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Machine Learning Automates Outpatient Coding

Accurate service line reporting is necessary for a healthcare organization to understand its total cost of care. Organizations that do not understand the total cost of care cannot be successful in risk-sharing and other forms of value-based payment, resulting in a loss of reimbursement.

In an effort to reduce costs, MultiCare Health System, an integrated delivery system serving Washington, decided to outsource all encounter coding, which eliminated the coding of outpatient encounters, negatively impacting service line reporting. To ensure accurate reporting, MultiCare asked its coders to assign an MS DRG code to all hospital-based outpatient encounters, which brought significant additional costs. To mitigate this, MultiCare utilized data analytics and machine learning to develop an algorithm that predicts the MS DRG code for hospital-based outpatient encounters.

By employing machine learning, MultiCare has achieved impressive results, including:

  • Successfully restoring service line reporting, enabling the organization to better understand the total cost of care, and supporting future participation in value-based care and risk-sharing agreements.
  • Ability to avoid additional labor costs that would be required to perform dual coding, saving more than $1M annually.
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Artificial Intelligence Improves Accuracy of Heart Failure Readmission Risk Predictions

A global pandemic, heart failure (HF) affects at least 26 million people worldwide, and its prevalence only continues to increase. Within the U.S. alone, 5.7 million adults live with HF, carrying a cost of nearly $30.7 billion each year. At 55 percent, HF represents the most common cause of Medicare readmissions, and HF accounts for 42 percent of total admissions for Medicare patients.

Readmissions for HF carry a heavy cost for patients and health systems, in addition to reimbursement penalties from CMS. This makes properly assessing the risk for readmission for patients with HF a top priority. MultiCare Health System leveraged artificial intelligence and machine learning to improve the accuracy of readmission risk predictions for patients with HF. Providing a more accurate risk score in a timely fashion gives care teams more time to intervene effectively and prevent avoidable readmissions.

Results: 

  • 85 percent estimated accuracy for heart failure readmission risk predictor. (LACE accuracy around 62 percent)
  • Three-fold increase in the number of HF readmission risk-predictions made each day.
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Accuracy of Readmission Risk Assessment Improved by Machine Learning

Hospital readmissions carry significant financial costs and are associated with negative patient outcomes. While the reasons behind patient readmissions are multi-factorial, and the specific rates vary by institution, nearly 20 percent of all Medicare discharges nationwide led to a readmission within 30 days. Preventing even 10 percent of these readmissions could save Medicare $1 billion.

North Carolina’s only not-for-profit, independent community healthcare system, Mission Health, is comprised of seven hospitals, 750 employed/aligned providers, and one of the largest Medicare Shared Savings ACOs in the nation. Mission had been using the LACE index to predict risk for readmission, and while it was helpful, Mission’s patient population was different than the population used to develop the LACE index, leaving the health system with some uncertainty regarding the readmission risk of its patients. With the help of data analytics, Mission developed its own predictive model for assessing readmission risk, aimed at preventing readmissions and improving outcomes for patients.

Results:

  • The area under the curve (AUC) for Mission’s readmission risk predictor is 0.784, outperforming LACE, and meeting the organization’s goal for performance.
  • Mission’s readmission rate is 1.2 percentage points lower than its top hospital peers.
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Machine Learning, Predictive Analytics, and Process Redesign Reduces Readmission Rates by 50 Percent

The estimated annual cost of readmissions for Medicare is $26 billion, with $17 billion considered avoidable. Readmissions are driven largely by poor discharge procedures and inadequate follow-up care. Nearly one in every five Medicare patients discharged from the hospital is readmitted within 30 days.

The University of Kansas Health System had previously made improvements to reduce its readmission rate. The most recent readmission trend, however, did not reflect any additional improvement, and failed to meet hospital targets and expectations.

To further reduce the rate of avoidable readmission, The University of Kansas Health System launched a plan based on machine learning, predictive analytics, and lean care redesign. The organization used its analytics platform, to carry out its objectives.

The University of Kansas Health System substantially reduced its 30-day readmission rate by accurately identifying patients at highest risk of readmission and guiding clinical interventions:

  • 39 percent relative reduction in all-cause 30-day.
  • 52 percent relative reduction in 30-day readmission of patients with a principle diagnosis of heart failure.
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DKA Risk Prediction Tool Helps Reduce Hospitalizations

Each year, more than 12,700 pediatric patients are diagnosed with diabetic ketoacidosis (DKA), a life threatening complication of diabetes. Texas Children’s Hospital sought a way to accurately predict risk of DKA in time for care team members to intervene before these patients suffered a severe episode.

The health system ultimately formed a multidisciplinary high risk diabetes team to devise pre- and post-discharge strategies, and DKA risk prediction tools aided by the Health Catalyst Analytics Platform built using the Late-BindingTM Data Warehouse.

Results:

  • 30.9 percent relative reduction in recurrent DKA admissions per fiscal year.
  • 90 percent of all patients with new onset type 1 diabetes at the Medical Center Campus have a documented RIPGC in their medical chart.
  • 100 percent of patients with type 1 diabetes have a risk index for DKA documented every 6 months.
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