It’s time for your EHR to be more than a documentation and decision support tool, and finally become the essential platform in driving effective and efficient care and interaction with your patients, regardless of the setting.
A big frustration we hear from our primary care clients is the lack of actionable data they have to work with. Even if care teams are getting reports from a value-based payer or 3rd party data aggregator, the information is often just a look-back at past performance with no insights on what care plans were successful, which patients they should be targeting and who those rising risk patients are. Understanding these pain points, we designed our care management platform to quickly identify rising risk or “prioritized” patients much further upstream in their care journey, ideally before those patients fall into the high-cost, high-utilizing category. Care teams gain insights into which patient sub-populations are achieving their care goals, what is driving that success and what barriers are getting in the way. If you are looking to truly transform your practice to deliver on value-based care contracts contact us in the "Request a Demo" link on this page!
Most health systems and primary care practices have developed various patient lists or registries, often for specific chronic disease patient populations. Typically, these patient registries offer care teams the knowledge of which of their patients have one or more chronic conditions, the contact information to reach out to those patients, and, in some cases, provide further insights as to any standard care gaps that need to be addressed. The challenge with limiting the registry to care gap closure and outreach is that clinicians are blind in their ability to identify those patients that are really in need of an outreach or further intervention compared to those patients that are managing their condition successfully and achieving their care goals. Addressing this critical limitation was a key area of focus in creating the C3LX Patient Engagement platform, providing care teams with what we call, “Prioritized Patients”. Our platform uses several algorithms to identify prioritized patients and communicate to the care team specifically what needs to be addressed. We allow you to efficiently give every patient exactly what they need. Now that is intelligent technology! Learn more about our comprehensive smart registries and overall remote patient monitoring and engagement platform by contacting us or requesting a demo.
Over the last several years, more and more devices and companies have expanded the options for remote patient monitoring. Blood pressure monitoring, Bluetooth scales, fitness trackers, etc. While this proliferation of patient generated health data is encouraging, care teams are inundated with an abundance of disparate data that isn’t linked back to their patient’s care plans nor their progress towards longer term care goals. Absent of putting this data into context or into “smart” dashboards, most clinicians don’t have the time or the platform to turn this data into something meaningful. Ideally, this data is synthesized with patient care goals and chronic conditions, analyzed to identify rising risk and prioritized patients, and is actionable for care teams to know who best needs their attention. At C3LX, we have created both the platform to manage the data as well as the intellectual property to make the data relevant and actionable for both care teams and patients. We are making patient generated health data an indispensable part of the health care equation. Find out more about how we are bring patient engagement and remote patient monitoring together, request a demo here.
Care managers who support patient populations and other providers are critical for successful value-based models. Typically care managers are either a part of a diverse care team within an individual practice or they function as a centralized unit providing wrap-around support for patient populations spanning multiple practices. Unlike the workflow of the physicians within a practice that tend to focus on the patient in front of them or the schedule for the day, care managers can take a more proactive view looking ahead at patients that require more active attention and dynamic engagement.
This year has been filled with small yet poignant personal and professional moments of peace and joy amidst a dark and difficult backdrop. At home, Angela and I were forced to slow down with our family. We played more board games, watched the great movies from past and present (I’d be glad to share the list!), completed puzzles, ate “social distanced” meals together with my aging parents, and found laughter that buoyed our spirits during those tough days. We discovered the catharsis of an expletive filled rant or the simple painful expression of our fears and vulnerabilities. We rediscovered simplicity and a slower pace. Even as we grieve all that was lost around us, I am thankful for those roses. I am most thankful for that unexpected time together!
The use of telehealth rapidly increased during the spring as it gave patients a needed way to connect with their physician and reimbursement restrictions were lifted. During this time of a rapid increase in adoption, patients as consumers expect more from their digital tools and compare their experiences to offerings from other industries. Notably, as we head into fall, already the usage of telehealth offerings is declining as physician practices open back up and patients feel safer to return to in-person visits.
- Scheduling appointments, refilling prescriptions and looking up lab results are important, but true engagement comes first in understanding unique patient needs, wants, motivations and barriers to achieving care goals and the lifestyle changes needed to be successful; and then in supporting patients along the journey to achieving those goals.
- Patients rarely have just one, clear, manageable issue. A smart platform would take in a variety of inputs and combine appropriate algorithms for treating a patient’s asthma, arthritis, depression, and weight reduction without the clinician having to synthesize these disparate data points on their own.
- Each care team member is able to see both the patient’s master plan and the relevant data and prioritization that is specific to their role and scope of practice. With the growing dynamic of team-based care, each member has a personalized dynamic dashboard to work in.
- The master plan and supportive tools need to travel seamlessly with the patient, whether they are at home with devices tracking their activity, sleep, and blood pressure; or on the road for work or play, even when seeing a specialist. The primary care team then needs the relevant data and information to come back to them through the platform in meaningful and actionable ways.
- The platform must remind care team members and patients of upcoming and overdue activities, suggest changes in the master plan when patient conditions and care needs change, and route messages to the appropriate care team member regarding new test results, data trends negatively, or when patient health goals aren’t on track or being met. All of these long before an adverse event occurs.
At scale, the Health Engagement Platform facilitates the thousands of master plans seamlessly, undergirds a myriad of patient/provider workflows, simultaneously traverses multiple care settings, and supports hundreds of thousands of highly personalized provider decisions; so that a population can be proactively managed as never before. This is the future of healthcare technology!