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Who Gets Paid for Reduced Hospital Readmissions and Who Can Solve It – The Disconnect

Posted on February 28, 2014 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 15 blogs containing almost 6000 articles with John having written over 3000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 13 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit.

If it seems like I’ve been really interested in hospitals readmissions lately, it’s because I am. A hospital readmission is a complicated thing. What’s not complicated is we know that we don’t want hospital readmissions. They are expensive and costing healthcare a lot of money. What’s not as clear is who is responsible and how we can motivate them to reduce readmissions.

Most people believe that a primary care doctor is the key to reducing readmissions, but I broadened that discussion in my previous post about post-acute being the real cause of hospital readmissions. I’ll be really interested to work with people to discover what the real cause of hospital readmissions are in a hospital. Either way, I haven’t heard people making the argument that the hospital is the one that’s responsible for the hospital readmission. I guess there’s something to say about how quickly or slowly the hospital releases the patient from the hospital being a contributing factor, but I haven’t heard anyone argue that’s a significant contributor (I’d love to hear if someone has other info).

I think this is important to understand, because it could describe that the hospital who will get the financial benefit of reduced hospital readmissions isn’t the organization that can actually solve the problem. Does it make sense for us to be paying hospitals for reduced admissions when in fact it’s the primary care doctor or post-acute organizations that can really reduce the readmissions? Are we relying on hospitals to reach out to primary care docs and post-acute organizations in order to solve this problem?

Obviously, more and more hospitals are starting to get into ambulatory practices as well. In these cases, then the hospital can also be the primary care doctor. However, that’s still only a small portion of healthcare. What about the rest?

Of course, we shouldn’t cut the hospitals out of benefiting from reduced hospital readmissions. It’s hard for a primary care doctor to reduce the chance of a readmit if they don’t know that one of their patients was admitted. The hospital needs to be involved to let the primary care doctor know. Long term care and skilled nursing facilities likely can’t do it on their own either. For example, some don’t have the expertise to avoid the readmits. However, could they rely on the hospital experts on an as needed basis to get access to the skills they need?

The only way we’re going to really reduced hospital readmissions is by having all of these organizations (and the patient) get on the same page and rowing in the same direction. However, it seems the current reimbursement model only incentivizes the hospital to participate.

What’s the Real Cause of Hospital Readmissions?

Posted on February 24, 2014 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 15 blogs containing almost 6000 articles with John having written over 3000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 13 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit.

To a person, I’m sure that every hospital has a detailed understanding of their hospital readmission number. Reimbursement depends on it and so every one or them knows that number well. However, how many of them really know the cause of their hospital readmissions?

As I consider the various companies working to reduce hospital readmissions, the vast majority (possibly all) of the ones I’ve seen and heard have focused on home health technologies. In theory, the idea makes sense. Someone is discharged from a hospital and so we need to provide them better home health technologies that can prevent them from returning to the hospital. This is the promise of home health technology and the media loves to cover it.

However, in a recent pre-HIMSS Google+ video briefing I did with Capsule, Stuart Long, their Chief Marketing and Sales Officer, made a comment about hospital readmissions that I’d never heard before. He said that the majority of readmits were coming from long term care and skilled nursing facilities and not from the home.

I found this to be a fascinating finding and one that made a lot of sense. However, I pressed him to know where he got the data for it. Since it was done from an internal survey, he offered me the following explanation of the finding:

Recently, Capsule surveyed the market to assess the level of financial pain that hospitals were feeling due to the Medicare penalties associated with 30 day readmissions coming from the patient’s home. We found that technology, although market buzz suggests otherwise, was not the main driver for hospitals mitigating the risk of penalty expenses associated with readmissions. To our surprise our survey of hospital CFO’s revealed that to date it has been the improvement of existing and newly deployed care processes that has had the most significant impact on the management of – in some cases even the reduction of – patient readmissions.

However, a consistent theme that was discovered across our survey was that the hospital readmission issues are not primarily coming from the home, but from long-term care (LTC) facilities and skilled nursing facilities (SNFs). Key points discovered include:

  • 60%-80% of readmits come from LTC & SNF
    • Mostly due to high co-morbidity (High number of simultaneous chronic diseases).
    • Discharges can vary to location based upon relationships with LTC’s and SNF. As high as 33% of patients to SNF, LTC and Home Health to “in network partners” where they have control through people and process.
      • 66% of discharges, however are “outside the network” to LTC and SNF where they have no insight to the patient.

This survey data supports the need for healthcare facilities to have a Remote Patient Monitoring (RPM) System & Clinical Decision Support solution for this population due to Accountable Care Organizations (ACO) and capitated reimbursement. To be able to effectively reduce readmissions and provide the best treatment of patients, much better care coordination is needed. For starters,

  • Data MUST be communicated to the primary physician. There is a driving need to send data to multiple caregivers.
  • There is a need to notify the primary physician or responsible caregiver in the event the patient show’s early signs of deterioration.

The additional challenge with the home is how to manage patient compliance. The current trend is to send an RN, Nurse Assistant, Case Manager or other outside company to the home for care.

Further to this point, a paper published by the Department of Health and Human Services OFFICE OF INSPECTOR GENERAL; “MEDICARE NURSING HOME RESIDENT HOSPITALIZATION RATES MERIT ADDITIONAL MONITORING” November, 2013 can be found here. This paper substantiates the problem with a specific disease condition that contributes to the high readmission rates from LTC and SNF’s.

In FY 2011, nursing homes transferred one quarter of their Medicare residents to hospitals for inpatient admissions, and Medicare spent an astonishing $14.3 billion on these hospitalizations. Nursing home residents went to hospitals for a wide range of conditions, with septicemia the most common.

I think this is a really important finding and I’d love to have it validated by readers of this site who have data from their hospital. Do you see the same thing happening with your hospital readmissions or something else?

If we assume that this finding is true, then the solution to the problem of hospital readmissions is very different than I previously thought. I think Capsule sees it as a tremendous opportunity for them to leverage their skills with connected devices in places like long term care and skilled nursing facilities.

As part of this strategy, Capsule just announced at HIMSS 2014 a new medical device information system that they’re developing. At first this sounded more like a device tracking system for medical devices. Is the device working properly? Where is the device? etc. Certainly it will have those features, but Capsule is looking at this medical device information system from a much larger perspective. They want the system to Connect, Monitor, Analyze, and Act. Connecting is what they’ve always done. Monitoring is the medical device management piece. However, Analyzing and Acting on the data those devices collects puts Capsule in a very new space.

I’ll be interested to see how deep Capsule goes with this and who they choose to partner with to put together the intelligence behind the “Analyze” and “Act” components. This will take some work and many will argue that this type of stuff should be done in the EHR. However, you have to remember that long term care and skilled nursing facilities were left out of the EHR incentive money and are way behind the rest of healthcare in IT adoption. Could these post-acute facilities put in a medical device information system from Capsule as a way to reduce hospital readmissions? Seems like an interesting and reasonable strategy to me. Plus, the hospital would be happy to pay for it if will indeed reduce their hospital readmissions.

EMRs Can Reduce ED Visits, Hospitalizations For Diabetics

Posted on September 16, 2013 I Written By

Anne Zieger is veteran healthcare editor and analyst with 25 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or www.ziegerhealthcare.com.

Using EMRs is associated with a drop in ED visits and hospitalizations among diabetics, according to a study covered in iHealthBeat.

The research, which appeared in the Journal of the American Medical Association, involved analyzing all of the 169,711 records for patients enrolled in Kaiser Permanente Northern California’s diabetes registry.

Researchers drew on data collected between 2004 and 2009. During this period, in 2005, KP began to stagger EMR implementations across the region’s 45 outpatient facilities, iHealthBeat reports.

The study found that EMR implementations were associated with the following results, according to iHealthBeat:

  • 10.50% decline in hospitalizations for preventable, ambulatory-care sensitive conditions, or about 7.08 fewer hospitalizations per 1,000 patients annually;
  • 6.14% decline in non-elective hospital admissions, or about 10.92 fewer admissions per 1,000 patients annually;
  • 5.54% decline in ED visits, from an expected 519.12 per 1,000 patients to 490.32 annually; and
  • 5.21% decline in hospital admissions, from an expected 251.6 per 1,000 patients to 238.5 annually

That being said, EMR implementation had no effect in certain areas. The number of physician office visits per year held steady at six; the frequency of times patients saw diabetic exacerbations remained level; and how often patients developed cardiovascular diseases remained the same, iHealthBeat noted.

The researchers concluded that these results represented not only an improvement in diabetes care, but also “the cumulative effect of EHRs across many different pathways and conditions.

This study is one of a growing body of evidence that effective EMR  use can reduce readmissions and improve outcomes.  For example, a recent study appearing in BMJ Quality & Safety recently concluded that EMRs can help reduce hospital readmissions of high-risk heart failure patients.

In that case, researchers used EMR-based software to sort high-risk from low-risk heart failure patients, using 29 clinical, social and behavioral factors within 24 hours of admission for heart failure. Using this tool, researchers were able to cut readmissions rates for the 1,700 adult inpatients study from 26.2 percent to 21.2 percent.

EMR Analytics Reduce Cardiac Readmissions

Posted on August 6, 2013 I Written By

Anne Zieger is veteran healthcare editor and analyst with 25 years of industry experience. Zieger formerly served as editor-in-chief of FierceHealthcare.com and her commentaries have appeared in dozens of international business publications, including Forbes, Business Week and Information Week. She has also contributed content to hundreds of healthcare and health IT organizations, including several Fortune 500 companies. She can be reached at @ziegerhealth or www.ziegerhealthcare.com.

A new study has concluded that EMRs can help reduce hospital readmissions of high-risk heart failure patients, according to a report in Modern Healthcare.

The study, which appeared in BMJ Quality & Safety, looked at more than 1,700 adult inpatients who had been diagnosed with heart failure, myocardial infarction and pneumonia over a two-year period at Dallas-based Parkland Memorial Hospital.

Researchers first used an EMR-based software package to sort high-risk from low-risk heart failure patients. The EMR analytics software drew on 29 clinical, social and behavioral factors within 24 hours of a patient’s admission for heart failure.

Using this tool, researchers were able to cut readmission rates for the studied patients by from 26.2 percent to 21.2 percent, according to EHR Intelligence. Not only that, hospitals were able to shift resources to patients at highest risk while they were still in the hospital.

As we who work in and around health IT know, reducing readmissions through better data analysis is something of an obvious move.  EMR users may not yet have the predictive analytics in place to make this happen, but I think solutions will be coming to the marketplace, and soon.

That being said, it could be a while before such solutions reach their full potential. After all, predicting patient needs is more likely to work if hospitals and health systems integrated EMRs with community medical practices, and we all know how challenging this is still.

Perhaps the work of building robust predictive analytics systems can begin in earnest in situations where the hospital owns the medical practice and both use the same system. But even in those cases, hospitals will still be treating patients seen by community practices outside of their organization.

Bottom line, this study is an interesting look at the possibilities of mining EMR data for direct patient care improvement. Let’s see how many more projects of this kind hit the news this year.

Hospital EHR Device Integration

Posted on January 11, 2013 I Written By

John Lynn is the Founder of the HealthcareScene.com blog network which currently consists of 15 blogs containing almost 6000 articles with John having written over 3000 of the articles himself. These EMR and Healthcare IT related articles have been viewed over 13 million times. John also manages Healthcare IT Central and Healthcare IT Today, the leading career Health IT job board and blog. John is co-founder of InfluentialNetworks.com and Physia.com. John is highly involved in social media, and in addition to his blogs can also be found on Twitter: @techguy and @ehrandhit.

This week has been pretty crazy for me as I’ve been attending three conferences back to back. Plus, the conference in the middle is the 120,000 person CES (Consumer Electronics Show) in Las Vegas. The healthcare section of CES has been growing like crazy. Those who had 10×10 booths last year now have 20×20 booths and the number of health IT related companies at CES has grown 20%.

As I’ve been browsing these ever growing booths about consumer health I’ve been smothered in various consumer focused devices. I’ve seen every sort of FDA cleared device including: Blood Pressure Cuffs, Scales, Dermascopes, Otoscopes, Pulse Oximeters, Stethoscopes, and Thermometers. The innovation with these devices is amazing. The integration with these devices and other device is amazing. The price point for these devices is dropping.

With all of this in mind, I’ve wondered why more hospitals aren’t taking a larger interest in what’s happening here. Not to mention why more hospital EHR vendors aren’t integrating with these devices as well. Someone asked me what’s the difference in these devices versus the ones that are being used in healthcare today. The obvious answer is price and brand recognition (trust). Although, they are all FDA cleared devices, so is there really a difference in the results? The FDA clearance process is quite rigorous. I don’t have the full answer to this question, so I’d love to hear from some hospital people and other device manufacturers to hear your view on it.

Maybe the answer is that hospitals are buying the big expensive devices because those are the devices that integrate with their hospital EHR system. If that’s the main reason, then we need more of the major hospital EHR vendors to start doing the medical device integration with these low cost alternatives. Imagine the cost savings.

The other side of the coin is hospitals deploying these devices to the patient. I’ve seen this in a few cases where the hospital wants to reduce readmissions. Although, it’s an interesting dance since it is largely under the purview of the primary care doctor. It’s always felt awkward that the hospital’s readmission issues are dependent on a group of doctors that don’t work in the hospital. Maybe this will change as hospitals buy up more doctors offices.

It’s an exciting time to see the devices coming to healthcare. I just wish I saw more hospitals and hospital EHRs involved in what’s happening. I wonder how many healthcare CIOs are seeing what’s happening and planning for it.

I predict 2013 will be the year of the consumer health device and I don’t think most hospitals or doctors are ready for it.

EMR Helps Philly Hospitals Reduce Readmissions

Posted on December 23, 2011 I Written By

Katherine Rourke is a healthcare journalist who has written about the industry for 30 years. Her work has appeared in all of the leading healthcare industry publications, and she's served as editor in chief of several healthcare B2B sites.

The pressure is on to reduce readmissions, and hospitals are hoping to leverage their ginormous investments in EMRs to help the job along.  Well, here’s a case where that actually happened.

A recent survey of 29 Philadelphia-based hospitals concluded that facilities submitting patient readmission data to the Health Care Improvement Foundation had seen a significant drop in readmissions over 18 months, according to Information Week.  The project, known as PAVE (Preventing Avoidable Episodes: Smoothing the Way for Better Transitions), focused on medication management, personal health record use and care transitions.

(Editor’s note: While IW once focused on broad enterprise IT issues, I’ve been impressed lately by the excellent job it’s done covering health IT. You may want to check it out.)

The 18 Philly hospitals that submitted the data saw a 7 percent drop in 30-day same-hospital readmission rates. More than 400 patients avoided readmission, representing a savings of $4 million just for the third quarter alone. That fell short of the project’s goal of a 10 percent reduction rate, but it’s pretty neat anyway, no?

The hospitals accomplished the readmissions reduction by building on tried and true quality improvement processes, largely focusing on transitions of care. But their efforts were enhanced greatly by EMRs and other forms of health data management, the magazine reports.

Having seen what can be done, nearly all of the hospitals are now implementing or evaluating a series of “passports,” documents compiling critical information on hospital care transitions, payor relations/utilization management, discharge and medication management. (My hunch is that the passports are being turned into pathways within the EMR; if I’m right, that seems like a real missed opportunity.)

Unfortunately, neither the  Health Care Improvement Foundation nor the magazine spelled out how the hospitals used their EMRs, though it’s obvious that they must of used data analytics tools.  And we don’t know which EMRs the hospitals have in place, which might offer some insights.

By the way, the PHR pilot was a bust. Researchers found that patients who’d get the most out of PHRs were least likely to maintain one. The group threw in the towel and developed a heart failure education book designed to educate patients in self-management.

All told, it’s good to see concrete demonstrations of  how EMRs can help hospitals meet critical goals.  While EMRs may still be a resource drain, perhaps they’ll finally be able to give something back.