Health information technology (HIT) can play a key role in reducing hospital readmissions, according to a new report from the CSC Global Institute for Emerging Healthcare Practices. CAST Executive Director Majd Alwan suggests that the report sends an important message to hospitals and to long-term and post-acute care (LTPAC) providers that want to help hospitals keep discharged patients in the community.

No single approach will lower readmission rates, say the authors of Preventing Hospital Readmissions: The First Test Case for Continuity of Care. However, interoperable electronic health records (EHRs) that are capable of exchanging health information, in addition to other HIT solutions, could go a long way toward helping providers reach that goal.

“Tracking patients will be essential to ensuring planned post-discharge care and support actually occurs in time to address gaps,” says the report. “This will only be possible with the assistance of health IT to accomplish communication and close loops.”

Readmission Penalties: Coming Oct. 1

The need to reduce readmission rates has captured the attention of hospitals and LTPAC providers since the Affordable Care Act became law in March 2010, according to InformationWeek Healthcare. That legislation established Oct. 1, 2012 as the date when Medicare would begin penalizing hospitals with excessive 30-day readmissions rates.

The financial stakes are high for hospitals as the October deadline approaches. Kaiser Health News projects that the Medicare penalties could cost 2,211 hospitals a combined total of about $280 million over the next year alone.

LTPAC providers also have a financial stake in the readmissions initiative, says Alwan. Their expertise in the areas of care transitions and coordinated care could help these providers forge new, long-term partnerships with hospitals seeking to reduce readmissions.

“Readmission reduction initiatives represent a significant opportunity for technology-enabled LTPAC providers to strategically partner with hospitals,” emphasized Alwan. “These providers can work with hospitals to coordinate care and stabilize newly discharged patients efficiently and cost-effectively, particularly when they use interoperable EHRs, remote patient monitoring, telehealth and medication adherence technologies.”

Avoiding Penalties: Some Suggestions

The CSC Global Institute report offers a number of suggestions to help hospitals avoid the Medicare penalties. These include using HIT to monitor patients after discharge. Such monitoring could help ensure that discharged patients are taking their medications as directed, receiving follow-up care from their physicians and continuing on the path to recovery.

The report also suggests that hospitals use a patient’s EHR to capture information that could shed light on that patient’s condition and circumstances. This information could help discharge planners:

  • Keep track of a patient’s medications and facilitate medication reconciliation.
  • Schedule follow-up phone calls with discharged patients and patient appointments with their clinicians.
  • Document when a patient completes transition milestones.
  • Stay in touch with the hospital’s clinical partners.

Interoperability: The Key to Success

Preventing Hospital Readmissions stresses the importance of establishing interoperability among a variety of HIT systems. The authors urge hospitals to integrate disparate EHR systems within the hospital network. The report also underscores the importance of making sure EHR systems maintained by outside partners, including LTPAC providers, can communicate with the hospital’s system. 

Achieving this integration will be challenging, says the report. However, a lack of interoperability will stand in the way of effective discharge planning and care transitions.

Despite these challenges, the report ends on a hopeful note. In particular, it applauds federal efforts to provide financial incentives to health providers that make “meaningful use” of EHRs. These incentive programs will “provide the critical foundation of much more complete patient information available in the EHR and the basic infrastructure for communicating with clinical partners through health information exchange,” the report says.