Jane Brock, M.D., on July 23
In a keynote presentation entitled “Is IT Moving the Needle? Reducing Hospital Readmissions & Improving Outcomes,” Jane Brock, M.D., MSPH, gave her audience a good deal to think about, on Wednesday, July 23, at the Health IT Summit in Denver, being held July 22-23 at the Hyatt Regency Denver Tech Center. The Summit is being sponsored by the Institute for Health Technology Transformation, or iHT2 (since December 2013, iHT2 has been in partnership with Healthcare Informatics through its acquisition by the Vendome Group, LLC, the parent company of Healthcare Informatics). Brock, the chief medical officer and clinical coordinator at the Denver-based Colorado Foundation for Medical Care, which is the Medicare quality improvement organization (QIO) for the state of Colorado.
Indeed, Brock’s organization, CFMC, helped to reduce readmission rates by 10.78 percent in northwest Denver, in a federally sponsored program that helped to document the potential for such innovative work (see HCI Senior Editor Gabriel Perna’s June interview with Dr. Brock here). What Dr. Brock had to say to the audience at the Health IT Summit in Denver this week was this: there are no “shortcuts” to successful avoidable readmissions reduction work, and while there is tremendous potential for IT to facilitate this type of work, all such facilitation will require intensive thoughtwork, planning, and process work; there will be no simple “automation” of processes, as the processes that are proving to be successful in this area are complex and just being figured out right now in the field.
“When you start to talk about IT solutions for readmissions reduction work, I have no doubt that it will be helpful and there will be a role, but teasing out the specifics is challenging. And the language of IT is very awkward, I must say; and when you get a bunch of IT people and clinicians together, it’s often challenging,” Brock told her audience on Wednesday. “And until very recently,” she added, IT folks were trying to work with folks who didn’t have the basic equipment needed to do what they wanted to do. So many systems were not able to be implemented until fairly recently.”
As she had told HCI’s Perna last month, “Historically, we’ve been trying to enact the perfect, finished solution and sometimes that has stood in the way of simpler steps. There are incremental things that could be put into place while we work on perfection, and yet the work on perfection is so overwhelming that sometimes we let the perfect be the enemy of the good.”
Brock expanded on those perspectives on Wednesday in Denver, telling her audience that in order to begin effectively reducing readmissions in a community, “You’ve got to build a better bridge, a more reliable bridge. You need to build a standardized discharge structure. You need good partners. So often,” she said, “hospitals discharge to individuals and organizations they really don’t know much about. You need timely communication. And then there are new players in the discharge process: navigators, coaches, and transitional care nurses. And you have to address the capabilities of people.”
In fact, Brock said, a key point is that right now, in many cases, what’s needed are relatively simple IT bridges, to help individuals involved in the discharge process communicate more effectively with one another, even as clinical and administrative professionals dig deeper to figure out the underlying causes of readmissions.
Often, she added, those causes are not purely medical; and in many cases, they are not strictly medical at all. Often, patients end up being readmitted because they lack the social structures to support them—family caregivers who can help them remain in medication compliance; problems around transportation, including such issues as not having enough money for bus fare to go back to their primary care physicians for follow-up office visits; problems with the layout of patients’ homes, or even homelessness and semi-homelessness. What’s more, data-facilitated analysis of readmissions occurrence is so often hobbled by an inability to get to some of those underlying issues for patients, particularly the non-medical issues patients at risk of readmission face.
“You need [patient] engagement, [patient] activation, preparation, confidence, good instructions, direct assistance,” to avert readmissions, Brock told her audience. “You need good patient activation measures. This whole notion of confidence is really where we need to be investing more work,” she emphasized. “In 2008, Medicare gave us a contract across 14 communities in 14 different states, involving 800,000 patients. The mission was, figure out who lives there, where they’re hospitalized, etc. And what we learned,” she said, “is that patients go home to an environment, and that home environment is much more influential to patients than the provider they saw. We learned that the readmission measure we’re using is problematic. Right now, Medicare calculates readmissions by dividing the number of discharges by the number of readmissions. Yet at the same time, a 40-day readmission is counted as an admission. There are a lot of issues involved, because as you get the community together to address transitions, the denominator goes down, too, not only the numerator. So number of readmissions per 1,000 of residents living in a community/zip code is better.”
More broadly, Brock said, the key point is that a huge amount of deep process and investigative/process mapping work has to go into readmissions work before U.S. healthcare leaders can become more confident that their analyses of the causes of readmissions are accurate and can begin identifying many of the important underlying causes. At the same time, she said, there are virtually no IT applications currently running that incorporate some key elements that need to be brought into effective readmissions work. For example, she asked rhetorically, “What’s important to the next provider, in a readmissions context? It is these things: pertinent labs and pending tests; medication changes; new problems and updated problem lists; the presence of liens and catheters; oxygen requirements; current cognitive status or change in cognitive status; skin condition/pressure ulcers; secondary insurance; the presence of any power of attorney.” Those items, presented as a checklist, seem to be incredibly difficult to insert into electronic communications and document-sharing processes among providers, she noted. “I just wanted someone to post this! But at the time, everybody was working on some kind of perfect, interoperable solution,” she told her audience.
What’s more, the emergence of new players in the discharge scene—patient navigators, coaches, and transitional care nurses—will have to be factored in, even as discharge processes become standardized, with discharge process standardization an absolute requirement for effective readmissions reduction work going forward, Brock stressed.
In the end, she told her audience, “The role of IT will be essential in work to reduce avoidable readmissions. But you IT professionals will have to become experts in workflow management in order to make automation meet its potential in this area.”