Physicians at the 972-bed Bronx-Lebanon Hospital Center, a non-profit healthcare system that encompasses two hospitals in New York City, were all for reducing their patients’ average lengths of stay (ALOS). They just had one question for the system’s leadership.
Reduce it to what?
Reducing ALOS has been a constant battle for providers everywhere. The financial ramifications from a private, federal, and state payer reimbursement level and an operational cash flow standpoint have made it a priority in numerous hospitals. Efforts to attack the problem of ALOS are inevitably linked to the federal mandate to reduce avoidable readmissions. However, some hospitals and healthcare systems are still trying to figure out how to quantify length of stay at a clinical level.
Providers in the state of New York use a coding product from health IT vendor 3M (St. Paul, Minn.) to capture All Patient Refined Diagnosis Related Groups (APR-DRG) classification information, which includes ALOS value and severity of illness. The challenge, according to Bronx-Lebanon CMIO Robert Leviton, M.D., is taking that length-of-stay value and pushing it to a point where the doctor can see it and use it in their daily activities.
What the team at Bronx-Lebanon did was create a “length of stay” clock, Leviton says. In one column, it showed the time the patient was admitted. In the other column, they took the coding based on the classification information, and showed the ALOS for that particular disease and its severity of illness. In a third column, it showed how much time the physician had left.
“The doctor can clearly see how much time they have left,” Leviton says in an exclusive interview with Healthcare Informatics. The clock, he adds, allows for doctors to figure out how much extra care they can provide during hospitalization and how much can be shifted to the outpatient visit. “As a result of this implementation, we saw 1.8 day reduction in length of stay in five months.”
Clinical Systems Integration
Leviton credits two products from Allscripts (Chicago) in helping get the ALOS clock off the ground. The actual counter was integrated into the hospital’s EHR. In addition, a care management product, which aims to consolidate various administrative processes such as discharge planning and utilization management, has allowed for the hospital’s leaders to review the various variables that add to or reduce a patient’s length of stay.
“[We’re] reviewing the doctor’s chart, identifying the deficiencies or missing data from the medical record, pushing a query letter to the doctor in a secure health message to Sunrise, tracking the doctor’s response, and recoding the letter,” Leviton says.
Essentially, Leviton says, recoding the letter involves getting the doctor to bring up specifics when it comes to different diseases such as congestive heart failure. “All of these variables affect the length of stay and the severity of illness. The sicker the patient is the more time we’re going to be given to take care of them. If it just reads congestive heart failure, you’ll get little time and no money.”
Once the administrators get those specific details, they can push out that updated information to the doctor’s EHR. The two systems, and the doctors and administrators behind them, work in conjunction to help effectively reduce a patient’s ALOS.
Leviton additionally credits another care management product from McKesson (San Francisco) with helping with this process. This one, integrated into the Allscripts product, helps Bronx-Lebanon determine if a patient’s documented criteria meets the standard-of-care for admission. Leviton says the hospital, through this product, was able to drive down organizational authorization denials from 14 percent in January to 8.2 percent in the past month.
On an ACO Journey
As Bronx-Lebanon journeys towards becoming an accountable care organization (ACO), Leviton credits the openness of his information systems in helping it reach that goal. For instance, he says, he built a product within the Allscripts EHR that helps track whether a patient has been readmitted in the dreaded 30-day window. This is just one of 173 projects created at Bronx-Lebanon using the tools Allscripts provides, he says.
Of course, challenges are bound to arise when implementing these kinds of changes. Leviton says one particular challenge for Bronx-Lebanon leadership was working with physicians and getting them to understand that traditional care paradigms have shifted.“We all need to recognize that the healthcare environment is extremely malleable at this point in time, and we all need to be flexible to address the many new challenges and initiatives that confront us daily,” he says.
In the big ACO picture, Leviton says it’s also imperative to work with payers to get an understanding of their needs while getting them to accept the hospital’s usage of electronic technology. “Many are still using data collecting techniques that are not current with hospital and physician office practice EMR's. Having health care plans and providers adopt interfacing of hospital and physician office EMR's is extremely important to manage patient populations and maintain smooth transitions of care,” he says.
For those who are looking to embark on a similar journey, Leviton advises that you understand a clear vision of the patient’s needs first, and then work backwards to the organization and its stakeholders.
