Problems Worth Solving

In 2009, the Centers for Medicare and Medicaid Services (CMS) began to publicly report hospital-level readmission rates. In 2010, the Affordable Care Act (ACA) was passed and two years later the Hospital Readmissions Reduction Program (HRRP) was established. It wasn’t until the CMS began reducing Medicare payments to hospitals with excess readmissions that real changes in healthcare began to take root. It was recently estimated that unplanned patient readmissions cost $40-45 billion a year—$27 billion is Medicare alone of which $17 billion is considered avoidable. Medicare is expected to withhold $564 million in federal reimbursements in 2018, affecting over two-thirds of the nation’s hospitals. 30% of the reimbursement decision is derived from how well hospitals score on the Hospital Consumer Assessment of Healthcare Providers and Systems (HCAHPS) survey, a measure of customer satisfaction. This has forced hospitals to completely revamp internal metrics towards care outcomes and patient satisfaction scores in an effort to maximize payer reimbursements and limit expensive readmission penalties.

Hospitals face a relentless push to improve the patient experience and support patients as active participants in the care process, when possible, versus passive recipients of care. Since 2006, Government has used HCAHPS as a standardized survey to measure patient perception of the quality of care received. The HCAHPS survey asks discharged patients 27 questions about their recent hospital stay. The ACA includes HCAHPS among the measures to be used to calculate value-based incentive payments in the Hospital Value-Based Purchasing program, which began with discharges in October 2012. In 2015, CMS launched star ratings on its Hospital Compare website as a way to streamline hospital ratings for patients trying to make healthcare decisions. CMS will publish 12 different star ratings on the Hospital Compare website for each facility: 11 of the ratings will be based on individual HCAHPS measures and the 12th is a composite star rating. While HCAHPS (and Press Ganey) patient satisfaction scores are quickly redefining hospital metrics for patient care, doctor pay and hospital star ratings, healthcare providers haven’t developed the tools for caregivers to accurately identify, measure and provide effective “quality of care” to improve their scores.

It is often quoted that we retain 20% of what we hear. While the facts behind the claim are dubious, it can be said that most of us remember little of what was said in the doctor’s office. And often, retention erodes with time. Most often we hear what we want to hear or what we conveniently want to believe. In stressful situations like doctor visits, or when leaving the hospital after surgery, the results are much worse. For Dr. David Langer and his Neurosurgery staff at Lenox Hill Hospital in New York, the drop in department productivity and the frustration experienced by patients were such that they knew they needed to better inform and educate patients and help them retain more of what was discussed during their care visits. Patient retention is a significant issue in rural areas, and particularly for elderly patients because of the long travel distances, often without the help of others to memorialize what is communicated by providers, leaving friends and family in the dark or unaware of a condition, diagnosis or treatment plan. The aging demographics in the United States will only increase the need for a more permanent way to communicate, share and memorialize patient experiences.

The causes and effects of poor caregiver-patient communication on hospital costs and patient outcomes has been studied extensively. According to researchers at the University of Maryland, hospitals “waste” approximately $12 billion annually—roughly $4 million for a typical 500-bed, acute-care hospital—due to poor communication among care providers in terms of lost productivity, insufficient time with patients and longer lengths of stay. In another study, CRICO (Controlled Risk Insurance Company, Harvard Medical) researchers found that 30% of all malpractices cases from 2009-2013 involved communication failure at an estimated cost of $1.7 billion and 1,744 deaths. It was earlier research by the Medicare Payment Advisory Commission (MedPAC) which showed that nearly 20% of all Medicare discharges had a readmission within 30 days that motivated Congress to make reducing early hospital readmissions a national priority. Once again, the primary cause was determined to be poor communication between caregivers and patients. A 2017 study published in BMJ Quality & Safety found that better patient-provider communication and higher patient satisfaction scores can reduce the likelihood of re-hospitalization by 39 percent. Patients who perceive their doctors as truly listening to them were 32 percent less likely to be readmitted. Results indicate that a hospital would, on average, reduce its readmission rate by five percent if it were to prioritize communication with patients in addition to complying with evidence-based standards of care. Five percent of a $40-45 billion dollar problem is a significant problem worth solving.

Reliable, secure and mobile medical data is critical to effective, quality healthcare models and metrics. Yet healthcare data is fiercely protected and siloed by the healthcare system, and for good reason. According to the Ponemon Institute, criminal attacks in health care have increased by 125 percent between 2010 and 2016 and have become the leading cause of medical data breaches. The study also found that 90 percent of health care organizations have experienced at least one data breach, costing more than $2 million on average per organization. The American Action Forum estimated that medical breaches have cost the U.S. health care system more than $50 billion since 2009. As the digital, paperless healthcare economy expands, cyber threats become more pervasive. Protecting medical data and ensuring its reliability, security and mobility will continue to be top priorities for all healthcare institutions and any technology solution.

Provider consolidations through mergers, acquisitions and consolidation projects intended to bring financial stability to entities that are loath to face the prospect of risk-sharing on their own have sprouted another problem–the inability to freely exchange and interpret data. Extensive rewrites of database constructs and code to maintain systems interoperability are expensive and time consuming. As physicians continue to accept employment in larger health systems, and those health systems shift from hospital-centric acute care centers to wellness networks with a focus on prevention, organizations are finding that their data sharing strategies must also change and adapt. Open-source solutions to these issues are necessary considerations if past mistakes are to be avoided and hospital data is to be mobile and reliable.

According to a 2017 GAO congressional report, 90% of eligible hospitals offered their patients electronic access to their own health data, yet less than 15% of hospital patients used the patient portal to view, download or transmit their medical records. Hospitals spend billions of dollars on branding and making their portals accessible to patients to view their EMR, yet very few have been able to achieve meaningful patient uptake.

In The American Recovery and Reinvestment Act of 2009 (ARRA), Congress separately enacted the Health Information Technology for Economic and Clinical Health (HITECH) Act to increase Electronic Medical Records (EMR) adoption and integration with payments for providers that show they have reached the standard for “meaningful use” of the newly created digital content. While important to force the switch from paper to electronic records, the EMR is of little use outside the provider and payer communities.