Instituting electronic medical record (EMR)-based appointment orders can significantly increase outpatient cardiology follow-up visits after hospital discharge but is not necessarily associated with a reduction in 30-day readmissions. So finds a pre-/post-implementation study published online by Cleveland Clinic researchers in NPJ Digital Medicine.
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“To date, it has been unclear whether use of an EMR-based intervention can improve rates of follow-up after discharge among patients with cardiovascular disease and how much improvement might be gained,” says senior and corresponding author Umesh Khot, MD, Head of Regional Cardiovascular Medicine at Cleveland Clinic. “Several years ago, we designed an EMR-based appointment order to schedule follow-up appointments at the time of discharge, and this investigation sought to measure its impact on rates of follow-up appointments and readmission.”
The formidable challenge of follow-up
The stakes behind the intervention are high: Timely follow-up after hospital discharge improves transitions in care and may reduce mortality. Furthermore, observational analyses have shown a relationship between increased outpatient follow-up and a reduction in 30-day readmission rates. Despite this evidence, rates of follow-up remain low.
In response, Cleveland Clinic’s Heart, Vascular & Thoracic Institute created an EMR-based appointment order to collect information about hospitalized patients’ follow-up needs and schedule an appointment prior to discharge. The order was implemented at the start of 2014 and providers were educated about the new order process.
“We recognized that EMR systems can play a key role in developing comprehensive systems of care to protect our most vulnerable patients,” Dr. Khot explains.
Study in brief
The study was undertaken to assess the impact of the EMR-based appointment orders by evaluating 39,209 cardiovascular medicine discharges at Cleveland Clinic’s main campus from 2012 through 2017. The 12,852 patients discharged in 2012 or 2013 (pre-order era) were compared with 26,357 patients discharged in 2014-2017 (EMR order era). In the pre-order era, scheduling of follow-up appointments was at the discretion of the patient’s clinical team.
Across the cohort, 75.7% of patients were white, 39.2% were women and 62.8% were Medicare beneficiaries. Mean patient age was 69.3 years. The pre- and post-order groups were statistically comparable by sex, but patients from the pre-order era were slightly older, more likely to be white and more likely to have insurance through Medicare or Medicaid.
Rates of the primary endpoint — having an outpatient cardiology follow-up visit within 90 days of discharge — rose from 56.7% in the pre-order era to 67.9% in the EMR order era (P < 0.001). After adjustment for patient demographics and payor type, use of the EMR order was associated with a more than threefold increase in outpatient follow-up (odds ratio = 3.28; 95% CI, 3.10-3.47).
Once the EMR order was implemented, its use by providers grew swiftly and steadily over time, from 49.9% in 2014 to 76.7% in 2017 (P < 0.001 for trend). Likewise, whereas the average rate of 90-day follow-up appointments was stable across the pre-order era, it steadily grew throughout the EMR order era, from 66.2% in 2014 to 70.1% in 2017 (P < 0.001 for trend).
However, the increase in follow-up visits with the EMR order did not correspond with a reduction in hospital readmissions, as the 30-day readmission rate rose from 12.8% in the pre-order era to 13.7% in the EMR order era (P = 0.016)
Making sense of the findings
“Implementing an EMR-based appointment order resulted in a substantial and sustained improvement in rates of outpatient cardiology follow-up after hospital discharge,” observes Dr. Khot. “Improved follow-up rates were seen in all socioeconomic and racial groups, and use of the EMR order was a greater predictor of follow-up than key demographic and socioeconomic characteristics.”
He and his coauthors attribute the rise in follow-up appointments to how the pre-discharge EMR order streamlines the scheduling process and reduces traditional barriers to appointment scheduling. “Observational studies show that multiple obstacles in the fragmented U.S. healthcare system —logistical, financial, transportation and socioeconomic barriers — can converge to make scheduling follow-up care challenging for patients,” Dr. Khot notes.
While the researchers were disappointed that increased rates of follow-up did not correlate with reduced hospital readmissions, they note that other U.S. groups have also reported an association between EMR system adoption and an uptick in readmissions. They speculate that the reason for the increase in readmissions may be multifactorial, including:
- Earlier recognition of illness as a result of the follow-up visit
- A need to manage acute exacerbations of disease
- Follow-up care representing increased connectivity to the healthcare system with resultant increases in care utilization
“In many cases sound and valuable interventions can improve care quality without lowering readmission rates, as the readmission rate doesn’t fully reflect the competing risk of death,” says Dr. Khot. “This study adds to others that point to a potential need to revisit the priority given to readmissions as a principal outcome metric.”
A readily adopted model
Meanwhile, the rapid and sustained adoption of EMR-based scheduling demonstrated in this study has led to expansion of the EMR-based order to all specialties across the Cleveland Clinic health system.
“This simple intervention can be readily reproduced and implemented by other health systems regardless of the specific EMR they may use,” notes Samir Kapadia, MD, Chair of Cardiovascular Medicine at Cleveland Clinic. “Our team has shown it is an efficient and effective way to promote higher rates of follow-up cardiovascular care for patients who stand to benefit from it.”