In an ideal world, providers from different healthcare organizations would have the people, processes and technology to work collaboratively and efficiently to smoothly transition a patient from one care setting to another. The reality is that many of them are not able to effectively coordinate care transitions, and that is taking a heavy toll on both healthcare economics and patient health.
According to a report published in Health Affairs, poor coordination of care transitions, and the resulting avoidable complications and readmissions, were responsible for between $25 billion and $45 billion in unnecessary healthcare spending in 2011 alone.
The data raise obvious questions. What systems and processes might an organization put in place to improve outcomes and reduce costs? How can technology be better used to improve care transitions? Here, we'll take a closer look at the technology and best practices that can help organizations close the gap on care transitions by making them more efficient.
The challenges of smooth care transitions
Care transitions are becoming an increasing point of focus in healthcare. As hospitals align with skilled nursing facilities, physician practices and other types of medical groups through shared-risk partnerships such as accountable care organizations, there is growing pressure to transition patients more efficiently across the entire continuum of care. Simultaneously, there are a growing number of regulations — from CMS' meaningful use requirements to national quality standards — that are compelling healthcare organizations to improve collaboration and communication in transitions of care. Financial incentives are creating a focus on — and ability for — solving the issue of disjointed care.
Yet multiple challenges are hampering healthcare organizations' best efforts. A lack of interoperable technology platforms, for instance, prevents important clinical data on care transitions from reaching caregivers in a timely manner. Although meaningful use requirements regarding clinical summary exchange are bringing needed attention to this issue, many EHR systems still lack the capability to seamlessly exchange information with other systems.
For example, when a hospital uses a different EHR than a patient's primary care physician, the physician may not receive hospital discharge summaries in a timely manner. Lacking this patient data, the primary carephysician may miss opportunities to provide care that could prevent a costly hospital readmission.
Another challenge, noted in the Health Affairs report, is that current regulatory policies may also encourage inefficient care and actually increase wasteful spending. Medicare and Medicaid payment policies, for example, have unintentionally created incentives to transfer patients back and forth between hospitals and skilled nursing facilities.
Focusing on people, processes and technology
With these challenges in mind, healthcare organizations can still reduce inefficiencies in care transitions by focusing on the three core tenets of great care: people, processes and technology. In order to transition patients across multiple care settings smoothly, it's essential to have a great team — organizations currently have capable clinicians and managers who are fully committed to providing the best possible care and responding to patient needs in a timely manner.
Consider further investment in care navigation programs. If clinicians require tools and training that would improve their workflow, an organization shouldn't hesitate to make those thoughtful investments. In making technology purchasing decisions, healthcare leadership should evaluate whether the prospective tool or system truly helps clinicians coordinate care by managing the efficient exchange of information and enabling clinical decision support. Are they going to use it? Clinicians should be involved in the decision-making process.
In addition to investing in the right number of qualified, passionate people — and the tools they need to do their jobs — a health care organization should also invest in the right technologies for improving population health management. This may include tools to analyze performance and extract relevant data at appropriate intervals so providers have the information they need in a timely manner. Purchasing the right technology for a care team is easier said than done, as there are multiple competing technologies that offer a wide range of capabilities to improve care transitions. A healthcare organization and its partners should also consider factors such as cost, user friendliness and return on investment.
While the task of choosing technology systems or tools may be challenging and complex, the investment of time and effort will reap rewards for years to come. Having the right health data exchange capabilities can help facilitate the sharing of pertinent clinical information during a care transition, allow for a more streamlined electronic referral process and ensure the patient is engaged at appropriate intervals. Conversely, if healthcare partners are not connected through a secure network that facilitates real-time data exchange, information that could positively influence outcomes and transitions will not reach the right people. The result: Patients don't receive the care they need and are at a greater risk for readmissions, or worse, trips to the emergency room — wasteful and often avoidable expenses.
Finally, technology must support great processes, or help improve existing ones. Too often healthcare organizations lack a well-defined care transition process and suffer from inefficient, disconnected systems. In this situation, both the organization and the patient pay the price. Today, there are technology platforms available that can help clinicians define specific care protocols for certain patient populations, such as high-risk cardiac patients. Real-time patient care notifications, for example, can prompt clinicians to intervene in a patient's care during major health events, which can help avoid a costly hospital readmission.
4 best practices for making care transitions more efficient
By improving care transitions, a healthcare organization benefits by reducing wasteful spending and improving patient outcomes. For medical groups that are ready to focus on "closing the gap" between transitions and spending, consider the following best practices:
1. Implement protocols and procedures around care coordination. A healthcare organization should consider conducting an in-depth workflow and technology analysis to assess specific processes and systems required to improve care coordination. Process changes might include protocols and tools to address how a clinician could alert her team when a patient experiences a high-risk event. In such a scenario, an organization should also consider implementing notification tools to monitor patient data in near real-time and send trigger alerts during major health events such as admissions and discharges to all members of a care team.
2. Identify the patient population you want to impact. While every patient can benefit from smoother care transitions and more timely interventions, healthcare organizations embarking on a process improvement effort should start by focusing on the highest-risk, highest-cost patients. A healthcare organization may even want to focus on specific disease states, such as congestive heart failure, using analytics tools to pull clinical information from disparate sources, and transforming it into standardized formats so it can be more easily shared.
3. Get providers connected on the same referral network and enable them with tools for secure messaging and referrals management. While there are ways to send data securely if providers aren't using the same network, data travel much more slowly if providers aren't connected on a single network or HIE. Creating a provider referral network allows better control of data, improved communication and the sharing of information quickly so providers can make informed care decisions.
4. Start small. Just as some of the best technology is only implemented after testing in pilot phases, the most effective process and system changes also start small. Consider focusing on one work stream or one clinical area first. Admittedly, it can be tempting to think in terms of overhauling entire systems across the organization to make care transitions more efficient at a faster pace. However, by taking a pragmatic, narrower approach, a healthcare organization will have the opportunity to perform fine-tuning as minor issues inevitably arise. As small changes are refined and become incremental (quick) wins over time, an organization will gain more confidence as it expands the scope of change and sees care transitions become more efficient.
Healthcare organizations face myriad challenges in aligning good people, processes and technology to improve transitions of care. However, making prudent investments is an important first step. The cost of inaction is simply too high in terms of poor outcomes and high readmission rates. As pressure mounts from regulatory agencies and fundamental shifts in business models, selecting the right data exchange platform becomes a paramount consideration. Following best practices around people and process and investing in an infrastructure that can grow with the provider network will ultimately yield the best outcomes for patients and for their provider organizations.
Nancy Ham is CEO of Medicity, a subsidiary of Aetna. She has a proven track record of innovative and high energy leadership in establishing, developing, growing and operating private and public healthcare information technology companies. She joined Medicity in February 2013. Before joining Medicity, Ms. Ham was president, CEO and a director of MedVentive, a provider of performance analytics for accountable care organizations and payers to manage cost, efficiency and quality. MedVentive was acquired by McKesson in 2012. Previously, she served as president of Sentillion, Inc., a leading innovator of identity and access management solutions for more than 350,000 caregivers practicing at over 500 hospitals. Prior to Sentillion, she was president of ProxyMed, Inc., the industry's second-largest independent medical claims clearinghouse with connectivity to over 450,000 providers, 30,000 pharmacies, 500 laboratories and more than 1,500 payers. Before ProxyMed, she was responsible for managing more than $50 million in revenue as general manager of institutional and connectivity service Healtheon/WebMD Corporation. Additionally, she served as senior vice president of business development and CFO at ActaMed Corp. She also spent five years in leveraged finance at GE Capital. Ms. Ham holds a bachelor’s degree in economics from Duke University and a master’s in international business studies from the University of South Carolina.