In principle, more emphasis on care coordination and the IT tools designed to manage it makes sense. When each clinician across the continuum of care knows what everyone else in the system is doing, the quality of care should improve and the costs should drop. If, for instance, the surgery team about to perform a coronary bypass procedure has all the details from a primary care doctor about the patient's medications and allergies, there's less risk of interaction between the anesthetic and those meds. And if the ambulatory clinician handling the patient's recovery has details on the patient's discharge instructions, that clinician can help the patient adhere to a postoperative regimen.
Such a well-coordinated approach could also cut costs by reducing needless duplicative diagnostic tests. If the electronic medical record (EMR) contains notes about a recent serum potassium, EKG or MRI test, there may be no reason for the next clinician in the chain to reorder it.
[ A physicians group finds payoffs in unexpected places after moving some business ops to the Web. See Digital Business Requires Dose Of Humility. ]
EMR systems that don't talk to one another across this continuum create a barrier to making this process work. If the hospital where this cardiac patient had surgery is a Cerner shop, but the patient's family physician uses PracticeFusion or DrChrono, they may not communicate well enough for the ambulatory doctor to get all the needed details. As many doctors in the trenches know, interoperability remains a major barrier to care coordination.
Another barrier is insurance coverage for physicians who are trying to make care coordination a reality. Until recently, they were not adequately reimbursed for time spent on care coordination, but in 2013, CPT codes for managing transitional care were put into the CPT codebook. CPT 99495, for instance, covers "communication (direct contact, telephone, electronic) with the patient and/or caregiver within two business days of discharge and "a face-to-face visit within 14 calendar days of discharge." That's a major step forward. Unfortunately, reimbursement codes are only part of the solution.
Poor care coordination is partially responsible for the high hospital readmission rates in U.S. hospitals, and reining in this problem is proving far more complex than anyone imagined.
There have been significant advances in hospital readmission prevention. Jacques Donze, MD, and his colleagues at Harvard Medical School analyzed thousands of EMRs to identify seven critical signposts that predict a patient's likelihood of being readmitted for a preventable problem. They include low sodium and hemoglobin at discharge, a length of stay of five or more days, and discharge from an oncology unit. Using these seven markers, the researchers created a scorecard to help clinicians predict who is most likely to be readmitted so that these patients can be targeted for special consideration.
But, put this positive development in the context of other less-than-successful initiatives. Medicare has spent serious money funding 34 demonstration projects, the aim of which has been to reduce costs by preventing hospitalization and enhancing care coordination. After collecting data for 10 years, the Congressional Budget Office (CBO) reports "no net effect on hospital admissions or Medicare expenditures," according to a report by Ari Hoffman, MD, and Ezekiel Emanuel, MD, PhD, in the Journal of the American Medical Association.
So what's fundamentally wrong? CBO offered some insights, stating that new electronic systems can "make it easier to reduce health spending if other steps in the broader healthcare system are also taken to alter incentives to promote savings ... [but] by itself, the adoption of more health IT is generally not sufficient to produce significant cost savings." Which is a long way of saying: IT itself can't fix complex healthcare problems.
What we really need is a reengineered healthcare system. Hoffman and Emanuel, from the University of California, San Francisco and University of Pennsylvania respectively, are on the right track in recommending such an overhaul.
Hoffman and Emanuel offer a solution similar to CBO's: "Clinicians need to abandon their long established approach of caring for patients in the hospital or the office. They have to provide constant access to a clinician who knows the patient and encourage communication with whatever mode patients are comfortable with -- telephone, e-mail or office visits." That approach also calls for wireless monitoring, telemedicine visits, at-home care and full patient engagement.
We're passed the stage where incremental improvements will work.