Reducing Readmission and Post-Hospital Mortality through Data beyond Your Borders

Author: Philip Smith

Readmission and Post-Hospital Mortality are difficult problems for today’s hospitals as they represent potential failures of hand-offs during critical transitions of care. However, since these often occur into the community rather than solely within the borders of the health system, they are often not captured within the hospital’s enterprise data warehouse or other traditional means. Often the complete data is not available to the hospital until the results are compiled and reported by the Centers for Medicare and Medicaid (CMS) several years later when penalties are assigned (CMS will be reporting 2016 penalties in mid-2017, for discharges Oct 1, 2011 – Sept. 30, 2014.). It is difficult to improve performance when data and information are not available in a timely fashion. The author has done extensive work in developing clinical close dashboards for other hospital measures and now has a process to obtain data using a patient-centric technique that overcomes the health system’s and hospital’s limitations. This novel process will permit hospitals to compile data at 30, 60 and 90 days following hospital discharge, provide pre-admission status for the prior 90 days, and follow joint replacement patients for up to 180 days. This new process will allow timeliness of data to validate performance improvement trials, determine optimal follow up intervals and improve predictive analytics. In addition, de-identified information will be utilized to create a readmission and post-hospital mortality benchmark well in advance of the current CMS benchmarks. Moreover, the process will allow discrete data for numerous interventions through leveraging clinical decision support from within the electronic health record. The process is being refined through a pilot at a large, multi-state health system in Q4 2016.

Co Author/Co-Investigator Names/Professional Title: Smith PA, MD