“It has been shown that if heart failure patients leave the hospital and get appropriate services while out, they will not get readmitted into the hospital so quickly – and that is better quality of care and also lowers the costs for the hospital,” says Adrian Zai, MD, PhD, MPH, Clinical Director of Population Informatics.
The web-based heart failure tracking system is based on a generic population disease management application known as the Registry Population Management (RPM) application developed at the Lab of Computer Science. It performs three important functions – it uses an algorithm to accurately predict inpatients who will likely to be discharged with heart failure, provides tools that facilitate linking these patients to appropriate services, and tracks the effectiveness of the hospital’s clinical services.
According to Zai, the goal of the heart failure RPM application is to better identify heart failure inpatients and then to improve their connections to appropriate post-discharge services.
To provide an example, the RPM application uses a series of variables and a built-in logistic regression model to determine which patients have heart failure. A nurse or other team member then finds a particular heart failure patient in the system and then decides to coordinate him or her to various post-discharge services. Most importantly, the application offers real-time reporting graphs that track the effectiveness of the patients’ services.
“We are using a Queueing Theory model to look at how we are meeting the demand,” explains Zai, “With this model, I can predict how long the queue is going to be, how long these patients have to wait before they can get connected [to care].”
Since February 1, 2008, the RPM application has been tracking heart failure patients at Massachusetts General Hospital. The same technology is also used to monitor outpatient diabetes patients. In this short amount of time, there has been a 122 percent increase in efficiency – from identifying patients with heart failure to making sure they are connected to care and stay out of the hospital system.
The RPM application is just one part of a larger Partners Healthcare High Performance Medicine initiative, dedicated to improving all facets of its patient care system. Partners Healthcare is the integrated health care system founded by Massachusetts General Hospital and Brigham and Women’s Hospital.
When it comes to improving the patient care system, Zai believes that the RPM application is a success. It works to improve the hospital’s efficiency, identify more heart failure patients, and connect these patients to important post-discharge services.
“Bottom line – it’s the right thing to do. It’s the right thing for the patients,” says Zai.