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Enroll patients on custom-tailored "longitudinal care plans" that can be easily adapted from a library of standard care plan templates for congestive heart failure, coronary artery disease, diabetes, COPD, hypertension, chemotherapy regimens etc. System-generated alerts for missed and upcoming visits and abnormal clinical measures are used to track chronic/other high-risk populations and ensure necessary preventative measures are taken to prevent costly readmissions and inpatient acute care.
Improve patient engagement via portal access to friendly summaries, proactive alerts to scheduled and unscheduled necessary care, medications, treatment history, and future appointments. Monitor patients' perception of care for all providers within your delivery network in a timely fashion to support attribution models for incentives.
Identify significant patients from a real-time database of patient medical history using complex clinical guidelines such as "all male patients >40 yrs old, with family history of diabetes, history of tobacco use, BMI>22.5 and HbA1c>7%". Medical history can be optionally sourced from existing clinical systems, such as Electronic Medical Record (EMR) systems.
Lead or participate in a care coordination workflow across your system or even beyond, that routes high-risk or high-cost patients across work-lists for various caregivers such as health coaches, providers and nurses, case managers, patient navigators etc., based on clinical guidelines and alerts that are initiated from disease-specific care plans.
Automates longitudinal care plan adherence to seamlessly link responsible providers to track necessary and appropriate care while proactively alert when off pathway testing is ordered or services are missed. Track chronic care and other high-risk populations to ensure all necessary preventative measures are taken to prevent costly inpatient acute care.
Provides foundation of Private Health Information Exchange between all members of your respective delivery system to homogenize critical clinical content from multiple sources to ensure proper care and appropriate utilization to your standard of care.