Change of Heart: Online Assessment Reaches Patients Before They Enter ER

Since its release in 2004, approximately 600,000 people in the United States have taken a free, online risk assessment called HeartAware through the Web sites of the 85 hospitals that offer it. The assessment, created by the HeartAware Network (a division of Byrne Healthcare) analyzes a person's risk for cardiovascular disease—the leading cause of death in the US.

Of those who have taken the survey, the company reports that about 20,000 individuals have been identified as at risk and, as a result, have received a free cardiovascular screening with a cardiac nurse at their hospital.

Advocates of the tool say it identifies those at risk for cardiovascular disease, provides them with education, and, in turn, prevents needless visits to the ER. Skeptics argue that the survey is an invitation for patients to enter the "medical mall" and purchase unnecessary services.

Program offers dose of prevention
According to Greg Gossett, president of Denver-based HeartAware Network (www.heartaware.org), a wave of non-invasive diagnostics in cardiovascular medicine was introduced around the time the tool was in development. He says the company saw this trend as an opportunity to begin identifying at risk individuals and educating them about the new resources that were becoming available.

The HeartAware assessment asks patients a set of 15 questions that revolve around known, major cardiovascular risk factors, such as blood pressure, cholesterol, weight, and family history. The company also gives hospitals the flexibility to ask additional questions if it lines up with what they want to know. For example, one hospital asks patients if they have seen a dentist recently, because physicians at the hospital were curious about the possible correlation between poor dental hygiene and heart disease.

Each hospital implements the tool a bit differently, some requiring more hand-holding than others to get up and running. HeartAware trains hospitals to use the tool and provides them with necessary resources. In return, the company receives a monthly fee to operate the program for them.

The majority of hospitals do not have outside funding, but Gossett says that he is starting to see this change. Some HeartAware providers have partnered with insurance companies to receive monthly reimbursements for offering the free screenings to their members.

Most of the facilities offering HeartAware target patients between the ages of 45 and 65 years old. Gossett says heart disease is more prevalent for patients in this age group, who have also been proven to be the most underserved.

"There's a subset of people out there who don't have symptoms and really need to get in front of a provider," he says.

Less than 10% of the respondents are over 65. Gossett theorizes that most patients in this demographic are already under the care of a physician or cardiologist.

The content of the completed assessments belong to the hospitals. HeartAware has a privacy policy and the hospitals that host the assessment each write their own disclaimer, according to their facility's policies.

"We only give out access to a few people within the hospital who need to know and access the data, such as the screener," says Gossett. "We have extensive measures to protect the data coming into this program."

Critics say program may offer pound of cure
L. Gordon Moore, MD is a family medicine physician who believes in low-overhead, high-technology medical practices that provide patient-centered care that is efficient, effective, and accessible. He says that he is skeptical of tools like HeartAware.

"If people start to go through a survey, we can find something wrong with you and we have a solution," he says. "They are going to be drawn into the medical mall and they are going to get chewed up."

Carol Luscato, who has risk factors and a family history of heart disease, recently completed the HeartAware assessment offered by Edward Heart Hospital (www.edward.org) of Naperville, IL. She was identified as at risk and qualified for free screening and testing. The hospital also advised her to complete an additional test of her heart function, which is not covered under the program.

"I don't care," she says. "A hundred dollars is nothing to me when it means my heart and my life." Moore says that behind most health assessments is a business model that has little to do with quality and more to do with driving volume. "If you drive patients into specialty practices for analysis and intervention, you drive up costs, you drive up mortality, and you drive down quality," he says. "If you drive patients into primary care practices where they have an established relationship, you drive up quality and you drive down costs."

In response to critics, Gossett says that the company isn't in the business of driving up utilization. "That's not going to help prevention," he says. "We want to see prevention justified and working in this country. So to drive up utilization isn't going to do anyone any good."

He says that if 1,000 people take the assessment within a community, about 40% will have two or more cardiovascular risk factors. As a result, they would qualify for a "very beneficial" screening. Of the 60% who do not qualify, Gossett says that since they have not been identified as at risk, they are not brought in for screenings.

Obviously, from a business standpoint, hospitals need to generate money to stay afloat. For this reason, Gossett says that they need to remain ahead of their competition and improve their service line in order to become market leaders.

"It's a real valuable differentiator for the hospitals to be offering free educational services that are dedicated to the people who need the resources—at risk individuals," he says. "We believe the win-win situation is providing an educational service and developing an early relationship with a patient so that when the patient does need care you've done some good things for them."

By comparison, if a facility chooses not to take proactive measures to identify those at risk, Gossett says they will see the patient in the ER when they experience their first heart attack.

Hospital reaches out to those at risk
"Cardiovascular disease is the leading cause of death in Illinois and also in the county that we serve," says Vincent Bufalino, MD, medical director of cardiovascular services at Edward Heart Hospital. Bufalino says that he was initially skeptical that patients would actually go online and complete the HeartAware assessment. However, the hospital now has over 10,000 patients who have taken it in the three months it has been available. More than 80% of those completing the questionnaire are new patients.

"The success was unpredicted," he says. "We thought over six months we might get 8 or 10,000 patients completing the assessment."

"Edward is one of the best hospitals in the nation with HeartAware in terms of their numbers and the people they're educating," says Gossett.

Bufalino reports that a third of individuals who took the assessment were at moderate to high risk and over 2,000 patients have scheduled appointments for the free consultation.

"These are not people who have had events," says Bufalino. "These are all people who are looking to prevent an event. From a medical standpoint, it seemed to be a unique way for us to reach a community that we serve, that we frankly aren't serving because they aren't coming in—yet they're at risk." He says the free screenings offered by the hospital provide patients with a unique opportunity to sit down, go over their results with a healthcare professional, and provide them with some direction in terms of next steps. Patients also see value in the free heart scan that some randomly selected patients receive as part of the consultation.

Luscato says the assessment offered her an opportunity to speak with a nurse for about 20 minutes regarding her risk factors and what she can do to make changes that will reduce them, such as lowering her weight. The free heart scan she received revealed that her arteries and aorta were in good health. The news provided her with much reassurance that she is on the right path to improving her cardiovascular health, especially considering that her mother suffered from heart disease.

"I accepted this as good news and I conduct my everyday life the way I always have," she says. "I exercise, I bike, I play tennis. I do various things that contribute to my health and that was proven during the test."

She says she came away from the experience knowing what her direction and goals need to be, specifically in terms of losing weight. "Will I achieve my goals in a month?" she asks. "No, the weight didn't come on in a month. I know it will take perseverance."

Bufalino states that some of the patients who have taken the assessment have undergone bypass surgeries and stents as a result of the screening. Others have started receiving treatment to prevent future problems. The hospital plans to follow up with patients to determine how many are coming into the system and receiving care as a result of the assessment.

Edward has marketed HeartAware on television, in direct mailings, and through their offices. HeartAware helps facilities produce advertisements and word their message, but does not place advertising and media spots for them.

Luscato is doing her own small part to spread the word. She hosts a local cable show in her community and discussed the program on the air. As part of the program, she took the assessment and was impressed that she got back results within five minutes of clicking Submit.

The hospital has no plans to pull the plug on the program any time soon. "Interest in the program sure hasn't stopped yet, so I think they're going to run with it for a while," says Bufalino. "It makes the community feel that their healthcare organization cares about what's going on in the community."

HeartAware continues to learn, grow
Gossett says there is no comparison between the HeartAware tool and the online risk assessments that consumers can take through Web sites like WebMD.com. "Those are a commodity, in my opinion," he says. According to Gossett the strength of the program lies in how the company has learned and continues to learn from the hospitals that implement it.

"If you take one of Barak Obama's recent quotes, he said we need to identify best practices, learn from them, and replicate them," says Gossett. "That's what we do. That's our role in this equation, to share best practices."

The company has plans to branch out in the future and offer risk assessments on other health-related topics such as various forms of cancer, weight loss, spine health, and joint pain, but the programs are still in their infancy.

"We believe that the process of stratifying the vulnerable individual and giving them educating resources is a benefit to the community," he says. "Our intention is to really promote early detection and prevention."