Creating mechanisms to identify all heart failure patients
regardless of where they were admitted or treated within the medical center was a key factor in the program.
This process took several months. Searching for
the admitting diagnosis on a daily basis using the hospital’s
electronic medical record (EMR) was time consuming
and was not always reliable in identifying patients
who had heart failure as a secondary diagnosis. We examined
this problem more thoroughly, and recruited the
Information Technology department to facilitate development
of an “HFST List.” This intervention created an electronic
link, a lifetime relationship between the HFST and
the patient. Any future encounters at the hospital would
result in the patient being identified for automatic electronic
referral to the team. The list of patients with heart
failure then became fluid, changing even hourly as patients
flowed in, through, and out the hospital.