Technological Breakthrough #1
Techonological Breakthough #2
Your hospital has a readmission problem.
Your CFO invites you out for what you think you will be a pleasant chat.
You cozy up to stool, and what you hear from said CFO is no surprise: “our hospital has a readmission problem!” Frown.
You then get your medicine (verbal instruction manual), as only a CFO can deliver it.
Time to hunker down, huh?
OK, juvenile anecdote, but the inspiration for this brief composition stems from two disparate streams: one hospital medicine (HM) related, the other from the “nothing in life is simple” file. They both channel into our readmission predicament.
The “life is not simple” inspiration sprung forth unexpectedly, and I only realized the similarity to my HM pickle when I began to write this post.
I have followed Don Taylor’s blog for some time (he now blogs here). A sharp academic, he writes often on health policy, palliative care, and most recently, his travails on one of HRSA’s working groups—tasked with redefining health professional shortage (HPSA) and medically underserved areas (MUA). He records the day’s events, warts and all, when his committee is live and operational.
Typically, his post will start with a description of what the group intends to accomplish that day—which characteristically reads like a laundry list of “to do’s” and how they will “get it done,” in the allotted few hours of meeting time. Not surprisingly, the discussions always take a convoluted turn, and what seemed simple at dawn, usually ends in ambiguity, stalemates, “friction,” and the creation of a new working group at dusk. One such bulleted outcome:
- making clear this was a ‘last chance’ designation….meaning only available if no other types of designations applied
- whether to have a income test or not; issue goes to broadening definition of underservice to those with relatively high means but who still cannot get reasonable care
- it got tied up with discussion of prisons, which are now being discussed separately
- what types of organizations could apply for such a designation
- some extra level of heat amongst some committee members that I didn’t ever get
Take home: nothing is ever simple. Yes, it seems obvious, but we all go into work groups and task forces thinking one thing, but because of input from disciplines we rarely caucus with, opinions from colleagues with different perspectives, or simple shallow-mindedness, we underestimate the complexity (or futility) of the task. Only in hindsight does the realization that gridlock would result seem obvious.
Okay, now to readmissions…
I participate in a care transitions working group organized by the Greater New York Hospital Association (GNYHA). They represent the interests of New York area hospitals; lots of intellectual firepower with a vigorous membership.
Over the course of several months and meetings regarding the readmission dilemma, GNYHA noted the following: 1) despite the availability of tools like SHM’s BOOST, current member efforts are a scattershot of interventions of varying intensity and effectiveness, 2) hospitals are clamoring for guidance, and, 3) there is a desire by members to utilize a practical tool (EMR-based) to assist them in reducing readmission rates and improve care transitions.
[Incidentally, if you are not up to speed on what is in the CMS pipeline and the penalties your hospital may undergo if readmission rates exceed the norm, here is a lay press take, and a recent 2011 JAMA overview submitted by BOOST booster, Mark Williams.]
After some hard work, channeling current best evidence, GYNYHA delivered, and they produced an impressive instrument. It is a work in progress however, and needs input from frontline users to help transform the tool into something functional.
With that focus in mind, GNYHA convened an ad hoc troupe, with me, Brad Sherman (an astute SHM member), and several others, to help streamline the prototype.
We all realized shortly after discussing the merits of the tool, that data input, not only the practicality of the task at triage, but its accuracy, the patient’s communicative skills and cognitive ability (and surrogate availability), as well as upkeep of information as the stay progressed, were all major issues.
Additionally, knowing CHF, COPD, DM, cancer, liver disease, etc., were all triggers to activate the intervention at the outset, we began to discuss the merits of the effort, and unbeknownst to some and without identifying these concepts directly, began to dissect the meaning of discrimination, calibration, and risk reclassification.
We frequently see studies that provide us with new prediction rules, or refine further the risks associated with condition “x,” or add the outcome of a new-found (and pricey) test to improve our diagnostic ability. In the end, for example, do we need to know that any condition plus depression produces a worse outcome; or age >65 plus a chronic condition will lead to a greater chance of a complication or readmission; or a cognitively impaired patient will become more cognitively impaired if exposed to the innards of an acute inpatient facility? No.
Internists encounter this weekly with the challenging diagnosis of pulmonary embolism. We do not frame the dilemma in the above terms by and large, and yes, I am taking some liberties. But the equation comes down to this: use a fancy tool and expend time you may not have, for a result that may give you a marginal improvement over current practice, or shoot from the hip (“gestalt”)…and probably hit the target. Or perhaps not.
Given the competing demands for financial and human capital, our aspirations are limited—and if we require an enlargement of the discharge enterprise, occasionally tapping that pause button is compulsory. As an aside, on just that question, PCORI—established by PPACA, came online for this purpose. Comparative effectiveness research is not just about “to AICD or not,” but its ability to instruct providers on the use of IT as well as its efficacious placement. This body embraces that ethic.
Regardless, the penalties resulting from underperformance in this domain are significant. Ask a CFO or CMO if an IT solution is the conduit to unravel this quandary, and the answer is yes, almost certainly. It is an understandable (and conditioned) response, at least where an HIT fix and a crisis can intersect.
However, while the term workflow tends to conjure up images of non-clinician types transforming decision tools into workable programs, if past is prologue, expect failures aplenty on the road to usability. Flawed as the faithful translation of an algorithm might be, and in this instance, that is not the case—the program is well done, it comes down to how the logic plays on a PC screen and whether silicone trumps white matter.
Looking at this readmission risk list, one wonders who would not be an appropriate candidate for evaluation:
Coleman et al, Posthospital Care Transitions: Patterns, Complications, and Risk Identification, Health Services Research 2004
Additionally, consider these potential interventions to address above:
- Dedicated ward pharmacist
- Pharmacist for post discharge “Rx” call backs
- Dedicated medication “reconciliationist”
- Midlevel discharge coordinator
- Midlevel or RN for call backs, post discharge
- RN or PA: community disease management
- Discharge follow-up capacity at post-acute site of care
- Palliative care and advanced directive implementation
This is not an exhaustive list, nor are these tasks fluff in the context of the existing evidence-base. They all are worthy of implementation.
Unfortunately, there is a cost for these services (which cannot be met in most hospitals currently), and for many institutions, it entails a culture change that will take a decade. Additionally, and not to underestimate the magnitude of this success story (an enormous effort), but the menu of hires, reengineering, and interventions required for our transition challenge is staggeringly larger.
How do you incorporate all this into an IT tool that we want to implement and embrace?
As they say, 50 different sites, 50 different puzzles, and what is good for my shop, may not be first-rate for yours. That is why we tire of hearing presentations from other, successful “marquee” institutions. Sounds defeatist, but most of us cannot perform like Mayo in 2011; at least without time and experimentation (culture eats strategy for breakfast—remember!).
I have thought this through, and this is not a case of sour grapes, at least from my corner of the isolation ward. I can understand however, if you wish to disagree–not dogma by any means and the remedies are elusive.
Firstly, are these tools ready for prime time when, a) our predictive abilities for patient readmissions are primitive at best, and B) the resource options we have at our disposal are limited. Secondly, will all this work translate into more meaningful outcomes in a “wired” institution, as compared to, let us say, an equally determined facility employing an “analog”approach?
The answer? It already passed you by (top of the post): abacus vs. mainframe + PCORI= 2015, and you need to stay tuned.
Until then, I will follow the literature carefully; after all, on rare occasions prediction rules are game changers and are widely adopted (CHADS, PSI, etc.). I will observe the HIT, meaningful use adoption curve, and when the right tools are out there, I will proceed cautiously and plow ahead.
However, for now, my sixth sense speaks, as it has seen the path of futile projects’ past. We all must tread cautiously; there are too many temptations that will lead us down an endless path.
I will conclude then with an instructive snippet of medical history to make my point (put on your thinking caps):
* 2000 B.C. – Here, eat this root.
* A.D. 1000 – That root is heathen. Here, say this prayer.
* A.D. 1850 – That prayer is superstition. Here, drink this potion.
* A.D. 1920 – That potion is snake oil. Here, swallow this pill.
* A.D. 1945 – That pill is ineffective. Here, take this penicillin.
* A.D. 1955 – Oops . . . bugs mutated. Here, take this tetracycline.
* 1960-1999 – 39 more “oops.” Here, take this more powerful antibiotic.
* A.D. 2011 – The bugs have won! Here, eat this root.
Of course, you can go this route too.
Lastly, I must pitch a shout out to my co-blogger Rachel Lovins. I can just hear my mom now: huh, a lead singer, and in a rock band? A nice Jewish doctor?
Hospital Medicine and Rock ‘n’ Roll !! The intensivists think they got something on us? Not a chance.