Issue Date: April 2011

Mastering Readmissions: Laying the Foundation for Change

Pioneers are Laying the Foundation for Serious Readmissions-Reduction Work

by Mark Hagland

EXECUTIVE SUMMARY

At a small number of patient care organizations nationwide, pioneering clinician, executive, and healthcare IT leaders are engaging in the serious work needed to lay the foundation for reducing avoidable inpatient readmissions, in such important areas as congestive heart failure. Not surprisingly, intelligently leveraging clinical IT is turning out to be a critical success factor.

Dallas, Texas remains noteworthy in the minds of many Americans for good steaks, ten-gallon hats, the Dallas Cowboys football franchise, and the 1970s soap opera Dallas (filmed in Hollywood, of course), among other things. But as a center for pioneering efforts to reduce potentially avoidable inpatient hospital readmissions? Even most healthcare professionals might not guess that point of distinction. Yet that is the reality, as a groundbreaking effort between two major Dallas hospital organizations is yielding results that could provide a model for hospital organization-based work in that important area. Meanwhile, just fewer than 300 miles to the southeast, in the city of Beaumont, a pioneering medical group seems to have cracked the code on medical group-driven readmissions optimization work.

What do the readmissions initiatives taking place in Texas have in common? In the first instance, the collaborative effort is being undertaken between Parkland Hospital in Dallas and the 24-hospital, Arlington-based Texas Health Resources (THR), in what could ultimately become a community-wide effort on readmissions. In the second instance, in Beaumont, the leaders of the 22-physician multispecialty medical group Southeast Texas Medical Associates (SETMA) are blazing new trails on behalf of their patients with chronic conditions. The leaders of all three organizations are using clinical IT strategically and innovatively to support their readmissions initiatives. And they are achieving significant results.

Very importantly, the work that the leaders at Parkland, Texas Health Resources, and SETMA are involved in will become increasingly critical to the providers' bottom lines. It's worth noting that two different sets of provisions in the federal healthcare reform legislation passed in March 2010 call for reductions in “unnecessary” readmissions under Medicare, with one of the sets of provisions linked to the soon-to-be-established Medicare value-based purchasing program. In short, federal healthcare policy makers are zeroing in on avoidable inpatient readmissions, and the time is now for providers to begin making progress in that area. Significantly, leaders in the organizations doing pioneering work in readmissions agree that leveraging clinical IT and the electronic health record (EHR) are essential elements to success in this sphere.

SOPHISTICATED RISK STRATIFICATION

Ferdinand Velasco, M.D.

In Dallas, a fortuitous collaboration has emerged between leaders at Texas Health Resources, led by Ferdinand Velasco, M.D., vice president and CMIO, and Ed Marx, senior vice president and CIO; and a team at Parkland Hospital, led by Ruben Amarasingham, M.D., who is both director of the hospital's Center for Clinical Innovation, and its associate chief of medicine services. How did that collaborative work begin?

Ed Marx

On the Parkland side, Amarasingham, an internal medicine hospitalist by background, and his clinical improvement team, have been working since December 2009 with a real-time risk-stratification data model that identifies congestive heart failure (CHF) patients at the highest levels of clinical risk, within hours of admission. “Every heart failure patient who is admitted gets risk-stratified using this model; and people in the highest-risk group get extraordinary interventions,” Amarasingham notes. The risk-stratification model has been worked out to a considerable level of refinement, incorporating 34 variables, some clinical, and others social and demographic. What's more, Amarasingham says, “The advantage of the electronic medical record in this context is that it captures all this data, and we have a mathematical model to produce this risk score.”

HAVE ORGANIZATIONS CREATED THE ELECTRONIC HEALTH RECORD PLATFORM TO BE ABLE TO LEVERAGE THE CLINICAL DATA OR NOT? IF YOU DON'T HAVE THAT AS A BASIS, IT BECOMES REALLY TRICKY TRYING TO REDUCE READMISSIONS, BECAUSE YOU'RE BASICALLY FLYING BLIND OTHERWISE. -ED MARX

So what happens once a CHF patient has been identified as being at the highest level of risk? “A number of things,” says Amarasingham. “Our software program will notify a heart failure ‘SWAT team’: a heart failure nurse practitioner, who will spend a lot of time with them; a pharmacist will spend an hour with the patient; a nutritionist will conduct a sodium-knowledge test and educate them and understand their dietary history; and an R.N. case manager will spend time working with them on the social work issues involved. And on discharge, the case manager will be heavily involved in medication reconciliation and making sure the discharge information is correct.” Then, within 24 hours of discharge, one of the nurse case managers will do a phone follow-up with each discharged patient, and ensure that that patient is seen within seven days of discharge at the hospital's heart-failure clinic, followed by a primary care physician visit within 30 days.

The result? At press time, Amarasingham and his colleagues were early in the process of data analysis on this program, but, he says, they are seeing very significant reductions in subsequent readmissions.

Meanwhile, at Texas Health Resources, Velasco, a cardiac surgeon by training, has been helping to lead colleagues in the THR system in a CHF program that is using a four-component care management protocol derived from the Transforming Care at the Bedside collaborative, begun in December 2009 by the Cambridge, Mass.-based Institution for Healthcare Improvement (IHI).

Among the IT-facilitated advances currently being made at THR hospitals, nurses doing the post-discharge follow-up phone-based assessment are now recording their notes into the health system's ambulatory EHR. What's more, Velasco says, “The next phase of that is to expand that to an interactive, Web-based encounter,” whose notes will be available to patients through the personal health record linked to the ambulatory health record (both products of the Verona, Wis.-based Epic Systems Corp., whose EMR is the core clinical IS for both THR and for Parkland). Already, says Velasco, strides are being made in reducing CHF-related readmissions.

But what is particularly exciting is that the Parkland and THR teams are currently laying the foundation for a metropolitan area-wide investigation into readmissions, in order to be able to assess what the rates of readmissions are for CHF patients to hospitals other than the ones to which they were originally admitted. Velasco and Amarasingham are excited about the research effort, even though the community-wide aspect of it may not yield any direct reimbursement benefits to either hospital organization under the emerging healthcare reform regulations. But both believe it's the right thing to do for patients and for the healthcare system.

CREATING THE EHR PLATFORM TO LEVERAGE DATA

THR's Ed Marx confirms the fact that the path towards building the IT infrastructure to support serious readmissions-optimization work is not so much mysterious, as simply daunting. “Have organizations created the electronic health record platform to be able to leverage the clinical data or not?” he says. “If you don't have that as a basis, it becomes really tricky trying to reduce readmissions, because you're basically flying blind otherwise.”

James L. Holly, M.D.

The key foundation for this work is clinical intelligence, or what the THR folks term “clinical business intelligence,” he insists. “The first level [to the foundation] is decision support, and we have quite a robust clinical decision support infrastructure,” Marx says, “And the next level is CBI, where we want to get to predictive analysis. That's where we're headed-we're not there yet, but we know that with the right data and algorithms, we could predict who might be coming back without the right interventions. And there's a whole host of analytics tools we could leverage.”

NATIONWIDE, JUST A FEW PIONEERS

While the work being done at Parkland Hospital and Texas Health Resources is absolutely at the cutting edge, the very fact of its innovativeness speaks to the core “chicken-or-egg” issue around readmissions-reduction work. Until the passage of federal healthcare reform, in the form of the Patient Protection and Affordable Care Act (PPACA), passed by the U.S. Congress and signed by President Obama in March 2010, there were few reimbursement incentives for doing this kind of work. Put bluntly, as everyone in healthcare knows, prior to healthcare reform at the federal level, nearly all the incentives, for hospitals in particular, rewarded waiting until patients were readmitted for inpatient care instead.

THE REIMBURSEMENT SYSTEM, AND ALSO IMPORTANTLY, THE INCENTIVES BEHIND THE REIMBURSEMENTS, HAVE NOT CONTRIBUTED TO WORK IN THIS AREA UNTIL NOW. BUT NOW THAT THEY'RE GOING TO BE PENALIZED FOR NOT DOING THIS WORK, IT'S GOTTEN EVERYONE TO SIT UP AND PAY ATTENTION. -KATE O'MALLEY, R.N., M.S.

But, say industry experts, things are set to change very quickly, which means that healthcare leaders will need to adapt very quickly to the emerging changes. “The reimbursement system, and also importantly, the incentives behind the reimbursements, have not contributed to work in this area until now,” confirms Kate O'Malley, R.N., M.S., the senior program officer at the Oakland-based California Health Care Foundation (CHCF). “But now that they're going to be penalized for not doing this work, it's gotten everyone to sit up and pay attention.”

A September 2009 CHCF report, “Homeward Bound: Nine Patient-Centered Programs Cut Readmissions,” looked at nine diverse case studies nationwide involving patient care organizations that have made headway in the readmissions area. “But,” O'Malley cautions, “these are early adopters; the challenge will be for your average provider to develop these activities in a way that will be sustained.” Most importantly, she adds, “Each of the models we looked at was developed on a relatively small scale to date.”

Of course, even relatively small-scale pilot projects, and even those without significant clinical IT facilitation, are demonstrating the feasibility and results that can come out of efforts in this area. For example, William S. Nersesian, M.D., the chief medical officer of the 1,200-doctor Fairview Physician Associates, based in the Minneapolis suburb of Edina, Minn., has been leading his colleagues in a collaborative care management project involving a local hospital and a local HMO, the 200,000-member UCare. In this case, UCare's associate CMO, Barry Bain, M.D., approached Nersesian with a proposal to create modest payment incentives for care transition management, noting that 20 percent of UCare's Medicare patients were being readmitted to hospitals within 30 days.

Notably, even without clinical IT facilitation, the program has shown meaningful results: at the outset, UCare's Fairview Physician Associates patients admitted to Fairview South Hospital were being readmitted at a 16.5-percent rate, whereas within five months, that rate had fallen to 11.6 percent, a 30-percent decline, Nersesian notes. Nersesian says he is eager to move forward in terms of clinical IT facilitation, but with FPA physicians working on about 30 different EMRs, much needs to be sorted through going forward.

SETMA'S BOLD MOVE INTO CARE MANAGEMENT

Are there medical groups that have unlocked the “secret” to intelligently leveraging clinical IT to systematically, successfully avert readmissions of their patients? A few, yes. One medical organization committed to the task is SETMA, a 22-physician organization based in Beaumont, Texas, just east of Houston. SETMA's CEO, James L. Holly, M.D., summarizes his organization's commitment both to care management and to clinical IT leveraging thus: “We operate on the principle that we wanted to facilitate as much knowledge as possible around the patient encounter, and we wanted to make it as easy as possible to do the right thing. And that's where we got the buy-in,” he says. “I've never met a physician or nurse who didn't want to provide good care; I've met clinicians who weren't willing to put the extra energy into it to make it happen. But they all wanted to do it right.”

Among the key steps that Holly and his fellow SETMA physicians have done is to put into place an automated process for calculating all 12 cardiovascular risk factors established in the famous, decades-old Framingham Heart Study (which include cholesterol numbers, blood pressure, and smoking status). As a result, Holly reports, “We're able to deploy all 12 risk calculators in one second, and we let them know in the visit, if you make the change, this is what difference it will make; and we're immediately able to incorporate that calculation into their plan of care. That's where the provider starts getting excited, the patient gets excited, and then everyone wants to get involved.”

What's more, when the post-discharge phone follow-up takes place, if the patient involved is not doing well, “They immediately get an appointment that morning; if they're doing well but are a little bit uneasy, they get an appointment for the following day,” Holly says. Very importantly, the notes from the case managers' follow-up phone conferences are all entered into the organization's EMR by the nurses.

IN THE PAST THE ISSUE HAS BEEN LACK OF INFORMATION; AND WE'VE MADE DECISIONS AS BEST AS WE COULD, BUT IN AN INFORMATION VACUUM. WHAT'S COOL NOW IS THAT WE'RE NOT ONLY LEVERAGING THE HISTORICAL DATA IN THE ELECTRONIC HEALTH RECORD, BUT WE'RE ALSO SEEING THE FRUITS OF THAT. -ED MARX

And at the strategic level, Holly and his fellow SETMA doctors have been using a business intelligence solution from the Ottawa, Ont.-based Cognos (since 2008, a division of the Armonk, N.Y.-based IBM) to continually assess the causes for the readmissions of their patients; and they are using the information from that process to continually improve their care management processes, using disease management templates embedded in their EMR (from the Horsham, Pa.-based NextGen Healthcare) to guide physicians whose patients have been identified as having one or more chronic diseases. (A fuller description of the implementation of that system is available on p. 16 of HCI's February cover story package.)

AT THE NEXUS OF IT AND CARE COORDINATION

All those interviewed for this article agree that a confluence of developments is making the averting and reduction in potentially unnecessary inpatient readmissions both more doable and more imperative, for a variety of policy and reimbursement reasons. Hospitals and physician groups alike will increasingly be affected by the payment changes looming on the horizon, as federal healthcare reform is implemented, and the Medicare program determines what an “unnecessary readmission” is, as well as cements the concept into its emergent value-based purchasing program, while the provisions in the Health Information Technology for Economic and Clinical Health (HITECH) Act push the envelope on the collection of quality outcomes data.

For Texas Health Resources' Marx, now is a time of opportunity to improve care management. “In the past,” he says, “the issue has been lack of information; and we've made decisions as best as we could, but in an information vacuum. What's cool now is that we're not only leveraging the historical data in the electronic health record, but we're also seeing the fruits of that. Everyone talks about leveraging data for meaningful use. But now we can really impact readmission rates, because now we have data. The second great part of this,” he adds, “is that we're cross-collaborating with other hospitals, and we're working together to do the right things for patients in our communities, and helping other hospitals, too.”

Marx's advice to his fellow CIOs, CMIOs, and other healthcare IT leaders? “Reach out and collaborate, internally and externally, just as we did with another hospital,” he says. “Sometimes, you may not have all the resources you need, or you might hear that someone else is doing something interesting. I always say, irons sharpen irons. Second, fight for those investments that will enable clinical quality, in this case, reducing readmissions. Fight because it makes a difference in the lives of your clinicians and patients. A lot of people want to skip that step, but it's important.”

SETMA's Holly notes that healthcare IT leaders will have to help their organizations overcome some very basic problems in order to leverage clinical IT to help avert readmissions. “We have two problems in healthcare that should be simple: maintaining an accurate and up-to-date problem list, and an accurate and up-to-date medication list, but they're incredibly difficult to do, even in an electronic environment.” And yet, to be successful in this area, he emphasizes, “You have to do that every single time.”

And, he adds, in order for CIOs and other IT executives to achieve success in working with front-line clinicians, “I think they have to genuinely collaborate, not just get people to be compliant-but collaborate where there's a commonality of interest for creating a standard for inpatient care data and for the transitions of care. If you have the best care in the hospital, but a sloppy transition, you'll lose 90 percent of what was accomplished in the inpatient setting. So they should sit down briefly, map out the determinants of excellence, and map out the capacity to make that happen; and it will take place when the EHR is used simultaneously among the hospital, nursing home and clinic, not necessarily the same vendor but interoperably.”

Ultimately, Holly says, building on early successes in this area will require further health information exchange (HIE) development. “I think a community-based HIE is critical to this whole process.” In other words, everyone needs to understand that the journey ahead on readmissions work will be long, challenging, and complex. But the work, all those interviewed for this article agree, needs to begin, now.

Healthcare Informatics 2011 April;28(4):10-16