A Conversation with Jake Lieman, VP of Engineering at Artifact Health

*Artifact Health is proud to announce its mobile physician query platform is now available within the Cerner App Gallery, a marketplace for healthcare software products that integrate with Cerner using Cerner’s Application Programming Interface (API). The Artifact/Cerner integration gives physicians mobile technology to ensure accuracy of patient records.*

Artifact recently completed Cerner Open Developer Experience (code) Program validation. We spoke with our own Jake Lieman, Vice President of Engineering at Artifact Health, regarding the code Program, the integration of Artifact’s mobile physician query platform, and the benefits for Cerner hospitals.

### What is the Cerner Open Developer Experience (code) Program?

The code Program is about furthering interoperability of patient information. But, it’s not just about technology. The code Program also encourages developers to solve today’s complex healthcare problems by providing them with a platform to build sophisticated, more reliable systems.

Healthcare providers and technology vendors have recognized traditional HL7 integrations to be slow, complicated and lacking in modern technologies. Over the years, we’ve all become efficient at building HL7 interfaces, but these integrations remain as one of the most expensive and complicated parts of the implementation process.

The code Program was designed to make it easy for technology vendors and health systems to integrate their own platforms with Cerner’s data using modern technologies and a new interoperability standard called SMART on FHIR. The code Program is Cerner’s implementation of the SMART on FHIR paradigm.

### What is SMART on FHIR?

SMART on FHIR is the combination of two complementary standards. SMART stands for “Substitutable Medical Applications Reusable Technologies” (a name only a programmer could love!) and is a standard for launching third-party applications from EMRs. FHIR stands for “Fast Healthcare Interoperability Resources” and is a standard for electronic exchange of health information.

FHIR, in particular, is a real paradigm shift for healthcare IT. With traditional HL7 integration, every hospital system maintains a copy of the patient record. When a patient is admitted, transferred, receives a labs result, etc., the source system pushes a copy of this information to all other systems that need it. All receiving systems store a copy of the information in case needed in the future. This process is a terribly inefficient way to do things. It requires multiple systems to store significant amounts of patient information they may never need.

FHIR turns this model on its head. Instead of the source system pushing all data to receiving systems, a receiving system pulls only the data needed from the source system FHIR APIs. With this model, the receiving system is guaranteed to always have the most current information on a patient and only has information on the patients it needs, preferable from both a storage and security perspective.

### How does a vendor’s application get validated for use?

The Artifact application has undergone an exhaustive review to ensure it meets the security, functional, operational and usability standards set by Cerner. The Cerner validation and certification process attests that Artifact can be implemented safely, efficiently and reliably for Cerner clients.

We were able to update the Artifact platform for use inside of PowerChart in just a few months. One of the reasons for this quick implementation is we built Artifact from the ground up to support FHIR API integration. When we started building Artifact six years ago, FHIR was not yet even a draft standard. However, we recognized that FHIR was the future, so we structured our underlying infrastructure to support both tradition push-based HL7 integration and pull-based API integration, such as FHIR.

### Why did Artifact Health decide to join the code Program?

Artifact is already deployed at many Cerner hospitals across the country. Providing an integration option directly supported by Cerner for future Cerner customers makes sense for a number of reasons, beginning with speed of implementation. When a hospital or health system signs a contract with Artifact, we want to help them get up and running as expeditiously as possible. We’re always looking for ways to optimize the implementation process for our customers.

Secondly, the code Program allows us to achieve turn-key, plug and play integration with any Cerner hospital. This reduces overall integration time, and more importantly, reduces the hospital or health system’s FTE resource time and costs by shifting integration responsibilities on to Artifact and Cerner.

Finally, as mentioned previously, using a pull-based API model for data integration with a hospital has many advantages, including reduced infrastructure and bandwidth requirements, reduced risk and increased security.

### How will Artifact’s inclusion in the code Program benefit Cerner clients?

Artifact’s availability within the Cerner App Gallery introduces Cerner hospitals and health systems to a mobile clinical documentation improvement (CDI) solution that gives physicians an easier way to respond to requests for documentation clarification, ultimately adding greater specificity to the patient’s record and giving providers back valuable time to focus on patient care.

Traditionally, the physician query process is onerous and time-consuming for physicians, clinical documentation specialists and medical coders. Cerner hospitals often resort to delivering queries to physicians through the Message Center, which is cluttered with many other messages and requires multiple steps for the physician to respond.

With Artifact’s HIPAA-compliant, cloud-based, mobile query platform, physicians can respond to a query compliantly in seconds with as few as three taps on their smartphone. Engaging physicians with a faster, more simplified process drives improvements in hospital coding accuracy and publicly reported quality measures.

In addition to turn-key technical integration and reduction in IT resources, Cerner hospitals can have real-time access to Cerner data within Artifact. This gives physicians everything they need to respond to a query without having to go back to the chart.

Artifact is also seamlessly available inside PowerChart so physicians have multiple ways to access Artifact and respond to documentation clarification queries.

### For more information
Contact Jake at jlieman@artifacthealth.com. View our code Program page here.

A conversation with Tammy Combs and Melissa Potts of the American Health Information Management Association (AHIMA)

*Tammy Combs, RN, MSN, CCS, CCDS, CDIP, AHIMA Approved ICD-10-CM/PCS Trainer, Director of HIM Practice Excellence, CDI/Nurse Planner at AHIMA

*Melissa Potts, RN, BSN, CCDS, CDIP, CDI Practitioner, HIM Practice Excellence, CDI/Nurse Planner at AHIMA

The American Health Information Management Association AHIMA represents more than 103,000 health information professionals in the United States and around the world. AHIMA is committed to promoting and advocating for high quality research and best practices in health information and to actively contributing to the development and advancement of health information professionals worldwide.

AHIMA and Artifact Health have partnered to provide hospitals with a mobile physician query platform that can utilize a library of electronic query templates developed and maintained by AHIMA experts. We spoke with AHIMA clinical documentation integrity (CDI) experts, Tammy Combs and Melissa Potts, about the importance of clinical documentation improvement during the COVID-19 pandemic.

### What is the greatest CDI and coding challenge hospitals have faced during the pandemic?

CDI programs are vital to the hospital’s financial sustainability and the accurate reporting of patient data. During this pandemic, we’ve seen hospital CDI and coding teams confronted with trying to maintain provider engagement around clarifying documentation for accurate coding purposes.

Historically, providers struggle with balancing administrative duties, such as documenting for coding purposes, and their desire to stay focused on patient care. During the last few months, hospitals dealing with COVID-19 outbreaks could not possibly expect providers to focus on anything more than patient care.

However, as hospitals are getting back to preforming elective surgeries, engaging providers around clarifying documentation for proper coding and reimbursement will be critical to their financial sustainability.

### What other CDI and coding challenges have arisen from the pandemic?

Another significant challenge was hospitals had to rapidly and unexpectedly move CDI teams to a fully remote model. This overnight transition required that hospitals procure and provide the correct technology to support productive remote work. And, all of this happening while having to furlough employees to reduce costs and stay solvent.

As the pandemic continues and spikes again in other regions, engaging providers around accurate documentation and coding is critical to our public health. CDI and coding teams ensure that the hospital reports patient disease burden accurately. Without correct documentation and coding, we as a community cannot study the true repercussions of this virus.

### During these next phases of opening up and hospitals getting back to normal operations, how critical are CDI programs?

The quality of physician documentation directly impacts hospital reimbursement. CDI programs are an extremely valuable resource to help document patient information completely and accurately so that the hospital may justify full and proper reimbursement for services.

To rebound from the pandemic losses, CDI teams must help hospitals find ways to continue and enhance engagement with providers when their documentation is unclear. Physician responses to CDI and coding queries help the hospital properly and compliantly code and bill for patient encounters. So, greater provider engagement around queries will translate into more accurate reimbursement for hospitals, at a time when they need it most.

Along with engagement around queries, CDI specialists are responsible for educating providers on new regulations and specific documentation requirements for accurate coding and quality reporting. CDI teams will be vital to delivering updated education on medical conditions not related to COVID-19, as hospitals begin performing elective procedures again.

### How is AHIMA helping hospitals deal with the pandemic?

AHIMA developed a webpage with links to numerous COVID resources. Included are two CDI query templates for COVID-19, which we added to our compliant query template library embedded within Artifact Health’s mobile query platform. The COVID-19 templates support two query opportunities brought to AHIMA’s attention by the CDI industry – diagnosis validation and diagnosis specificity of COVID-19.

Also, AHIMA’s COVID resources webpage includes other resources and information to support the healthcare industry during this pandemic, such as free educational webinars.

### What benefits does the alliance between AHIMA and Artifact Health offer hospitals and health systems?

The integration of AHIIMA’s expert, compliant query template library with Artifact Health’s innovative mobile physician query platform can help hospitals ensure accurate reimbursement and quality scores. Physicians are able to answer queries compliantly in as little as 30 seconds from their mobile device or desktop.

The ease and convenience of the Artifact mobile app is more satisfying for providers than receiving queries through email, in-person interruptions or the EMR system, and ultimately helps hospitals get queries answered as quickly as possible.

### For more information
Contact Tammy Combs and Melissa Potts at cdiexperts@ahima.org.

Accustomed to Instagram, Millennial Physicians Won’t Stand for 1980s EMR Technology

Millennials (born 1981-1996) are now a driving force in medicine. The first generation to have grown up with ubiquitous internet access, Millennials have high technology expectations. And hospital technology has to evolve as a result.

According to Pew Research, 93 percent of Millennials own a smartphone (versus 90 percent for Gen X, and just 68 for Baby Boomers). Of the average 242 minutes Millennials spend on the Internet each day, 211 minutes of it – or 87 percent – is on a mobile device. They are accustomed to being constantly connected.

 A millennial nurse practitioner recently told me of her hospital’s EMR system, “It’s so time consuming to do something so simple – the opposite of my experience using Facebook and Instagram.”

And then they start working in a hospital setting, where the most commonly used EMR software was originally developed before many of them were born.

In a Wall Street Journal article, one physician leader shared that millennial physicians on staff at her hospital questioned why EMRs and clinical documentation couldn’t be more like using an iPhone. Anyone who uses Instagram on a regular basis and then uses an EMR would be shocked – the experiences could not be any more different.

A millennial nurse practitioner recently told me of her hospital’s EMR system, “It’s so time consuming to do something so simple – the opposite of my experience using Facebook and Instagram.” She feels most of her time is taken up by documentation, yet the EMR doesn’t provide the means for her to add notes in her own voice – it’s all drop down, predefined selections. This is probably why mobile apps for the major EMRs have between a 2.5 – 2.6 rating on the app store. The bar has been set very low.

In a mobile-first era, we are asking our physicians and other medical staff to use software interfaces that were originally designed well before the advent of mobile devices. One anonymous millennial physician, writing for MedSpace, said that for every one hour of patient care, s/he spends two hours entering data into an EMR. Another, writing for Medical Economics, pleaded for new user interfaces, saying, “I have yet to meet a young physician colleague or trainee who has displayed any emotion greater than lackluster contentment with their medical record system.”

The frustrating user experience associated with EMR technology is a chief contributor to physician burnout – a very troubling issue in the healthcare industry. Even before the COVID-19 pandemic struck, the numbers of physicians reporting burnout, fatigue and depression were on the rise. In fact, in a Jan 2020 Medscape report, 42 percent of physicians reported feeling burned out, and one in five reported that they are depressed. The most common reason physicians cited for their burnout (55 percent): increasing administrative burdens, like charting.

Bringing back the “Joy in Medicine” is something hospitals all over the country are prioritizing so they can attract and retain the best staff. Reducing administrative tasks so physicians can spend more time on patient care has been identified as a key to addressing burnout, so hospitals are researching tech solutions to automate things like physician queries on documentation.

Physician queries are designed to make sure physician notes are accurate and complete in the medical record, and they play an important part in hospital reimbursements, quality metrics and patient care – especially during the current COVID-19 pandemic, when hospitals need to capture full reimbursement for the complex and expensive care they are providing. Higher query response rates and completion of more queries can translate into millions of dollars in additional reimbursement and higher quality scores for a hospital. It is, however, a very time-consuming process for physicians, and one that reduces time available for patient care.

Artifact Health has automated this task so it can be done on a physician’s smartphone in a matter of seconds, easily and compliantly. Hundreds of hospitals such as Johns Hopkins Medicine, Children’s National Hospital and UPMC Western Maryland have already put this mobile technology to work to ease the administrative burden for physicians, clinical documentation specialists and coding staff.

Healthcare mobile apps are especially needed right now, during the pandemic, because they allow physicians and other hospital staff to more quickly and easily access and triage information while at the hospital or from home – where many non-essential staff are currently working.

Within a few years, millennial (and then, Gen Z) physicians will become the majority, and these younger physicians will be making the purchasing decisions at hospitals and health systems. They will demand technology that has the same ease of use they are used to, and without a doubt, will select modernized solutions that give them more time for patient care.

A conversation with Brian Sanderson, National Healthcare Leader at Crowe LLP

*Crowe LLPis a public accounting, consulting and technology firm with offices around the world. Crowe uses its deep industry expertise to provide audit services to public and private entities. The firm and its subsidiaries also help clients make smart decisions that lead to lasting value with its tax, advisory and consulting services. Crowe is recognized by many organizations as one of the best places to work. As an independent member of Crowe Global, one of the largest global accounting networks in the world, Crowe serves clients worldwide. The network consists of more than 200 independent accounting and advisory services firms in more than 130 countries around the world.*

We spoke with Brian Sanderson, National Healthcare Leader at Crowe, regarding the financial impact of the COVID-19 pandemic on hospitals and health systems and the steps they may consider taking to recover quickly.

### How has COVID-19 impacted hospitals’ revenue cycle?

We’ve calculated that most hospitals will need to operate at 110 percent of their previous volumes for six straight months to offset the volume declines we saw from mid-March through April. For most organizations, this will be a significant throughput challenge combined with the need to prioritize the pent-up demand of elective surgeries.

We’ve seen revenue cycle metrics actually improve over the course of April, primarily because of the lower volume – less accounts, more focus on collections. But, we’re concerned that late May and all of June will show very volatile performance.

### What steps are you recommending hospitals take to limit the negative impact of the pandemic?

We’re recommending hospitals focus on three main priorities:
1. Institute an “acceleration mindset” by condensing schedules and increasing hours of operation.
2. Focus on coding and capture precision – capture every procedure, CC, etc. that they are entitled to. It’s not time to be sloppy with documentation.
3. Introduce more automation to their business models. Labor has become severely impacted by flexing and furloughing of staff and is an inhibitor to differential success. Hospitals should use the chaos of the crisis to reinvent how they operate.

### How can clinical documentation improvement and coding teams help hospitals rebound?

The spotlight on coding documentation has intensified as the country attempts to understand and quantify the impact of the pandemic. Securing additional federal reimbursement will depend on a hospital’s ability to document and code COVID-19 cases accurately.

Organizations that have the tools, methodologies and sufficient focus on coding and documentation are in a much better position to respond and will be quicker to capture the pent-up demand for the remainder of the year. This skillset will be the differentiator for hospitals when it comes to achieving margin, and in many cases, bond covenants and cash flow metrics.

### What programs and initiatives should hospitals be implementing now to maximize cash flow?

We see five key elements of revenue recovery for hospitals:
1. Recapture patient demand in a strategic way using three levers:
* Assure patients that they will come back to a facility free from contamination.
* Reconfigure operations for more throughput.
* Assist physicians with the acceleration of the consult/schedule/operate process.
2. Segment operations distinctively between contagious and non-contagious areas – e.g. inpatient wards, outpatient tracks, etc. Part of the issue with the cancellation of electives was the government looking negatively at co-mingling all patients, and therefore more space was procured (at the expense of other services).
3. Become experts at revenue cycle operations – revenue projection, service mix analysis, capturing, processing, billing and collecting.
4. Challenge the clinical operating model. Now is the time for hospitals to move aggressively towards telehealth and the digital gatekeeping it can provide. Included in this shift are dispersed sites of care, touchless patient access, risk tolerance for value-based contracts, etc. The business of “one foot on the canoe, one foot on the dock” straddling of old and new models should be abandoned and hospitals should use this pandemic experience to charge solidly ahead in one clear direction.
5. After mastering the first four elements, hospitals must focus on the patient experience. Many hospitals will not be able to rapidly pivot and capture pent-up demand, and patients will seek care elsewhere. To the degree that other hospitals can provide a better experience, patients and their families could become their new market share.

### How is Crowe helping your hospital partners?

Crowe simplifies the business of healthcare through revenue and risk lenses. We help hospitals capture and account for revenue to keep them solvent. Crowe’s Revenue Recovery Program focuses on the elements hospitals need to accelerate and achieve to return to financial stability while improving their risk profile. Our key solutions include: revenue cycle operations, outpatient charge capture, finance and reimbursement services, as well as internal audit.

### Would you like more information?
Connect with Brian at Brian.Sanderson@crowe.com.

A conversation with Laurie Prescott, CDI Education Director for HCPro

*Laurie L. Prescott, RN, MSN, CCDS, CDIP, CRC, CCDS-O is CDI Education Director at HCPro.

As an acknowledged industry authority in healthcare compliance for over 30 years, HCPro delivers information, education, training and consulting products and services that meet the specialized needs of the healthcare industry. Its team of renowned CDI educators, led by Laurie Prescott, have applied their substantial clinical and coding experience to the design of an electronic query template library for Artifact Health. The library provides compliant templates and process guidance so healthcare facilities can better capture the true complexity of their patient population.

HCPro and Artifact Health have partnered to provide hospitals with a mobile physician query platform that utilizes a library of electronic query templates developed and maintained by HCPro/ACDIS experts. We spoke with Laurie about the impact of COVID-19 on U.S. hospitals and the importance of clinical documentation improvement efforts at this time.

### COVID-19 has caused unprecedented turmoil for hospitals in major cities across the U.S. at capacity with healthcare providers working overtime to triage and treat patients. Why is proper coding of patient hospital stays important right now?
Many people associate proper coding with hospital reimbursement. However, during a pandemic coding actually plays a much more significant role in understanding how deadly diseases quickly spread from country to country, like Ebola, SARS and now COVID-19.

So yes, proper coding of COVID-19 will be important for hospitals to stay afloat financially – to get reimbursed for all of the services they are performing and to apply for funding from the government to keep them in business. But, the coding of COVID-19 will be more critical for statistical reasons and advancing the study of the disease to hopefully prevent similar outbreaks in the future.

### How does the coding of patient data inform public health decisions?
The fact is, ICD-10 codes were designed for epidemiological purposes – to track, report and better understand public health diseases.

Public health officials and scientists look at coded patient data to better understand and tell the story of exactly how diseases are spread, the symptoms and complications, the underlying conditions that influenced outcomes, the impact on age groups and gender, how many people died and how the outbreak compares country to country.

The rapid spread and high mortality associated with COVID-19 is further underscoring the importance of capturing codes correctly.

### How important are Clinical Documentation Improvement (CDI) initiatives during COVID?
During a crisis or a pandemic like COVID-19 the hospital’s CDI team becomes even more essential. Increased patient encounters and disease information must be captured and coded correctly to keep the hospital solvent and provide accurate data for research studies and pandemic modeling.

Healthcare providers must have guidance around properly documenting COVID-19 patients and the complications that arise from the disease which can have broad or vague symptoms, such as respiratory issues. CDI teams are the educators. We ensure that providers have the information they need to document accurately for proper coding.

### How is HCPro/ACDIS helping hospitals right now?
We are supporting hospitals with guidance on documenting COVID-19. We have developed a compliant COVID-19 physician query template which helps increase the specificity and accuracy of the symptoms and complications resulting from the disease. This new COVID-19 template is available to the hospitals we work with, and we are grateful this type of information can be used by physicians, public health officials and researchers to more accurately map the disease and its widespread impact.

Through our partnership with Artifact Health hospitals can utilize our full library of compliant CDI physician query templates. Our library is kept compliant and updated for our hospitals to incorporate new coding guidelines as well as new diseases, like COVID-19.

### Need more information?
Connect with Laurie at lprescott@hcpro.com. For information regarding HCPro’s CDI Boot Camps, click here.

Elements of Consideration During CDI Review of COVID-19 Patients

Bridging the gap between the clinical transcript and coded data

COVID-19 may be the headline but, as a seasoned clinical documentation improvement (CDI) professional, I always ponder what’s the rest of the story? As we learn more about the disease and its effects on the body systems, CDI is challenged to look through the documented words and identify gaps between the written story and the data that will eventually be used to tell that story.

CDI’s challenge has always been to bridge the gap between the clinical transcript and the coded data. With a goal to make sure the coded translation agrees with the provider’s clinical determinations, CDI identifies and clarifies areas not in alignment (e.g., urosepsis versus sepsis associated with a urinary tract infection).

Another element of consideration during a CDI documentation review is to determine why patients with the same diagnoses receive different levels of care. For example, let’s say a patient with a urinary tract infection presented with altered mental status and fever with orders to admit to medical floor. Another patient with a urinary tract infection presented with altered mental status and fever with orders to admit to critical care. CDI looks to answer questions, such as:
* What is the difference between these two patients?
* Are both patients receiving the same antimicrobial management?
* Do comorbidities account for the difference in the intensity of service?
* Is there evidence of acute organ dysfunction or failure associated with the infection?
* Is there an undocumented diagnosis that requires critical care management?

Healthcare is now confronted with a disease that no one has ever had before. Coronavirus disease (COVID-19) is caused by the virus identified as severe acute respiratory syndrome coronavirus 2 (SARS-CoV-2). COVID-19 clinical presentation is similar to, but not a direct match with, other disease processes. Treatment is different and changing as new data and new intervention results are analyzed. In unprecedented moves, Coding Guidelines published a temporary new code specifically for COVID-19 accompanied by interim Coding Clinic information for technical guidance. DRG groupers were also revised to accommodate these changes midway through Federal Fiscal Year 2020.

Against the backdrop of these changes, CDI evaluation of clinical documentation, through the lens of clinical and technical translations, did not change. What changed, however, was documentation describing COVID-19 and SARS-CoV-2 related illness, diagnostic results, and treatment. Let’s begin the CDI review with provider documentation and associated CDI considerations.

Documentation may include diagnostic statements such as “SARS-CoV-2 Pneumonia”, “SIRS due to COVID-19”, “COVID-19 Cytokine Response Syndrome”, “Acute Hypoxic Respiratory Failure due to SARS-CoV-2 Pneumonia”, and “Cytokine Storm due to COVID-19.” Before sorting through these or similar COVID-19 documentation findings, it may be necessary for CDI to consider:
* Cytokine Release Syndrome
* Refer to Coding Clinic First Quarter 2020 for a clarification of previously published coding guidance.
* As a “syndrome,” refer to the Official Coding Guidelines Section I.B.15 Syndromes.
* Cytokine Storm: An overwhelmingly dysregulated inflammatory response resulting in high levels of cytokines (immune system proteins).
* Section I.B.15 of the Official Coding Guidelines, Syndromes: *Follow the Alphabetic Index guidance when coding syndromes. In the absence of Alphabetic Index guidance, assign codes for the documented manifestations of the syndrome. Additional codes for manifestations **that are not an integral part of the disease process** may also be assigned when the condition does not have a unique code.* Although there is no ICD-10-CM code for systemic inflammatory response syndrome (SIRS) due to infection, SIRS is a “syndrome” and, as such, would be coded according to these Official Coding Guidelines.
* Definition of sepsis
* Sepsis-3 Definition: *In lay terms, sepsis is a life-threatening condition that arises when the body’s response to an infection injures its own tissues and organs.*
* CDC Sepsis Definition: *Sepsis is the body’s extreme response to an infection. It is a life-threatening medical emergency.*
* CMS Sepsis Core Measure (SEP-1: the Early Management Bundle, Severe Sepsis/Septic Shock Measure is a CMS National Inpatient Quality Measure, which went into effect October 1, 2015) defines sepsis as:
* SIRS Criteria, 2 or more of the following:
* Heart Rate >90
* Respiratory Rate >20
* Temperature >100.9F or <96.8F * White Blood Cell Count >12K, <4K, or bands >10%
* AND known or suspected source of infection
* Severe Sepsis and Septic Shock are defined as:
* Severe Sepsis:
* Two SIRS criteria, AND
* Known or suspected source of infection, AND
* End-organ dysfunction which includes any one of the following and excludes evidence that is considered chronic or secondary to medication (e.g., ESRD with creatinine >2, Coumadin with INR >1.5):
* Prior lab values used to determine end-organ dysfunction must have been reported within 6 hours preceding the onset of severe sepsis.
* Hypotension defined as
* Systolic blood pressure <90, OR
* MAP <65, OR * Drop in systolic blood pressure of >40 mmHg from the last previously recorded systolic blood pressure considered normal for that patient
* Creatinine >2, OR Urine output <0.5ml/kg/hr for >2 hours
* Total Bilirubin >2
* Platelets <100K * Coagulopathy: INR >1.5, OR aPTT > 60 seconds
* Lactate >2 mmol/L
* Acute respiratory failure as evidenced by new need for invasive or non-invasive mechanical ventilation
* Septic Shock is severe sepsis with
* Hypoperfusion despite adequate fluid resuscitation, OR
* Lactate > 4