USA - Can I.T. Keep The Patients Away?

Clinicians who have gotten attached to patients being discharged shouldn't get too choked up-there's a good chance they'll be seeing them again, and soon.

Providers have been aware of problems with patient readmissions, but what was once a back-burner priority has suddenly grown into a looming dilemma, thanks to the move by Medicare to start penalizing hospitals that consistently show high rates of readmissions. And information technology plays a huge role in efforts to reduce readmissions, but providers are struggling to determine where I.T. will have the biggest impact in the process of extending the care continuum in a hybrid paper/electronic environment.

In federal fiscal year 2013, which begins in October, the Centers for Medicare and Medicaid Services will penalize hospital with high readmission rates-readmits within 30 days of initial discharge-the equivalent of 1 percent of their total Medicare billings, with the penalty rising to 2 percent in fiscal year 2014 and 3 percent in 2015. The program will focus on readmission rates for three common conditions-congestive heart failure, pneumonia and acute myocardial infarction (heart attacks). CMS was authorized to roll out the penalties through the hospital readmission reduction program tucked into the massive Affordable Care Act. It also has shined a light on readmission rates by publishing hospitals' 30-day readmission data for heart failure, pneumonia and heart attacks on its Hospital Compare site at www.hospitalcompare.hhs.gov.

The Dartmouth Atlas Project, which for 20 years has used Medicare data to document variations in how medical resources care consumed in the United States, found that overall, 16.1 percent of hospital patients were readmitted within 30 days of initial discharge. That rate, despite the billions of dollars poured into clinical systems over the years, has actually increased slightly in recent years-the readmission rate in 2004 was 15.9 percent, according to the project's research.

CMS estimates that costs associated with preventable readmissions exceed $17 billion annually. Another study by the Agency for Healthcare Research and Quality estimates that for Medicare patients aged 65 and older, about 19 percent of all hospital stays were readmissions within 30 days.

The decision to penalize high readmission rates comes on top of a 2008 move by CMS to stop reimbursing hospitals for readmissions for 10 hospital-associated conditions, including falls and trauma, vascular catheter-associated infection, stage 3 and 4 pressure ulcers and air embolisms.

The threat of losing a percentage of Medicare billings sent a shiver through numerous hospital board rooms, says Thomas Yackel, M.D., the chief health information officer at Oregon Health and Science University, a Portland-based academic medical center which encompasses two hospitals and a number of physician practices. OHSU had more than 800,000 total patient visits last year, including nearly 31,000 inpatient admissions and 31,000 emergency department visits.

"This is the basic truth-the hospital, in our case and at many other academic facilities and health systems, pays for everything," Yackel says. "It's the revenue-generator that allows the medical school to survive and pays for all the other programs. So when executives see a potential payment adjustment, even if it's a small one, it gets their attention. Executives act on these things."

But understanding the reasons for readmissions is an emerging science, Yackel adds. Some conclusions can be drawn fairly easily-disease states such as CHF leave patients frail and physically vulnerable, making them likely candidates for readmissions-but a host of underlying social and medical complexities still need to be interpreted. "That's the first thing that strikes you when you look at readmission data-you just don't know what causes many of them," he says. "There's no great predictive formula that says if you do these five things, readmissions will drop dramatically. But hospitals are starting to do things that make great common sense, and that's a start."

Some consensus has emerged: a disconnect between patients and multiple caregivers-lack of communication about post-discharge appointments, medications and execution of care plans-causes many readmissions, as does the lack of intensive medication reconciliation, which results in patients not understanding how and when to take prescribed medications and stop taking others in their bathroom medicine cabinets.

Scratching the surface

Many hospitals are using those two areas as starting points for their efforts to reduce readmissions as they gear up for more intensive programs to understand their underlying causes.

While that's a good place to start, the industry is really just scratching the surface when it comes to understanding the problem, says Michael Hollenbeck, vice president of health care at Predixion Software, a San Juan Capistrano, Calif.-based vendor of predictive analytics.

"At this point the industry has to do broad swatch interventions they can do across the board, but we've learned that at each institution, cultural issues and local practices have a significant effect on readmissions," he says.

Case in point: Predixion analyzed readmissions for a New York health system and found that patients who were on psychotropic drug therapies were "pretty much guaranteed to be readmitted to the hospital," Hollenbeck says. But at another client site in Texas, psychotropics were such a non-factor in readmissions that Predixion initially thought it had crunched the data wrong.

"Think of readmissions right now in terms of credit scoring, and think what a mess commercial lending would be if those lenders didn't have FICA scores to base decisions on," Hollenbeck says. "The health care has no standardized data that can guide caregivers to their highest probability candidates of readmissions, so they have to look at ways to universally lower those readmissions."

While shortcomings in patient hand-offs and other process-related care issues are a widespread industry weakness, the fundamental reason for high readmission rates are the disease states themselves, says Steven Shapiro, M.D., chief medical and scientific officer at University of Pittsburgh Medical Center, a massive integrated delivery system that encompasses more than 20 hospitals and 400 other care facilities, along with a health plan covering 1.6 million lives.

Long, complicated lives

"We've advanced to a point where we can keep people alive much longer, but the result is that the elderly patients we treat are living with multiple chronic conditions," Shapiro says. "The same issues we're seeing with our elderly population is what CMS sees when it looks at the data. There are certainly opportunities to better educate the patient and keep them on care plans, but some readmissions are unavoidable." To illustrate his point, Shapiro points to UPMC's readmission rates for chronic obstructive pulmonary disease. While readmissions for other disease states such as congestive heart failure have dropped significantly with more intensive care plans, the health system hasn't been able to bring down COPD readmission rates, which hover around 15 percent. "A large subset of patients with severe COPD gets readmitted frequently, and we haven't been as successful with disease modifying therapies as we have with other conditions. Right now the industry doesn't have the answers to COPD, which is now the third-leading cause of death in the United States."

However, UPMC has found care gaps that need to be addressed. One area it's homed in on is medication reconciliation, Shapiro says. A study that had UPMC personnel visiting patient homes to figure out what meds they were taking found that less than half were following the correct medication regimens after discharge. That's an enormous problem, Shapiro adds, considering how critical those therapies are, but somewhat understandable due to the prolific number of medications many patients are on.

UPMC has stepped up the intensity of its medication reconciliation process by pulling data from its in-house pharmacies as well as some outside facilities. That's part of a focus on very detailed care paths developed by UPMC for certain conditions such as CHF. "We thought that putting so much structure around the hospital care would increase the length of stay, but we found in a CHF pilot study that they actually reduced LOS by 20 percent. We're watching them more carefully than we had, and reacting to changes in their conditions more quickly," Shapiro says. The finding jibes with a 2011 study by Thomson Reuters that found a statistically significant correlation between higher readmission rates and longer initial hospital stays. The study, which analyzed readmission data for heart patients in nearly 4,000 U.S. hospitals, found that hospitals that were better at complying with widely accepted treatment guidelines had lower readmission rates for heart attack and heart failure patients.

Overall, the readmission rate at UPMC for congestive heart failure patients has dropped significantly-to 13 percent from more than 20 percent for late-stage CHF patients-in the year since the programs were instituted.

In addition to more regimented care during a hospital stay, UPMC is using the HealthTrack personal health record software from Epic Systems to put medication regimens and post-discharge plans into patient PHRs. More than 100,000 patients are actively using PHRs, Shapiro says, and the health system is developing patient educational videos as well as testing hand-held applications that would enable patients to communicate health information back to caregivers.

UPMC also has made significant technology investments to eliminate the disconnects between inpatient and outpatient data exchange. It's using software from dbMotion to give caregivers a consolidated view of electronic records from its inpatient EHR, from Cerner, and its outpatient records system, from Epic. The dbMotion software basically fills in the blanks between the records systems, pushing data from one to the other as needed.

Oregon Health and Science University has made a similar effort to eliminate communication drops via the Epic Care Everywhere Network, which alerts primary caregivers and other providers when a patient has an encounter at any facility that can tap into the network-which in the greater Portland area, is just about everyone. All the major health systems are Epic users, as are the majority of physician practices.

After an encounter occurs, the primary care physician is sent a Continuity of Care Document, an electronic document exchange standard developed by ASTM International and Health Level 7 to enable sharing patient summary information, including progress notes, lab values and other documentation from encounters. In addition, discharge summaries also are sent to primary care physicians when their patients leave the hospital so the information can be passed onto care managers and other staff responsible for coordinating post-discharge care.

OHSU also is providing a low-tech service that faxes an admission record to the primary care doctor, a record that also includes the name and phone number of the attending physician.

Closing the loop among hospitals, patients and other caregivers has been a struggle for the health care industry. While every hospital provides some form of discharge instructions, they often are worth about as much as the paper-stubbornly, paper-they're written on.

In the case of Portland VA Medical Center, a switch from a paper to an electronic discharge process resulted in "drastic" improvements in readmission rates for same-day surgeries and inpatient cases, says Pattie Boast, program analyst for the operative care division.

The medical center for years had provided handwritten discharge instructions to patients, many of which were done somewhat half-heartedly by busy physicians and provided no clear instructions on how to get help with any post-op complications. A few years ago Portland VA automated the creation of discharge summaries to combine standardized directions and nurse notes with physician discharge orders from the medical center's electronic health record, the Computerized Patient Record System used by the Department of Veterans Affairs, that's built on the VistA platform.

Getting personal

The discharge summaries, which are created using software from iMed, are still handed out to patients in paper form, but include much more personalized and detailed information-as well as the number to a nurse advice line. In addition, nurses can adjust the font size and other formatting on the form to make it easier for patients to read.

Along with providing better post-discharge instructions, the medical center also decided to give patients preliminary discharge instructions before they came in for same-day surgeries, giving them a chance to digest the information when they're not under medication.

But getting post-discharge instructions into an understandable format is half the battle. The Dartmouth Atlas Project found that only 42.9 percent of patients released from the hospital had a primary care visit within two weeks of discharge. Factoring in that glaring care gap is a first step in understanding readmissions, says Wayne Pan, chief medical officer at the Individual Practice Association Medical Group of Santa Clara County, better known as SCCIPA. "When we analyze our readmission rates, we consider one avoidable if the patient wasn't seen within two weeks after discharge by a primary care doctor or specialist, or if we haven't done a medication reconciliation 'event' when they were hospitalized. You can't get readmissions to zero, but these avoidable incidents mean you just don't have a system in place."

SCCIPA, which comprises 280 primary care physicians and 550 specialists, found that while area hospitals were providing discharge instructions, there wasn't enough effort to confirm that those instructions were acted on. So it's set up a program mixing more patient interaction with increased electronic documentation.

At discharge, the plan is distributed to a care team tasked with having a confirmed follow-up with a patient within 48 hours of discharge. A member of that team also confirms the actual date and time of the patient's initial post-discharge appointment, and they also follow up via the phone to make sure that the appointment actually took place.

The documentation is entered into the medical group's Coordinated Care Platform, which combines two different information systems; Access Express, developed in-house, and Excelicare, a clinical application from AxSys Technology, based in Glasgow, Scotland.

Access Express was initially built to handle HMO contracts and authorization processes, but SCCIPA expanded it to include care utilization and clinical pathways, among other documentation. The Excelicare system stores clinical data such as pharmacy info, labs, and radiology and discharge reports. Nearly 40 percent of SCCIPA's physicians are using some form of electronic health record at their individual practices, Pan says, but everyone's hooked into the Coordinated Care Platform and SCCIPA mandates the use of the system.

The medical group focuses its readmission reduction programs on three conditions-CHF, COPD and pneumonia-as well as patients with four or more disease states, those who have been hospitalized two or more times in six months, or have been to an emergency department three or more times in six months.

Pan says SCCIPA's efforts have gotten readmission rates in the "low teens" for its overall patient population, but the group hasn't been able to significantly reduce readmissions for its Medicare population. "Medicare patients are sicker, and we just don't know how we're going to get those numbers down," he says.

Here's the thing about tackling readmissions: To do so typically requires significant investments by providers for staff to do intensive management of patient populations, as well as additional I.T. investments. It's expensive, and the net financial benefit now is that providers don't lose Medicare billing revenue. Yackel, from Oregon Health and Science University, says that seed money is crucial as the industry moves from a fee-for-service model to something "a little more thoughtful."

"We really are in an interesting transition period that's requiring the care community to change its motivations," he says. "What has driven us to this point was that the incentives in the market directed us to consume resources where they'd be reimbursed-maybe a patient could have spoken with a pharmacist about issues with their hypertension, but they instead would see a doctor because that encounter was reimbursed.

"But that's not how the future's shaping up. We're going to have to do what makes the best sense for the patient. But during this transition we're still operating in a fee-for-service structure, which makes it tough to increase resources without getting higher reimbursements for it."

OHSU, for its part, is getting help during the transition. The John A. Hartford Foundation has provided grant money for OHSU's Care Management Plus program, which relies heavily on I.T. to coordinate care for chronic disease patients. In addition, a consortium of local payers is picking up the tab for care managers at OHSU facilities who identify and contact patients who are utilizing high amounts of resources.

Roadblocks

The efforts at OHSU are an example of the broader, industrywide effort to move the chains when it comes to establishing a continuum of care, spurred by the carrots and sticks CMS is throwing out via accountable care and related payment reforms, value-added purchasing, and the rest of a vast array of programs. But even the most medically and technologically aggressive health systems have to deal with the multitudes of caregivers that are bringing up the rear.

"Hospitals have made significant progress with deploying EHRs and getting data into a shareable electronic format, but it's still enormously difficult for them to hand off that information to caregivers in post-acute facilities," says Jody Cervenak, a director at consultancy Aspen Advisors who spent 20 years at University of Pittsburgh Medical Center, most recently as CIO for the physicians division, which comprises more than 2,000 employed UPMC physicians.

"There are so many points in this care continuum still running on paper, so that data is going from electronic to paper, and often has to be converted back to electronic when it gets to a primary care office."

There has been progress, but what's needed hand-in-hand with improved automation are incentives and structure around accountability for readmissions, she says.

"The questions that need to be answered are whether the patient being discharged is ready for the world. Do they have friends and family to create a safety net? Can they articulate what their discharge plan is? Are they ready to perform certain actions on their own? These, like so many issues in health care, are a matter of incentives, and the incentives in a fee-for-service aren't aligned to address them. But changes are coming."

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