Case management for such "frequent flyers" offers a remarkable opportunity for savings. Better care for diabetes patients alone can easily cut costs by 4%, according to another of our Roundtable participants, Dr. Edward Jeffries, CMO of Baton Rouge (LA) General Physicians. It's notable that all these moves would improve patient health as well as save money.
Underpinning these necessary changes is technology. Electronic medical records that are accurate, portable, and based on real-time data are a precondition for identifying frequent flyers and improving their care. Clinical informatics, along with nurse informatics and pharmacy informatics, is a key to preventing readmissions. Data analytics offers a way to flag problems before they slam your bottom line.
Like many of their colleagues, Brooks and Jeffries laud the patient-centered medical home model as a means of cutting costs while improving care quality. Although PCMH is much more than an IT project, it requires a substantial IT investment to become reality.
At one of our recent Rounds events, which are executive discussions hosted by a healthcare system and simulcast to a wide audience, C.R. Burke, president and CEO of St. Joseph Heritage Healthcare, listed five elements of the medical home's IT infrastructure: EMR/EHR, patient health records, shared case management, physician utilization, and risk stratification/predictive modeling. All of these must work in concert.