadblocks or burdensome aspects of it, but what did you encounter along the way?

Stephanie Saucier: Yeah, Laney, I wish I could say that it was easy, and I also wish I could say that it was still easy, but there's a lot of work that goes behind it. I am by training just a cardiologist, I'm a lipid specialist, I'm a doctor, I don't know IT. I don't know how these things work. And so for me, it really started at asking some questions, not knowing where to start. I utilized some questions about, Hey, what can the EHR help me with? How can we make this work? And there was other similar BPAs that have already been established, such as from the PROMPT-Lipid trial right down the road from me. And so I said, okay, well, this is what they've done. Then I talked with some key stakeholders. So I talked with my co-chair in the preventive world. I talked with our head of cardiology, and then we also talked with primary care and said, okay, what do you envision as making this something that's helpful? And initially we got the go ahead with some tweaks, like not having it be a popup, having it live within the chart, and also having that option of we don't know what to do, send them to the cholesterol management specialist. So we really implemented a lot of the information from the primary care team. And then so we got to work, and unfortunately with big healthcare systems, a lot of times IT has a laundry list of things that they're creating. And so we got in line, and it took quite a long time before we really started getting going in terms of the creation and behind the scenes, we were able to start picking out and really defining based on the guidelines, who these patients, what was going to fire and who they were going to fire for. And then unfortunately, we had another roadblock. There was new leadership change over from the primary care department and some new goals with all the time that had lapsed with us trying to create this initiative. Things have changed. And so then we kind of got put on hold and we said, okay, well, they're not ready for this to be live at the moment, so how can we go about still utilizing EHR to identify these patients and identify where we're having gaps in care and gaps in lipid management? Because again, this is one of those risk factors that is incredibly modifiable and it's incredibly easy to make a difference in of patient's long-term care. And so what we decided to do was to run the BPA on silent mode where it wouldn't be firing at the primary care providers, but it would still be firing in the background. This way, we're able to collect information about each primary care provider and we can say, Hey, if you are doing a great job, which we hope you are, then it's not going to fire for you or for your patients. But if it is, maybe we can guide you and give you evidence of which patients need a little bit extra help and support. And so that's where we are right now, and it's really trying to, we're running it in the background to hopefully gain that insight and then bring it back to the primary care providers again and say, okay, what do you think about implementing this in a more larger scale at this time? And so I think that that's something, those are some of the roadblocks that we've encountered and ways to work around it. And it's really been a team effort. I've had repeat meetings with leadership. It's important that we talk about the population health of both our healthcare system as well as the nation as a whole. Because again, if we're doing a great job, then these BPAs wouldn't be necessary, right? So that's where we kind of have taken this to really run with.

Laney Jones: Thanks for all those helpful insights. And I know our episode is coming to a close here. So what advice do you have for others that might be looking to implement initiatives in their own health systems?

Stephanie Saucier: I think that's always the best question is what advice do I have? Well, I think it's really important, and I hope that people have seen that it's really important, that we're able to measure the reach. How many patients are we reaching? How effective is what we're implementing, right? Because you don't want to implement something that's not effective. So making sure that you can measure the reach, the effectiveness, and how well people are utilizing it. So we're also able to track using EHR how often this is going to be utilized. And so I think that's really important. It's also really important for people who want to do this in their own healthcare system to understand the how and the why something works. And so understanding your own healthcare system's culture, who do you need to go to? Who are those key stakeholders? Those are important things. I think none of the roadblocks, both the good ones and the bad ones or the kind of deviations in the road along the way are bad. I think we can learn from every type of concern that comes out. I think it's really important that we're sharing experiences and solutions to these problems. These problems are not unique to one healthcare system. They're across the country, they're across providers, they're across patients. And so making sure that we're having conversations like the one that we're having right now where we can really talk about what solutions I used, what might help you, and I think that that's going to be helpful. Also, remember, we all have the same goal. Our ultimate goal is to provide a higher level of quality care to our patients. And last but not least, I always say never give up. So be creative, work together. Don't be discouraged if there is something that comes up, because again, at the end of the day, we're all in it to take really great care of patients. And I think using implementation technology is one of the ways that we're going to get there.

Laney Jones: Thanks for all those helpful tips and tricks. And I think the one thing that I would just add for all of those who are hoping to implement in the future too, is that even though all the learnings that Dr. Saucier talked about on this amazing podcast, there are always going to be adaptations and different ways that you might need to adopt it for your system. And there's not one solution that fits all. And you might have different stakeholders that are supporting your work versus what we talked about today, but none of those are wrong, and they all help to create this larger story and help to improve Cardiometabolic health. So we will wrap up this second episode of this podcast series of discussions. Amgen is hosting with Becker's or will divulge into important work of the LATTICE Consortium and its efforts to share and scale implementation science with healthcare systems across the country. If you missed our first episode with Dr. Francois Marvel of Johns Hopkins Hospital, be sure to check that out. And please stay tuned for our next episode. And be sure to visit lattice consortium.com to learn more in the meantime.

Becker’s Representative: Thank you Laney and Dr. Saucier for your time in that informative conversation. We also want to thank our podcast sponsor Amgen. Dr. Saucier has been compensated for her participation. The projects discussed may have been in full or part financially supported by Amgen. You can tune in to more podcasts for Becker's Healthcare by visiting the podcast page at Becker's hospital review.com/podcasts. This podcast was sponsored by Amgen. Participants are under contractual agreements with Amgen.

Becker’s Moderator: Welcome to Becker's Healthcare podcast. Today's episode dives into a real world look at the implementation of electronic health records within a large health system. This episode is sponsored by Amgen, and with that, I'll turn the floor over to Amgen’s Carrie Swihart.

Carrie Swihart: Hello, everyone. It's a pleasure to be here on Becker's Podcast. My name is Carrie Swihart, and I am the Associate Director of Health IT Strategy at Amgen. I'm excited to be joined by Dr. Nihar Desai from Yale School of Medicine and Dr. Alan Brown from Advocate Lutheran General Hospital. And I'll turn it over to you guys to introduce yourselves. Doctor Desai?

Nihar Desai: Great, thanks so much, Carrie and Alan, delighted to be with you. I'm Nihar Desai. I'm a cardiologist and vice chief of the section of cardiovascular medicine at the Yale School of Medicine in New Haven, Connecticut.

Alan Brown: Hi, and I'm Alan Brown. I am the director of the Lipid Clinics for Advocate Healthcare and clinical professor of medicine at Rosalind Franklin School of Medicine and Science in Chicago and a past president of the National Lipid Association.

Carrie Swihart: Thank you, Nihar and Alan, for joining me today to have this important conversation about how to implement EHR-based interventions in complex healthcare systems to bridge gaps in care among cardiovascular patients. We'll kick off the questions here. First, for those who haven't listened to our previous podcast episodes, I'd like to provide some background on implementation science, as well as the LATTICE Consortium and its efforts to address cardiometabolic patient needs through this approach. So let's kick it off by talking a little bit about what implementation science is. Dr. Desai, I'll turn it over to you first.

Nihar Desai: Yeah, Carrie, it's a great place to start. And I think when I think about what implementation science is, I really think about the science of processes and tactics and strategies and tools that help ensure and facilitate the adoption of evidence-based practice, standards of care, to the patients that we serve. And I think it's important to think that there actually is a science to that work. And so when we go from discovery science to development of novel therapies to testing those novel therapies, the final step in that process then, is ensuring that those evidence-based, guideline-based tools and recommendations and strategies actually make it to the patients that we serve. And that sort of final step of that puzzle, you know, really is where implementation science comes front and center.

Carrie Swihart: Thank you, Dr. Desai. Dr. Brown, thoughts?

Alan Brown: Well, I totally agree, as always with Dr. Desai. I think that we often look at gaps in clinical care between what we know and what we do. And the dilemma that we have is that we often make assumptions as to why we haven't implemented guidelines, for example, and those assumptions can be wrong. So the challenge of implementation science is to identify why those gaps occur, try to consider all the different steps that may be a breakdown in the process, and then put things in place to make sure that we move the needle towards better outcomes for our patients. And though that's an arduous process, and it takes a lot of thought, the rewards are terrific.

Carrie Swihart: Thank you both for your insight there. I'll pivot a little bit to cover what LATTICE is, and you may have heard from previous podcasts, but LATTICE stands for Leading Awareness To action Through Implementation of Cardiometabolic Efforts. And Amgen and the LATTICE experts established a LATTICE consortium last year to really raise awareness about what both Dr. Desai and Dr. Brown spoke about, efforts in the field of implementation science to address unmet patient needs within cardiometabolic care. The LATTICE experts do represent 50 health systems across the US, and the consortium projects collectively reach an estimated 5.2 million patients. And the goal of LATTICE is to share information and resources on evidence-based tools and methodologies that can be broadly adopted, adapted, and integrated into to improve the quality of cardiometabolic care. So, turning it back over to you, Nihar and Alan, would you be able to share some background with our listeners on your respective EHR initiatives? Dr. Desai, I will again start with you.

Nihar Desai: Sure, Carrie, happy to. So, our project was something that we refer to as the PROMPT-LIPID Intervention. I think the predicate for PROMPT-LIPID was a couple of, I think, very salient observations and points. First, that LDL cholesterol is one of the most important, if not the most important, modifiable risk factor for cardiovascular disease. Second, that despite our understanding of LDL cholesterol, there was this persistent kind of gap in the way that we were actually practicing the therapies that we were using for patients, the LDLs that we were achieving for them, and what those evidence-based documents would have advocated for us. And so, to kind of meet that gap, if you will, we sort of came to this understanding of, you know, what are all the different tools and what are all the different ways, what can be brought to bear to try and address this evidence-practice gap, and the most ubiquitous actor now in the healthcare system is the electronic health record. We've spent hundreds of millions of dollars adopting these electronic health record platforms in various different health systems, my own health system included. And for too long, I don't think we've leveraged them to actually drive quality, to drive value, to really make things better for the patients that we serve. And so our idea was based on all of that kind of backdrop to say, hey, can we develop a decision support tool embedded within the electronic health record that was real-time, targeted, tailored, individualized, and had embedded ordering capabilities? So, at the push of a single button, the provider could essentially follow the evidence-based recommendations that the guidelines, for example, have advocated for. And it turns out when we implemented that into the Yale New Haven health system, we saw about a 42% relative increase in the use of evidence-based lipid lowering therapies for our patients with high risk atherosclerotic cardiovascular disease. And it turned out, if you looked at the subset of providers that most favorably kind of interacted with that decision support tool, there was a more than twofold increase in the use of evidence-based lipid lowering therapies. And so we were very excited by these results. It was an important finding, I will admit it was a finding within one health system. And so the frontier for our work now is, how do we scale this to other places, to other EPIC-using electronic health record health systems? And can we do this not just within one system, but across many systems and many, many more patients?

Carrie Swihart: Thank you, Nihar. Dr. Brown, I will pivot over to you. I know we've talked about in the past, EHR being a tool, but also the process for implementing such an implementation. So I'll turn it over to you to discuss that further.

Alan Brown: Yeah. So, my experience with using EHR to change clinical practice goes back to the early 2000s. When I was participating with a private practice group of cardiologists. And at that time, the LDL goal for people with coronary disease was less than 100. So a little more liberal goal than we have today. But at any rate, our practice had 22% at goal, which was double the national average, but was still embarrassing. So we came up with an idea using our own homegrown electronic record to just flash an alert at all of our colleagues when a patient came in that told them, was the LDL on the chart, and were they on a statin? And amazingly, in the first year, in 20,000 consecutive coronary patients, we went from the 22% to goal to 60% at goal, just by reminding the physician through the electronic record while the patient was in front of them, hey, there's no LDL on the chart, or the patient is not on a statin. And they tended to choose the correct statin and the correct potency to be able to hit the goal at that time. We also have benefit from having a universal EMR now within our large healthcare system. Advocate Healthcare is now the fifth largest healthcare system, and we have EPIC in the entire practice across the United States, which is definitely a benefit, just as Nihar had described. But we recently did a look at patients who were admitted with acute coronary syndrome, at least at the twelve hospitals in Illinois, as part of our system. And the data was kind of shocking. So, of those admitted with acute cardiovascular event, 49% actually filled their high dose statin at the time of discharge. And at one year, only 36% were adherent to high dose statin. And in fact, over half of them were off their statin at one year, which kind of mirrors the national data. And it was kind of interesting that in this study, that patients who had a higher baseline LDL tended to have better adherence to the high dose statin. There were some ethnic differences in adherence, with Caucasians being a little bit more adherent than some other ethnic groups. And interestingly, younger patients were more likely to stay on their high dose statin than patients over 75 years old. All of these are interesting bits of data to show that, number one, we're nowhere near where we need to be for these highest risk patients with acute coronary syndrome. And number two, there are probably a lot of factors that affect why patients are not on their therapy. And rather than shoot from the hip, we have to have a good process to figure out how to close that gap.

Carrie Swihart: Thank you, Dr. Brown and Dr. Desai. To further elaborate on that process that you spoke about, Dr. Brown, I know that, again, the EHR is just a tool this study showed those gaps in care. But what do you think are important points that we need to look at when addressing the process within implementation effort?

Alan Brown: So, as you know, Carrie, I'm a big disciple of the four disciplines of execution, Covey's book. And what those four disciplines require are to define your wildly important goals. And I think for us, the goals are to make sure patients are on their treatment and also that their LDL thresholds are achieved. And then the bigger challenge is to define the lead metrics, which determine whether patients will be on their therapy and whether they'll achieve their goals. For example, was the prescription written at the time the patient was discharged with acute coronary syndrome? Did the patient fill the prescription? If they went off the prescription, why did they? Was it fear of side effects? Was it maybe some other physician who told them they didn't need it? We don't really know the answers to that. And then over time, why at one year was there not reinforcement to make sure that the patient was back on therapy? And I think as a group of experts, all of us in the Consortium would be able to give some insights on what all those lead metrics should be. Then once we have those lead metrics that will tell us whether we can achieve some improvement. We need to develop a dashboard and measure those things, and we'll have to choose appropriate teams for each of those metrics with the people who could actually make changes in those different metrics. And that'll be a challenge to identify who are the right people to be on the teams for each of those lead metrics. And then finally, what they call a cadence of responsibility, which is weekly get togethers for each of those teams to see whether we're moving the needle on each of those different items. I think if we're thoughtful as a group, we should be able to come up with the appropriate metrics and we should be able to identify the right people to move the needle on each of them.

Carrie Swihart: Thank you, Dr. Brown. I know navigating complex health systems to implement these EHR systems can be daunting. So if we could get input from the both of you on how you started using EHRs to aid implementation science research, and can you share some of the roadblocks that you have encountered along the way or some of the learnings throughout your process? Dr. Desai, I'll start with you.

Nihar Desai: Sure, Carrie. I think one of the key roadblocks or challenges, something that Alan and I have spoken many times about, is if you were to stand up in front of a group of providers and tell them that your plan was to introduce another decision support tool or another interruptive alert in their workflow, chances are there's going to be a lot of people that are going to start running for the doors. Because we have had such a difficult time with the EHR. And I think for too many places and for too many of us, it has actually become a principal source of our professional dissatisfaction. And the truth of it is that our current configuration of the EHR is littered with too many unhelpful, unsophisticated, interruptive alerts that actually prevent me from doing the work that I am, you know, trying to do and trying to take care of the patient in front of me. And so I would say the biggest roadblock or challenge that we had to face, and I don't want to minimize this because I think it's a very important one for anyone that's interested in being in this space, is to earn the trust back of our colleagues, is to restore and rebuild our sense of, you know, collaboration and collegiality and our willingness to work within the EHR. And I think the way that we did that, frankly, was by respecting and honoring the hard work that those individuals on the front lines of clinical care bring. There's a lot of wisdom that they have, and if we were to listen to them, then I think they will be the principal advocates for helping us make progress. And so what we did within the context of PROMPT-LIPID was we convened a series of user focus groups and we asked our frontline clinicians, hey, if we were going to create a tool around LDL cholesterol for patients with very high risk atherosclerotic cardiovascular disease, what do you want that alert to look like? What functionality should it have? How can it actually help you? When should it fire? What capability should reside within the alert? I think our solemn commitment to them during those focus groups was that you would never see an LDL alert be live in our health system until we had built what they had asked us to build. And so did it take us longer to build what they asked us to build? Yes, it did. We had to pull information from other parts of the electronic health record. We had to make a much more sophisticated, you know, alert system. We had to have the ordering capability embedded within the alert so that with the push of a button, we could have all the downstream orders go in for the patient. But I'm awfully glad that we took the time to do those focus groups and to develop the alert that we did, not only for the sake of PROMPT-LIPID and for this one project, but frankly, for the broader social compact and for the social capital that is built amongst the group. And so for those that are interested in working in the EHR, I will tell you, you're going to face some headwinds, you're going to face some reticence and some hesitation. I think you have to acknowledge that upfront. And I think the best way to make progress there is to actually bring people in, engage them directly, and have them feel like they are absolutely involved in the design and the ultimate deployment of whatever tool is built.

Carrie Swihart: Excellent point, Dr. Desai. It's so important to get the boots on the ground that are going to be impacted by that implementation involved from the beginning. Dr. Brown, any insight into roadblocks that you encountered along the way and how you overcame them?

Alan Brown: Yeah. So, first of all, I agree with all the things that Dr. Desai said about alerts. And as we move towards value-based care, a lot of things are going to change. We're going to require uniformity of care for our high-risk patients in order to have better outcomes, keep our costs down, et cetera. And over the years, though, the EMR is fantastic at identifying gaps, when you leave it up to the individual practitioners to implement something with alerts or not. The results have shown some improvement, just as Dr. Desai's project, but we're still not where we want to be. So I really think the future is going to be to use the EHR to identify treatment gaps and also to tell us whether we're winning or losing in our battle to provide better care. But probably smaller teams within the healthcare system are going to take responsibility for managing chronic disease in order to provide more uniformity of care and a high level of expertise. Many of us, and I know Nihar’s also thought about this, think that maybe a high-level team using physician extenders or some people on the street to implement would manage things like dyslipidemia and probably like diabetes to make sure all our patients are on the appropriate therapy and that as many patients as possible can achieve their goals. One of the dilemmas with that is the same kind of dilemma we learned with the EHR, is that patients are getting cold calls now from auto insurance companies and scam calls. And so finding the right way to communicate with patients that you represent their healthcare system and that you're calling to make sure that their quality of care is appropriate is a bit of a challenge. And we have to find ways that are trusted to communicate with patients, especially if we're going to remove the link with the primary care physician and try to provide team-based care. So I personally believe that that's the only way we're going to have uniformity of care across large healthcare systems in the future. But there are many challenges in how to implement that and I'm looking forward to those challenges because I think hopefully, finally we'll be able to do a better job.

Carrie Swihart: Great way to wrap this up. So, to close at our time here, what advice do you have for those looking to implement EHR initiatives and learnings into real world practice? Dr. Desai, we'll start with you and then wrap up with Dr. Brown.

Nihar Desai: Great, Carrie. I would say to everyone that's interested in working in the EHR and trying to make progress, that it's incredibly important work. And so I would just say that if we don't get this part of things figured out and sorted out and right-sized, then all the investments we've made on the discovery science, all the investments we've made in terms of new therapies, all the investments we've made in terms of clinical trials and guidelines and literature and all the publications that are out there, I'm afraid if we don't get this part right, to ensure that those highly effective therapies actually make it to the patients that we serve, it's frankly all for naught. And so it's critically important if we're going to solve the challenges and improve health and health care in this country. It's not an easy, you know, set of tasks that you're about to embark on, but know that you're also not doing it alone. That there are people like Alan, like myself, like others, you know, that, that are working in this space that are keen to collaborate and share ideas and, and bring people together. And so, you know, if you happen to be interested in that space, then, you know, I would certainly just encourage you on that. We all need everyone's best efforts, you know, on the implementation side of things, and that certainly avail yourself of the resources and the mentorship network that exists out there.

Carrie Swihart: Thank you, Dr. Desai. Alan?

Alan Brown: I would echo what Dr. Desai says. We're both emotionally invested in better care of patients. I think we should keep in mind that the EHR is a tool. It's not necessarily the only solution. But you have to have a dashboard. You have to be able to measure where you're starting, and you have to tell whether you're winning or losing as you embark on getting patients under better care. And the EHR is critical for that. So any implementation project for better healthcare requires baseline measurement, longitudinal, real-time follow up, and being able to tell whether you're winning or losing of all those potential metrics where you'll need to intervene. And then finally, you know, the future, especially as we move towards value-based care, is uniformity of care. And that's something that's going to be critical. And I'm not discouraged by that. I'm actually excited by that because I think that as medicine moves towards value-based care, with whatever criticisms might be there, it's going to lead us to do a much better job of getting the broader population taken care of.

Carrie Swihart: Thank you, Dr. Desai and Dr. Brown, for these helpful insights. As a reminder, this episode is the third in a series of discussions Amgen is hosting with Becker’s, where we'll delve into the important work of the LATTICE Consortium and its efforts to share implementation science with health systems across the country. If you missed our first episode with Dr. Francoise Marvel of John Hopkins Hospital, and our second episode with Dr. Stephanie Saucier of Hartford Healthcare, be sure to check those out and stay tuned for our next episode. And be sure to visit latticeconsortium.com to learn more about implementation science. In the meantime, thank you, Dr. Brown and Dr. Desai for joining us today, and I will turn it over to Becker’s.

Becker’s Moderator: And again, thank you Carrie, Dr. Desai, and Dr. Brown for your time and this very informative conversation today. We also want to thank our podcast sponsor, Amgen. Dr. Desai and Dr. Brown have been compensated for their participation. Dr. Desai’s project was financially supported by Amgen. You can tune into more podcasts from Beckers healthcare by visiting the podcast page at beckershospitalreview.com/podcasts.

Becker’s Moderator: Welcome to Becker's Healthcare Podcast. Today's episode explores the factors influencing C-Suite decision makers as they consider projects for implementation. This episode was sponsored by Amgen. With that, I'll turn the floor over to Amgen's Carrie Swihart.

Carrie Swihart: Hello everyone. It's a pleasure to be here on Becker's podcast. My name is Carrie Swihart and I'm the Associate Director of Health IT Strategy at Amgen. I'm excited to be joined by Dr. Edward Fry from Ascension Health. Dr. Fry, I'll let you introduce yourself.

Edward Fry: Hi, good to talk to you all and touch base, Carrie. I'm a former and fully reformed interventional cardiologist who now practices general cardiology, but my primary day job is as the Ascension National Cardiovascular Service Line Director. And with that I have line of sight over system-wide CV quality, best practices and operational performance. And I've been at Ascension and its forebearers for now 33 years, and I've been in this service line role for more than 12 years.

Carrie Swihart: Thank you, Dr. Fry, for joining me today and to have this conversation to explore how C-Suite decision makers go about selecting EHR projects to implement in their health systems to bridge gaps in care among cardiovascular patients. First, for those of you who haven't listened to our previous podcast episodes, I'd like to provide some background on the importance of leveraging implementation science to address cardiometabolic patient needs. Dr. Fry, can you talk to us a little bit about the importance of implementation science?

Edward Fry: Yeah, certainly. And maybe just to take a step back, because obviously this is within the context of a large multi-state national health system that is focused on high reliability, quality and safety and has a mission towards serving the poor and vulnerable. And as such, we certainly have economic interests and concerns providing over $2 billion worth of unreimbursed charity care each year. So, implementation science is a critical part of being able to deliver on those goals and that mission. So, as you well know, we know from clinical practice guidelines and from the literature and from current professional educational materials, we certainly learn what to do, the knowledge base is pretty well established. Implementation science is really to close that gap between the knowledge base and the actual care of the patient in terms of how do we take those novel therapies, those changes in practice and construct our care delivery in a way that they actually reach the patient and fulfill the benefit that we know that's been proven through clinical trials and other scientific efforts. So implementation science requires really operationalizing that fund of knowledge and at Ascension we've done that really through developing a system within the cardiovascular service line comprised of process improvement groups or what we call affinity groups centered on the subspecialty areas of cardiology, whether it's interventional cardiology, and within that we really include both acute and chronic ischemic heart disease, electrophysiology, heart failure, open heart surgery, structural heart disease, peripheral vascular disease imaging, and preventive cardiology, and really rely on the content experts within our large diverse service line to help guide us in terms of best practices and to help develop the metrics and KPIs that are necessary to measure that we are reaching our goals when we try to implement a novel therapy or change a particular method of care delivery to prove that we're actually achieving what we want to do. So whether that is in terms of improved quality, better safety, better efficiency, better overall operational performance.

Carrie Swihart: Thank you Dr. Fry, quite a large task for you there across all of cardiology, but can you speak a little bit more in depth on the project for your ASCVD patients?

Edward Fry: Yeah, sure. I will sort of expand the scope a little bit to say that each year we take on a new project or task or a new focus across each of these process improvement groups. And within the group focused on chronic and acute coronary disease, we saw that we really had gaps of care in terms of pretty simple things even such as measuring or consistently measuring and documenting LDL cholesterol in patients both in the acute setting and in the ambulatory setting, and really set that as a system-wide annual metrics to try and close that to get as close to a hundred percent as we could. And as we discovered, most of the time we do have that information. It's an issue of getting it in the right hands, the right documentation, and presenting it in the right way. But one particular group that we really felt deserved attention are those patients who were presenting with acute coronary disease. Many of them may well have LDL documented, but really assuring that that is part of their acute care. And as you all know, the emphasis these days is in such rapid throughput that a lot has to get accomplished during that period of time when there's contact between patient and the healthcare system. So we looked at, were we getting the information in front of the frontline caregivers both at the physician and non-physician level so that we could be assured that when the patient was being treated or certainly ready for discharge, that we could help close that gap between the inpatient and the outpatient follow-up by making sure that if patients were not at goal with their LDL following an acute coronary syndrome, that we were taking advantage of all of the therapies as well as maximizing the therapies to make sure that they reach that goal, whether that was maximizing statin therapy, adding non-statin medications if truly they were not at that goal and had been identified as being high risk and help make sure that that was initiated and started as part of their transition to the longer term outpatient follow-up.

Carrie Swihart: That’s great, Dr. Fry. I know there was a lot of steps that led to this process. What factors really led to this project becoming a priority for you and maybe who was involved in that process?

Edward Fry: Yeah, again, I'll go back to say that the magic is not the what, it's the how. And as we well know, there's multiple obstacles from a implementation science standpoint. The dissemination of knowledge piece I don't think is really the major problem, it's other barriers such as technical ones, information management, integrating disparate EHR systems, creating standardized order sets, having standard metrics of measuring compliance in the follow-up. And then probably one of the biggest ones, and I think this is not unique to our healthcare system, but any system of size, I think, many, if not most of our patients may actually have their follow up both originate and have their follow up outside of the system in, for example, I'm in Indiana and in our practice in Indianapolis, a fairly centralized sort of hub and spoke model. Many of our patients, even up to 70% of our patients who are acutely hospitalized within our healthcare system, their follow-up will be with a non-system, primary care physician, maybe even a non-system cardiologist if they're sort of far afield. So being able to translate and communicate the needs and the therapy and the follow-up that's necessary, that's a challenge. And that's where I think trying to make processes as standard as possible, as simple as possible and as measurable as possible, it has really been important to try and close those gaps.

Carrie Swihart: That's an excellent point, Dr. Fry in terms of, you know, standardizing utilizing the electronic health records to create a process. In addition to that, what advice would you give to those looking to gain C-Suite buy-in for these types of standard processes to be integrated into their systems and implementation projects?

Edward Fry: Yeah. Well, I think the shared communication, again, not unique to this particular project. It really has to be sort of a culture that is present and developed and nurtured and matured where the clinical community and the administrative community are working together in lockstep. I think that's incumbent on the clinical community then to really communicate. So why is, in this particular case, achieving a target LDL cholesterol below a certain level in this acute phase and longer term in a chronic disease management phase? Why is that important to the overall outcomes of our patients, their safety, the economics, the long-term economics related to that in terms of reduced future hospitalizations or readmissions, which may be a relatively short-term economic vantage, but longer term in terms of reduced morbidity and costs related with care. And certainly as we, nobody's going to sort of suddenly turn on a neon sign and say, we have all switched over to value-based care. But I think as we develop our care pathways and as we work across the system clinically and administratively, we have to realize that value-based care is really the end game that we all need to strive for and will arrive at in some point in time. I personally think that point in time is getting more and more close, and so making the case that projects like this, processes like this really translate into mutual benefit, both at the clinical level, operational performance level, and at the financial level for the health system.

Carrie Swihart: Thank you, Dr. Fry. Any closing comments before we wrap up?

Edward Fry: Well, I would say this is a team sport, and that team is pretty broad. I mean, you know, in cardiology, we're lucky to understand the value and importance of the care team and all its contributors, but I would extend that team aspect to, again, other physicians and care providers who are outside of a particular health system that they have to be part of that team and industry and the biomedical, pharmaceutical and device partners also need to be part of that team effort too. It's not necessarily just a vendor client relationship, but both parties can benefit from working together and learning together with the shared common goal of trying to improve patient's overall outcomes and really to hit all parts of the, all four parts of the quadruple aim.

Carrie Swihart: Thank you, Dr. Fry, for these helpful insights. This episode is the final installment of a series of discussions Amgen has hosted with Becker's where we dove into the important work health systems are doing to scale implementation science across the country. Be sure to check out our previous installments of the series featuring Dr. Francoise Marvel of Johns Hopkins Hospital, Dr. Stephanie Saucier of Hartford Healthcare, Dr. Nihar Desai of Yale University School of Medicine, and Dr. Alan Brown of Advocate Lutheran General Hospital.

Becker’s Moderator: Thank you, Carrie and Dr. Fry for your time on this and this very informative conversation. We also want to thank our podcast sponsor Amgen, and you can tune into more podcasts from Becker's Healthcare by visiting the podcast page at beckershospitalreview.com/podcasts. This podcast was sponsored by Amgen.