eClinicalWorks Blog Details

  • 17 April 2019
  • Blog

TCM: From Post-It to Proactive


Matt Cady, Chief Innovation Officer at Florida’s Adult Medicine of Lake County, says that before his practice began using eClinicalWorks to track patients moving among care settings, they had a system in place: Post-It® Notes and spreadsheets.

In other words, in spite of having the cloud-based eClinicalWorks EHR, when it came to keeping track of patients moving from a hospital setting to home, they were still, in effect, using paper records. Each provider knew what was going on with their patients, but communicating that information to colleagues was cumbersome and time-consuming.

If the members of the Transition Care Management (TCM) care team was ill or on vacation, that department would effectively be closed for the day because no one else at the practice understood what to do with the available records.

In the last year, Adult Medicine has gone from Post-It Notes to proactive procedures that give each provider and all office staff unprecedented visibility into each patient’s case. 

Adult Medicine did two things:

  1. The first and most fundamental improvement was beginning to use the eClinicalWorks TCM module to track patients, reconcile their medications, and ensure they came in for post-discharge appointments within the time required.

  2. The second change was to combine the practice’s TCM and Chronic Care Management teams to eliminate multiple, confusing phone calls to patients and ensure that all staff were taking a unified, efficient approach to care TCM, Cady said, gives Adult Medicine the means to track patients with high accuracy, which has made “…a dent on cutting back on those readmissions.”

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Cady said the practice enjoys the ease of use that comes with having a comprehensive cloud-based EHR from eClinicalWorks, along with Population Health solutions such as TCM. “It gives the whole office visibility into who’s in the hospital, who’s out, and what the time frames are we’re dealing with,” Cady said.

Previously, he added, the practice would have data up to two weeks old, which meant that the opportunity to provide timely transition care was already gone. Now, medication reconciliation is done promptly, staff ensure the patient is ready to go home to a safe environment, and follow-up appointments are scheduled on time. And the TCM module helped identify falls as one of the major risks facing patients recently discharged from the hospital.

pop-health-wheel-2018-graphic-220x200px@2x “Upon discharge now, there is actually a protocol of what will happen and how we will address the risk of falling at the patient’s house. Whether it may be the need for durable medical equipment or a change in medication, we’re actually able to get some good insight and actually reduce the problem.”

– Matt Cady, CIO, Florida Adult Medicine of Lake County


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