We know that the right healthcare data, used meaningfully, can ensure patients receive the right care at the right time, help avoid unnecessary duplication of services, and prevent medical errors. Data can also help lower readmission rates and, as a result, healthcare spending. Despite this evidence for powerful outcomes, communities are often stuck at the first step: a lack of data-sharing.
Where is the bottleneck? Every hospital, clinic and other healthcare operation generates a massive amount of data. However, a recent survey found fewer than 4 in 10 health systems successfully share data with other systems. Additionally, only slightly more than two-thirds of technology executives at U.S. hospitals and health systems are effectively sharing data within their own organizations. One hurdle includes a lack of clear direction from leadership. Healthcare leaders need to be specific with their teams about not just the need for connecting to data, but the use cases and value for sharing internally and externally and generating insights from raw information. Data is critical to the goals of every healthcare leader—but is it being treated as such?
Hospital readmission, for example, is one of the costliest problems for our healthcare system. The Centers for Medicare and Medicaid Services reports nearly 1 in 5 Medicare beneficiaries experience a readmission to the hospital within 30 days, costing more than $26 billion each year—to the detriment of patients, providers and taxpayers. A full 20% of readmissions are likely to be prevented in patients with three or more chronic conditions if they are contacted by a provider within 14 days of discharge. This loop can be closed with the right processes in place, starting with ensuring providers are alerted to and have information on the hospital stay and discharge.
The Inland Empire Foundation for Medical Care ACO, where I serve as CEO, has done important work on these goals. We’re one of the most comprehensive PPO networks in Southern California, responsible for the care of more than 9,200 Medicare patients, many of whom are chronically ill. We organized the Foundation Accountable Care Network, a Medicare Shared Savings Program ACO, and have seen compelling results in our efforts to reduce readmissions (39.4% reduction in patient readmissions post-discharge) by leveraging data we get from Manifest MedEx, a not-for-profit statewide health data network.
IEFMC receives admission, discharge, transfer (ADT) notification services and longitudinal health records, as well as clinical and claims data in real time. Our ACO practices are alerted immediately when a patient is seen in the emergency department or is admitted or discharged from the hospital—allowing care teams to promptly react and initiate post-discharge follow-up within seven days.
FACN receives on average 190 notifications per month from Manifest MedEx for their patient panel of 9,200 patients, and seven-day post-discharge follow-up visits are extremely high because of this data. Of the total cohort of patients hospitalized in 2021, 68.6% were evaluated within seven days of hospital discharge, and 31.4% were not. For those who were not, the readmission rate was 25.5%, in sharp contrast to the readmissions rate for those who were—just 15.6%.
Care teams need to see patient histories to determine who needs the most help. Clinical and claims data matter equally to create a thorough picture of a patient’s health and medical history and to see how they are utilizing healthcare. They need to know the minute a patient is seen in the hospital and when they are sent home. Our ACO practices know which patients have had more than four ED encounters in the last six months and can target these patients for interventions. The data also identifies patients with multiple chronic conditions and need additional management which has significantly decreased per beneficiary per year spending.
We need to broaden the types of data we are looking at, especially from a health equity standpoint. Shared health information should include accurate race and ethnicity data, and sexual orientation and gender identity (SOGI) for all patients. Most hospitals do collect race and ethnicity data; North Carolina is doing this successfully, reaching 94% documentation of race and ethnicity for COVID-19 vaccinations after implementing stringent data collection requirements. However, SOGI data across the country is inconsistent, and many health IT platforms have not yet adopted consistent, interoperable data fields and value sets for capturing this information. The United States Core Data for Interoperability (USCDI) process facilitated by the Health and Human Services Department’s Office of the National Coordinator for Health Information Technology is helping to address this, and we should all get behind efforts to streamline and make interoperable SOGI data.
Healthcare leaders should be signing on to this and incentivizing data-sharing. We have the data, and we know how to use it to make it valuable across the board. It’s time to eliminate the bottleneck.