reducing readmissions with bi and analytics · 2018-09-11 · reducing readmissions with bi and...

Copyright © 2018 AAJ Technologies All rights reserved.Reducing Readmissions with BI and Analytics www.aajtech.comCopyright © 2018 AAJ Technologies All rights reserved.

Reducing Readmissionswith BI and Analytics

Copyright © 2018 AAJ Technologies All rights reserved.Reducing Readmissions with BI and Analytics

Agenda

● Hospital Readmissions: Slides 4 - 7─ Michele Russell, CEO, Russell Consulting Group

● A Care Transition System (CTS) to Reduce Hospital Readmissions: Slides 8 – 10─ Ed Kirchmier, VP Global Delivery, AAJ Technologies

● Dashboards to Forecast Healthcare Outcomes: Slides 11 - 12─ Kevin Oppenheimer, Principal/Owner KGO Consulting Group

● Data Analytics to Predict When a Patient Will Readmit: Slides 13 - 18─ Andrew Satz, Co-Founder, Data Scientist and Futurist, Metrix Labs

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Hospital ReadmissionsMichele Russell, CEO, Russell Consulting Group


Hospital Readmissions Overview

Under Hospital Readmissions Reduction Program (HRRP), CMS withholds up to 3 percent

of regular reimbursements for hospitals if they have a higher-than-expected number of

readmissions within 30 days of discharge for seven conditions:

● Chronic lung disease

● Coronary artery bypass graft surgery

● Heart attacks

● Heart failure

● Acute myocardial infarction

● Hip and knee replacements

● Pneumonia

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Hospital Readmissions Overview

● About 80 percent of the 3,241 hospitals evaluated by the Centers for Medicare and

Medicaid Services (CMS) this year will face penalties

● Medicare under the Hospital Readmissions Reduction Program (HRRP) will reduce

reimbursement for 2,573 hospitals for fiscal year (FY) 2018

● An analysis of the data also showed CMS under HRRP will withhold $564 million in

payments over the next year

Source: Kaiser Health News

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HIPAA Privacy & Security / Risk Mitigation

In addition to creating a culture that focuses on the security and privacy of

Protected Health Information (PHI), our technology plays a significant role in

preventing data breaches.

● Tracking and audit trails

● Physical security of the data

● Limited user access to data

● Role-based security

● Protection of sensitive subsets of PHI

● Ongoing control of user access regardless of the hosting environment

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Where does / will your data live?

The three major types of cloud storage used in enterprise deployments are:

● Public

● Private

● Hybrid Cloud

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A Care Transition System (CTS) to

Reduce Hospital Readmissions

Ed Kirchmier, VP Global Delivery, AAJ Technologies


Care Transition Problem

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Pre-Discharge

Discharge

EMR/ADT (Hospital)

Order Management(Home/Community

Providers)

Rx Dispensing(Pharmacy)

Practice Mgmt Sys(PCP/Specialists)

HospitalVisit

SNF

Mental Health

HomeALF

Insufficient Educationand

Lack of CoordinationLeads to Readmission

Patient

Discharge Instructions

● PCP/Specialist Follow-up

● Rx Scripts

● Nutrition Guidelines

● Wound Care

● PT Orders


Care Transition Platform

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Care Coordination & Coaching

Pre-Discharge DischargePost-

DischargeFollow-Up

Medication Management

Nutrition Management

PCP/Specialist Follow-up

Red Flags / Signs & Symptoms

Home & Community Services

Personal Health Record

EMR/ADT (Hospital)

• Case• Visits/Assessment• Care Plan• Appointments• Orders

• Workflows• Reminders• Notifications• Alerts

Order Management(Home/Community

Providers)Rx Dispensing

(Pharmacy)

Practice Mgmt Sys(PCP/Specialists)

Goal: Reduce Re-admissions

HOSPITAL VISIT HOME/FACILITY VISIT VISIT(S)/CALLS


Dashboards to Forecast Healthcare

Outcomes

Kevin Oppenheimer, Principal/Owner KGO Consulting Group


Dashboard 30 Day CMS Readmissions

Report

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Data Analytics to Predict When a

Patient Will Readmit

Andrew Satz, Co-Founder, Data Scientist and Futurist, Metrix Labs


Causation versus Correlation

A patient is hospitalized for pneumonia with a history of chronic COPD. The

patient is readmitted within thirty days.

● Only 7.4% of patients readmitted had pneumonia. 92.6% of those readmissions

were caused by comorbidities rather than the pneumonia

● While a prior pneumonia case is highly correlated to readmission, it’s not

necessarily the cause

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Data Dimensionality

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Sex Weight Ethnic City BP Smoker COPD Pneumonia Heart Disease GI

F 142 H M 130/80 Y 2 4 3

M 178 A F 170/90 N 5 1

F 203 C M 130/90 N 1 3 2

M 187 A P 170/90 Y 3 2

F 162 A P 170/90 Y 3 4 1

F 120 H M 80/50 N 4 2

M 263 A F 80/50 Y 2 5 2 4

M 207 C P 130/80 N 5 4 3


Reducing Data Dimensionality:

Feature Importance

If we want to identify these additional factors for readmission, we need to

evaluate ‘feature importance’. This lets us find causal and correlated features

associated with the outcome. Then we can build an algorithm off of those

features, which can be used to classify patients and predict readmission

As a result, we can identify those patients most likely to be readmitted and

why. This would enable caregivers to deliver focused interventions to

vulnerable patients

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Using A.I. to Avoid Readmissions

The effort:

A health system aggregated and integrated their clinical, financial, administrative,

patient experience, and other relevant data

Important features were algorithmically selected based upon their statistical

importance. Features included: Medicare severity diagnosis related group (MS-

DRG), use of tobacco, residential zip code, financial risk, healthcare utilization, age,

marital status, admission source, medication, provider, and more

More than two dozen machine learning models were built to predict readmission

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Using A.I. to Avoid Readmissions

The Results:

The team’s hypothesis was that patients on a larger number of medications

would be at the greatest risk for readmission

But the data revealed that patients with no medications were at the greatest risk

The data showed similar patterns regarding age. While the team assumed older

patients are at the highest risk, the data showed that its younger patients were

at greatest risk

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www.aajtech.com

Additional Information:

[email protected]

800.443.5210

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reducing readmissions with bi and analytics · 2018-09-11 · reducing readmissions with bi and...

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