Southeast Texas Medical Associates (SETMA), a primary healthcare group based in Beaumont, Texas, is using IBM business analytics software to gain greater insight into hospital re-admissions, reviewing trend data to help identify causes and design interventions to prevent patients from having to return to the hospital soon after discharge.

In just the first six months of the practice level research, officials say, SETMA has been able to cut the number of its patient hospital readmissions by 22 percent by helping doctors identify trends, and assess treatment protocols to support the creation of a more comprehensive post-hospital treatment care program.

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According to a recent University of California San Francisco study, titled Hospital Readmission: Influencing Factors Identified, unplanned hospital readmission within 30 days occurs for nearly one in five Medicare patients in the United States. These readmissions are not only extremely costly, but they can put the patient at higher risk of increased illness, and in some cases death.

SETMA is utilizing IBM analytics software to identify the treatment interruptions and causes that lead a patient back into the hospital after discharge. Physicians collect data on specific patient characteristics that did not require re-admission, beyond traditional information to include ethnicity, socioeconomic groups, the follow-up care received and how much and how quickly they were able to receive that care, against those who were re-admitted for hospital treatment.

Analytics leads to prevention

IBM analytics software allows the clinicians to determine similarities within re-admitted patients, and institute new post-hospital treatment plans that will replace the typical transition of care documents to include recommendations, such as immediate at-home care, or interventional support if the patient lives alone. SETMA describes these types of treatments as the most vital component in a patient’s recovery plan.

Physicians of the SETMA practice have also implemented preventative care programs by analyzing key data of their more than 7,500 patients, including comprehensive background information, demographics, types of treatments, history of prescription care, risk factors and outcomes. IBM business analytics software enables doctors to better assess trends in their patients, so they may quickly adjust medications or treatments.

Prior to implementing its analytics solution, SETMA's doctors would typically spend more than an hour evaluating data on individual patients. Today, they are evaluating data points of patients with similar conditions across the entire practice, allowing them to evaluate trends and gain valuable insight around more effective ways to manage illness.

New measures

SETMA doctors are also calculating cardiovascular risk measures at each and every office visit, something, officials say, was typically unheard of before. What used to take a physician over an hour to sit and calculate just one patient’s score by hand can now be done in less than a second. With a simple click of the mouse, key data points are instantaneously captured into one report

For example, a doctor can now point out key risk factors around relative heart age scores, so if the patient is 65 years of age, but is showing a relative heart age of 75 years, it allows the physician to discuss ways in which they can work together to adjust lifestyle choices to regulate those numbers.

In addition, patients are able to view, track and compare their own progress against other patients with similar conditions by providing patients access to data related to their own personal health goals, helping the physician offer a more personalized care environment.

“Each day we challenge ourselves to respond faster, more efficiently and more effectively to the needs of our patients," said James Holly, MD, CEO, Southeast Texas Medical Associates. "You’d be surprised at the demand we get from our patients; they expect us to not just treat their ailments today, but to help them put plans in place to tackle ailments and challenges they will eventually face when dealing with a chronic disease like diabetes."

He adds that, "smarter healthcare is about always staying one step ahead for your patients, it’s about analyzing information to meet the changing needs of your patient, and the IBM analytics solution allows us to do that.”

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Clinical support staff at SETMA are also working more productively with the help of analytics, officials say. For example, if a patient is scheduled for an office visit on a Friday, staff can instantly run reports of all the patients due in on that day for check-ups and review their status to see if anything is out of date or whether extra screening work is required. Now, blood work can be done in advance of their appointment with a physician, giving the doctor instant access to the updated information. The test results are discussed face to face with the patient in the exam room, allowing the patient and doctor time to discuss outcomes and put a plan in place around next steps.

SETMA continues to make additional improvements within its system to deliver advanced and personalized care to patients, and to further its preventative care mission. With the use of analytics, SETMA physicians identified a trend in their diabetic patients that started in October and that lasted through the end of December. They began to see their patients were losing control and becoming less disciplined with their dietary habits when trying to get through the holidays.

SETMA responded with a diabetes intervention program that included increasing the frequency of testing, compliance with medications, suggestions on handling diet choices during this difficult time of year, including increasing patient’s exercise to help balance their sugar levels. After just one year of implementing the program, SETMA saw a significant improvement in its diabetic patient population, with a decrease in annual patient visits by nearly 15 percent during this time frame.

“IBM analytics software allows us to deliver care intentionally, rather than coincidentally," said Holly. "When we see a patient with a master plan already designed based on analysis of their data, we can intentionally intervene in their lives in ways that will make a difference, and that is a beautiful thing.”