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Get Out - And Stay Out

June 26, 2009
by Daphne Lawrence
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With readmission penalties on the horizon, CIOs are laying the groundwork for post-discharge solutions

Stephen Jencks, M.D.

Stephen Jencks, M.D.

A recent study published in “The New England Journal of Medicine” reported that 20 percent of Medicare patients are readmitted to hospitals within a month. Bills being introduced in Washington suggest that hospitals may soon be held accountable for these costly readmissions - which in 2004 alone cost Medicare a whopping $17.4 billion.

“A lot of people see this as a ‘right now’ issue,” says Stephen Jencks, M.D., a Baltimore-based consultant and principal author of the study. “This topic is of as much interest for its ability to leverage real change as it is for the benefits to the patient.”

Rich Temple

Rich Temple

That real change means a paradigm shift in the business model of care delivery from incident-based to episode-based, and thus, to keeping patients out of the hospital. “In the current model, there's absolutely no incentive for a hospital to reduce readmissions,” says Rich Temple, former CIO of St. Clare's Health System in Denville, N.J., and currently CIO of AristaCare Health Services, a network of long-term care facilities based in South Plainfield, N.J. “It's a very perverse system,” he adds.

Robert Wachter, M.D.

Robert Wachter, M.D.

But as politicians nationwide jump on the healthcare reform bandwagon, most agree that sweeping changes will pass, as bill after bill is submitted in Washington. Sooner rather than later, many say, hospitals will be penalized for these costly readmissions through lower Medicare reimbursements.

“I think cuts in reimbursement for readmission are inevitable,” says Bob Wachter, M.D., a San Francisco-based consultant and author, who believes the timeline will hinge on overall healthcare reform. “There are savings that they need to find under a rock somewhere, and there is a decent sized budget line that says we're going to save a lot of money by preventing excessive readmissions.”

If health reform happens, most agree some aggressive tactics to promote better transitional care at the time of discharge has to be part of the package. “This is one of those targets that seems so right in so many different ways, it's hard to figure out who will argue against it,” says Wachter.

Candidates for the opposition include hospitals and doctors, who stand a good chance of losing valuable Medicare money if penalizing legislation is passed. But many ask why hospitals should be held accountable for patients' compliance once they leave the facility. “Is it fair for a hospital to get dinged for public reporting on its mortality rates because a patient had a certain lifestyle?” counters Wachter. “That's not fair either, but nobody thinks twice about that.”

And though any post-discharge interventions like remote monitoring (and the FTEs to read those monitors) will cost strapped hospitals money, they may have to bite the bullet. “Hospitals do all sorts of stuff they can't afford if it's mission critical,” Wachter says.

The data that shows many readmissions are preventable is strong, particularly for some chronic conditions like congestive heart failure (CHF). Often, steps to prevent readmissions are not that expensive or complex - and some CIOs are already preparing for what seems to be inevitable.

“What we're seeing now is a more global approach to patient care, and that's where technology is really going to play a role,” says Mrunal Shah, M.D., vice president of Physician Technology at the five-hospital Ohio Health system in Columbus. “We know there are limited resources for patients once we discharge them, but there are ways to get involved.”

The technology that Shah is leveraging at Ohio Health is a Web-based, patient-specific education tool from Chicago-based Emmi Solutions that the hospital is using as part of a pilot program around post-discharge care. Most agree some enhanced attention to patients' engagement and education at the time of discharge is a key factor in preventing readmission. Shah is currently establishing baseline measures for the pilot, which targets CHF patients - one of the CMS measurables for readmission.

As part of the program, patients access education modules specifically tailored for them both in the hospital and back at home; Shah says the hospital gets a report on whether patients accessed the education and watched it in its entirety. Nurses document that content was provided, and Shah says he has the ability to report and follow up on that data. “Part of our baseline is what we expect from people,” says Shah, whose pilot began in May. “We hope to show an impact within 90 days.”

Many activities, in addition to patient education, have been demonstrated to decrease readmissions, and like so much in healthcare, interconnectivity is a big stumbling block. “A great many organizations believe that the health record begins and ends at the walls of their organization,” says Jencks. “But this is a place where effectiveness rests in the ability to share information.” He says sharing can be as simple as sending a prescription to a local pharmacy on behalf of a patient, or as complicated as having a multilevel record that different people can access when authorized.




Why aren't we looking at an easier way to share patient records? France uses the Vitale Card. It works in all computers and has the patient's entire medical history including reports like x rays. You don't have to worry about the various electronic information systems compatibility or incompatibilities. This works very well in France and the patient carries their own record with them on a plastic card with an embedded gold chip. If it is lost, you simply it in the mailbox and the card is returned to it's owner. Way too much time, energy, and money being spent in this country on figuring out how best to share patient information across the varied care continuum. Someone is making money off the inadequacy of our information systems and the goverment is footing the bill.