How Learning a New Healthcare Language Saves Lives & Dollars

HEDIS®: Putting an End to Data Nightmares

Published on Thursday April 11, 2019

Dr. Martha R. Rodriguez used to have data nightmares every time her practice was inundated with lists from insurers showing gaps in patient care. Since using the HEDIS module and dashboard from eClinicalWorks, her practice now has templates that can work with real-time data to proactively close those gaps in care. Plus, knowing which patients need which tests allows them to easily create Messenger campaigns for more effective patient outreach.

Adam Siladi: Tracking for quality measures is often seen as a necessary but cumbersome part of participating in value-based healthcare, but some practices are using tools available to them to alleviate that burden and drive improved patient care. One of those practices is MMR Healthcare here in Boynton Beach, Florida, and speaking with me today is Dr. Martha Rodriguez, CEO and president of MMR Healthcare. Dr. Rodriguez, thanks so much for your time. Now, HEDIS is a standardized measure set that’s used by about 90% of the payers out there. Are you participating in any contracts that look at HEDIS, and which of your payers are participating?

Dr. Martha Rodriguez: Yes, we use HEDIS in our practice a lot, because we have managed-care contracts. And ever since the concept came out, we’ve been following it and using it a lot. It’s always been very difficult, but we’ve managed to maintain a five-star score since the HEDIS module came out.

Siladi: Five stars, of course, being that top level that everybody’s shooting for, and of course, there are some nice incentives to get there. But what were your challenges with participating in HEDIS before you got the module from eClinicalWorks?

Dr. Rodriguez: Honestly, it was the nightmare of my life, because we were inundated with lists from the insurance companies. Every day we would get a new list — these patients have missing eye exams, these patients are missing mammograms. Go back to a staff member, order the charts, then give another list. Sometimes my knees would shake when I had to give another list of patients who didn’t have the colon test. It was every day a new list, always working backwards, always depending on data 90, 120 days old. Now, all of that is gone.

Siladi: Is there a diagnosis code for physician anxiety for HEDIS measures?!

Dr. Rodriguez: Burnout is a frequent diagnosis code! They’re all burning out!

Siladi: Well, we’re here of course speaking with you because you’re using the HEDIS dashboards to reduce that burnout, and we’d like to get a little bit of details of why, so let’s talk about how the eClinicalWorks HEDIS dashboard and tools that are available are helping to make that less of a challenge for you.

Dr. Rodriguez: Oh my God, I’m so excited about this HEDIS dashboard and his HEDIS module, because really it’s incredible. To be able to know when you are seeing a patient when measures are missing is so incredible and transforming that I cannot describe it. It has also helped me to modify the way that we document. Because, for instance, even though the HEDIS dashboard is so helpful, it depends on everybody making the information appear there. So, with the use of the dashboard and the HEDIS module, I was able to create a template to collect data in a way that I never, ever, ever had to go back and be reviewed again. We would know when we see the patient, what’s done, what’s not done, and what’s left.

Siladi: No more guesswork about whether this gap is open, closed yet, things like that. Now, you were talking about getting daily reports from your payers, and I know many offices will also get a monthly visit from a payer representative to help them keep track of care gaps and show them where they need to do work. Now, this is obviously something that takes a lot of time out of their day when they could be dedicating that to patients. How is the HEDIS dashboard helping you to see those care gaps? Where are those showing up? Is that only in the dashboard? Is it at the point of care? What tools are available for you?

Dr. Rodriguez: No, both. We have the Population Health on the right-hand side of the panel that tells us at the point of care what the patient is missing, and then we have the dashboard to follow it that we can catch it before it goes away from us. But most importantly, by using the measure — for instance, there is a measure that is very difficult, and that is the diabetes measure. And in the Medicare lives portion of that if you fail one portion of those measures, you fail the whole measure, and you lose the payment. Example, if the patient has controlled blood sugar, but hasn’t had an eye exam, and doesn’t take a statin, or takes a statin and takes an ACE inhibitor, which is a medication, so one of them is not correct, you lose the whole measure, which is a huge loss in income. Using the Population Health module, I created a template that when we see a diabetic patient, we have a section that tells us to complete each portion of that diabetes measure in one shot at the point of seeing the patient and we’ve never had a problem again.

Siladi: And you haven’t had to log out and check a report, or got to a payer site?

Dr. Rodriguez: Never!

Siladi: Or even go to that other dashboard in eCW?

Dr. Rodriguez: Never!

Siladi: Now, you are here obviously with other providers. What has their reaction been to having the care gaps in that right panel for them?

Dr. Rodriguez: They love it. They love it because they don’t get yelled at so much! Because you know it’s frustrating when you have to keep going back and doing work. And you cannot always depend — We have so much to do, and so much documentation to do, doing it once is more than enough. They have really embraced it because they know, when they collect the data, it’s done. When they see the patient the next time, it tells you — it’s so nice to see all the measures completed. That’s amazing. So they’re very embracing to it all.

Siladi: Green lights all the way, that’s what we want to see! Now, version 11 also adds an integration with the Messenger tools that are available in eClinicalWorks. How is this helping with your outreach and improvement of patient care?

Dr. Rodriguez: So, we use the Messenger to let patients know when they are missing a measure. For instance, we let them know to call our office to schedule a mammogram or to call our office for a flu shot. We have flu clinics and we send messages to tell them to get their flu shot or their pneumonia shot or to check their blood sugar. Whatever we need, we just create campaigns based on that.

Siladi: So that must save a lot of staff time?

Dr. Rodriguez: Oh my God, tremendous. And it ties the patient to a practice in so many ways. That’s just one example of what reaching out to patients brings back to the healthcare system.

Siladi: You mentioned that your office had achieved a five-star rating on some of your HEDIS measures. What role did the HEDIS dashboard play in achieving that five-star status?

Dr. Rodriquez: Well, since the HEDIS model came out, we had five stars. When the practice grew, and we were unable to collect the data that we are collecting now, one year we lost the five stars. I almost died, because I don’t like that. Well, we got the tool and we went right back up to five stars because we were able to collect the data the way that we couldn’t do it before. It’s just too hard, there’s no way to do it. It’s too many measures, too many people involved, too much staff time — that it gets one time in the tool, and that’s it.

Siladi: So, it sounds like what you’re saying is that prior to your office expanding, it might have been manageable even though difficult to stay on top of those HEDIS measures, but then when your office grew it became harder to know what was going on and make sure everyone was doing the same thing. So, you were able to increase your visibility into what was going on in your practice and make sure everybody got on the same page to bring those HEDIS measures back up to five-star rating.

Dr. Rodriquez: Yeah, and the thing is, we depend on data that is old. If we don’t use the tool, the only data we have available is old data. So, if they give us a list in December of a patient that hasn’t had an eye exam, and it’s the end of December, what use is that? We lose the stars. Now, with the tool, nothing escapes us, because we have the information at the point that we need it.

Siladi: And it’s integrated with all of the clinical information that you’re gathering right there in your practice. Excellent. Well, Dr. Rodriguez, thank you so much for your time here today. If you’d like to know more about the HEDIS tools that are available from eClinicalWorks, check out, or speak with your Strategic Account Manager.

And don’t forget to check out our other podcast episodes on iTunes, YouTube, or For the eClinicalWorks Podcast, I’m Adam Siladi. Thanks for watching.

HCC: Speaking a New Healthcare Language

Published on Thursday April 11, 2019

For Dr. Martha R. Rodriguez, Hierarchical Condition Category (HCC) coding is really a language of its own, and one that today’s practices must learn in order to effectively deliver quality care and manage their budgets. The HCC module from eClinicalWorks has helped her practice more accurately risk-stratify patients, leading to better care. Providers at MMR Healthcare are thinking differently than before, and speaking a common healthcare language — with dramatically improved results.

Adam Siladi: The shift to value-based healthcare means that the industry is changing, but not always in ways that we can see. That’s why risk stratification is so critical for offices that are moving toward value-based care. Both in the ways that we describe the patient’s condition but also in the ways that we participate in the healthcare system itself. Here to speak with me about her practice’s experience with the Hierarchical Condition Categories and HCC, which is a method for risk stratification, is Dr. Martha Rodriguez, CEO and president of MMR Healthcare here in Boynton Beach, Florida. Dr. Rodriguez, thank you so much for your time. So, one question that we get asked often is, if I’m a provider who’s still billing for 99213, the office visit code, why do I care about risk stratification in HCC? I mean, in other words, if these providers are not part of a managed-care contract, they’re not in an ACO, or part of alternative payment programs, they might think that there’s no reason to participate in HCC. What are your thoughts on that?

Dr. Martha Rodriguez: Well, I have very strong thoughts about that, because I believe that if you don’t participate in HCC modules and HCC programs, you’re going to be out of practice. I mean, healthcare, we know what doesn’t work. We know that the way we were doing it didn’t work. The only way to transform the future is to use risk to evaluate the cost of patients’ care and be able to direct budgets appropriately.

Siladi: How is HCC, since HCC and risk stratification is such a critical part of this shift, how is this changing the way that primary care is being perceived in healthcare overall?

Dr. Rodriguez: Well, primary care has taken the lead — which is different in healthcare, we used to be the last on the list — it’s us, that we are able to identify the patients’ risk and direct care after that, that is really going to change healthcare. Using this model is the only way that we can identify the patients, and have to evaluate the risk and categorize them.

Siladi: Now, risk stratification with the HCC model is dependent mostly on the conditions that the patient has. Why is accurate coding so important for HCC, and how does primary and secondary manifestation codes play into that?

Dr. Rodriguez: Well, HCC is really, in my opinion, a language. You know, it’s not what you say but how you say it. So, education and learning this language is important, but documenting is also important. And to track your documentation so you do it appropriately as many times in the year as necessary is a big task and it’s a challenge. So the use of a tool really helps a facility face that.

Siladi: Why is accurate coding with HCC so critical, and what role do primary and secondary codes play into this model?

Dr. Rodriguez: Well, HCC is critical, but it’s the HCC that really dictates the categorize of risk of a patient. Without us appropriately identifying the primary and secondary diagnoses on a patient, documenting them properly and reporting them properly, then the government doesn’t know what amount of budget to allocate to each patient. It is HCC that guides the government and us to do that.

Siladi: And of course then if they’re not allocating enough resources for that patient in the value-based model then that’s going to affect the providers who are caring for those patients as well. What are the biggest challenges to participating in HCC and succeeding in HCC?

Dr. Rodriguez: The biggest challenges in HCC is a program that needs education. It takes a shift in mind. We were used to just writing a diagnosis and going on to the next. It does require more documentation. It does require paying more attention, that you report that documentation the amount of times that it needs to be reported. It does require a shift of mindset.

Siladi: A lot of practices are saying that they get reports from their payers, their ACO, whatever plans they’re participating in, that include lists of these conditions that need to be recaptured for HCC. Is this enough, or are practices really shortchanging themselves if they don’t have some other way of doing this?

Dr. Rodriguez: Oh my God, that’s not even close. The fact is that in the past the way we worked with those lists, we’d get a list of diagnoses that we had to report, is that we had to have staff manually go back and order charts and report and rebill and redo, a lot of times losing the chance — because you can’t alter a note after 30 days — so a lot of times you lose the chance to report things appropriately. Depending on the insurance company data, which is always 90 to 120 days late, it makes you lose an incredible amount of financial benefit from the HCC module.

Siladi: So, in other words, I think what you’re saying is you’re playing catch-up a lot, and you’re having to dedicate a lot more staff time because of that. Now, of course, you are using the eClinicalWorks HCC module, which is built into the Progress Note and comes with a dashboard. What does the information that you get look like there and how does that help you be more proactive than reactive?

Dr. Rodriguez: Oh, it changed dramatically. It’s now at the point of service when we see that patient that we can see how we report things and how the score increases dramatically based on your information and your documentation. So, you’re tangibly able to follow that and see what you’re missing at the point of care.

Siladi: What steps did you take to make sure you and your staff are accurately coding to improve that patient care?

Dr. Rodriguez: A lot of education. We’ve had consultants come in and continuously come in and educate our staff and ourselves. We also have insurance companies who have people available who educate you constantly. So we have monthly seminars for them. Education is critical for HCC success.

Siladi: And does the tool play a role in that education?

Dr. Rodriguez: The tool plays a big role in that education, because by the use of the tool we can demonstrate to the clinicians, if you didn’t put this diagnosis look at the score, versus putting this diagnosis, right in front of them. It’s critical. It’s incredible.

Siladi: How does the eClinicalWorks HCC module increase accountability while also improving the providers’ experience at the point of care?

Dr. Rodriguez: Well, that’s a very interesting question, because in a practice, for instance, like mine where we have several clinicians, it’s very difficult to know what the other clinicians are doing. In the past, we really didn’t know, for instance, if a clinician is doing a physical, if they approached all the critical HCC conditions. With the module, we’re able to see what was done in each visit, and we’re able to track and see what the score of the patient is as the year is progressing, something that is dramatically different from what we used to do in the past.

Siladi: So are we have discussed the use of the HCC module with a single patient, but as we said, it also comes with a dashboard. How are you using that dashboard to gain better insights into what’s going on in your patient population?

Dr. Rodriguez: Well, the dashboard is very helpful because the dashboard offers something that we never had. One issue that we find very difficult is, for instance, when you identify a patient that needs diagnoses reported, then you have to go to the front desk and look in the computer when the appointment is. In the dashboard, you’re able to see the trend of the HCC, what’s happening with the HCC. You’re able to export the data, and more importantly you’re able to see even when the patients next appointment is so that you don’t miss the patient’s collection of data, which is critical for the year’s data.

Siladi: Now your group, MMR Healthcare, is part of an ACO here in Florida. How has the HCC module helped your practice with that participation?

Dr. Rodriguez: The HCC module has increased our HCC scores dramatically because we’re able to follow it throughout the year. I mean, like, dramatically. We can see every month the increase in HCC scores that we couldn’t ever do before. We were dependent on data that was sometimes a year old from the ACO. We can see now on a monthly basis the dramatic improvement in the HCC score. I mean, it’s really dramatic. We get reports from the insurance company about the HCC score, what the projected is, and what the past HCC score was, and a lot of times because the practice grew so much, and we have different clinicians and we cannot always know what they are doing, we never really knew what was happening to the HCC. We held the highest HCC score in Florida for many years, and when the practice grew I lost control of that because I didn’t know what the other clinicians were doing. And because I depended on old data, it was very difficult to change that. Since we have the module, it has been a persistent, consistent increase in the HCC score every month, because we’re able to change it at the point of care.

Siladi: A lot of emphasis is being placed on the need for collaboration between primary care and other settings of care for the patient, integrating behavioral health, integrating pharmacists and so on. You collaborated with radiologists. Where did that idea come from, and what did you do about it, and why does that relate to your HCC scores?

Dr. Rodriguez: So, when the HCC module came out, I realized like I said earlier it is a language. And unless we all spoke the same language, we weren’t going to get anywhere. So, what I did is, I went to the radiology group that we used in the area, which was a very big group that was out of the hospital, the closest hospital here, and I educated all the radiologists on HCC. I educated them on — I gave them templates on how to read x-rays. In the past, for instance, a simple chest x-ray would say “nodule disease.” Well, that doesn’t serve us any purpose, because to document arteriosclerosis of the aorta, we need a backup radiology test that tells us that. So, I educated them on the importance of mentioning the size of the aorta in a chest x-ray, something that was never done before. Or, the way the vertebrae looked on an x-ray. All of those things that were never done, by educating the radiologists, we were able to increase the HCC scores dramatically.

Siladi: All because you had that backup of the information that supported what you were really looking for. So, I guess, don’t be afraid to work and reach out beyond the walls of your practice and work with those other providers. Dr. Rodriguez, thank you so much for being here and thank you so much for your thoughts on HCC and why that is critical for your practice. If you’d like to learn more about the HCC module available from eClinicalWorks, you can check out or speak with your Strategic Account Manager. And don’t forget to check out our other episodes on iTunes, YouTube, and For the eClinicalWorks Podcast, I’m Adam Siladi, and thanks for watching.

TCM: A Single Scoreboard Leads to Clear Wins

Published on Thursday April 11, 2019

When MMR Healthcare started using Transition Care Management from eClinicalWorks, they learned the chronic heart failure, falls, and influenza were the leading causes for hospital readmissions among their patients. With unified dashboards to keep all providers informed about each case, they have improved compliance with follow-up appointments, helped patients with their medications, improved patient education around diet and lifestyles, and reduced their hospital readmission rate down to 10-12%, well below the national average of 18%.

Adam Siladi: Preventing readmissions holds major potential for improving patient care while reducing costs, but tracking discharges has traditionally been difficult to manage, and trends in preventable utilization can often go unnoticed. That’s why we’re here speaking with Dr. Martha Rodriguez from MMR Healthcare here in Boynton Beach, Florida, about how her practice has been using the Transition Care Management tools from eClinicalWorks to facilitate those efforts. Dr. Rodriguez, thank you so much for being here.

Dr. Martha Rodriguez: Thank you.

Siladi: Tell us a little bit about your practice and why Transition Care Management is so critical for your patient care.

Dr. Rodriguez: So, our practice is a primary care physician practice in Boynton Beach, where we treat mostly chronic conditions, mostly geriatric patients. And in our practice, in particular, we have a big set of tools that we use to track patients, identify them for their risk, identify them when they have issues of hospitalizations, and follow them to avoid readmissions.

Siladi: If we’re looking at utilization overall, across the nation, what are some of the trends that we’re seeing that we’re trying to impact here?

Dr. Rodriguez: So, the trends that we’re seeing is, we’re not getting anywhere. Unless we coordinate, and get together, and use data, point-of-care data, to change outcomes, we’re seeing that we’re not making much progress. There are some serious conditions that keep repeating themselves just because we don’t utilize the data that is available to us to change those outcomes.

Siladi: And is there a readmission rate nationally, is there a national readmission rate?

Dr. Rodriguez: The readmission rate nationally is about 18%, which is very high.

Siladi: Now, many practices don’t get reliable notifications from their hospitals, so tracking and managing TCM is a bit difficult. What is the risk for practices and patients if they don’t participate in TCM?

Dr. Rodriguez: Well, the risk of not participating in TCM, the number one risk is that you’re — major financial loss, both for the practice and healthcare, because if you don’t identify the patient when they’re hospitalized, you cannot change the outcome of the hospitalization or prevent a readmission. And two, the whole thing can be more costly because there’s a disconnect among the team.

Siladi: What is your office doing to overcome that first hurdle and figure out when patients are being discharged?

Dr. Rodriguez: So, we use a tool that we have available to us. It sends us a message any time that the ID of a patient hits a facility, we get a message. And that immediately starts a process in our office. We involve the patient in the TCM program, and we follow the patient throughout their admission. There is a team that is involved. We have a person who calls the patient in the hospital every day, documents in the tool all the notes of the conversations for everyone to know. If the patient had any procedures, any medication changes, everything is documented, and the patient is followed throughout their admission. Once discharged, we use the tool to bring the patient back within the limited time that we need to, so that we don’t lose the window of time that is important to prevent the readmission. And as you know, there is a punishment that is going to be carried through if the patient is readmitted within the next 30 days following an admission. So, we put the patient in the tool to track them through the 30 days so that we avoid any of those problems.

Siladi: Was your office participating in Transition Care Management before you started using the eClinicalWorks features available?

Dr. Rodriguez: Yes, we’ve always done Transition Care Management in our office. Not necessarily billed for it, because we ourselves didn’t know the financial value of billing for it, but we looked at the bigger picture, because we have a big managed-care practice. So we looked at the millions of dollars that can be saved by doing transition of care on a global basis. So, since we have learned that, we have always followed the patient from admission to discharge, following discharge. The beauty of the tool is that it’s one-stop shopping. In the past, we had a person that took care of the hospital calls. We had a pharmacist who took care of the MTM [medication therapy management] or the reconciliation process part. We had the front desk scheduling the appointment. And not necessarily everybody knew what the other person was doing. Since having the tool and having everything in one place, the efficient, the cost of doing it, and the outcomes have all been improved.

Siladi: So, there’s a benefit to be gained in the healthcare system. We’re saving money overall, but it sounds like there’s always also a financial benefit there for your group because you’re able to manage that so much more effectively. Now, what kinds of targets has MMR Healthcare set for TCM? Where did we start out, where are we now, and what is your goal going forward?

Dr. Rodriguez: My target has always been to beat the country’s readmission rate. I think that we can do that, and we’ve proven to be able to do that by using transition of care. The national average is about 18%, ours is about maybe 10, 12%, and we could have never done that had we not identified the patients that needed to be followed from hospital day one to the 30 days following a post-discharge with a system that created the collection and the management of the information.

Siladi: In what ways has having the TCM dashboard improved your ability to manage patients in that very difficult time? What kinds of strategies are you putting in place? What are you learning from the use of this module?

Dr. Rodriguez: To our surprise, and even though I claim to be very educated, carrying TCM I learned very quickly what were our targets. For instance, we found out that CHF [Chronic Heart Failure], falls, flus, were one of our biggest, biggest problems for admission to the hospitals. Using that data, we created a CHF clinic in our office with the use of Nova University staff, which is in our office, the pharmacy school. And we created a CHF clinic. Since we started with that clinic, we have never had another readmission for CHF. The tool helped us identify which were the diagnoses that were most important to target, and therefore we were able to modify them.

Siladi: Now, you mentioned a partnership with Nova Pharmacy School. Tell us how that fits into your strategy here at MMR Healthcare, and what that partnership looks like.

Dr. Rodriguez: So, we got recognized for PCMH back in 2014, and PCMH is a recognition that comes from proving excellence in teamwork, which is how I’ve always practiced. And I’ve always known that the pharmacist is a key player in the team of patient care. The patient being the leader, but the pharmacist is really important, because the pharmacist is the one that carries through the medications, and those can change everything. So, since we learned that, we partner with Nova Pharmacy School, and we are a satellite for their school. Their students rotate through here, and we have Dr. Genevieve Hale here in the office twice a week. She’s a professor at the pharmacy school, and she leads the CHF clinic and the hypertension clinic, and they see patients just like we do, and follow patients in-between our visits. Whatever is needed. They call the patients and make sure they have done their refills. They check to see if they are having their insulin, for instance, done properly. They educate them on the use of insulin. If needed, they prefill their pillboxes. They bring the patient in and do a pillbox for a month, so the patient doesn’t have to do it. Whatever need we identified, they’re able to help us carry it from a pharmacy perspective.

Siladi: It sounds like you’re really hitting home that idea of collaborative care, making sure that everybody who’s involved in the patient’s care is well aware of what’s going on with all of the other parts, and it sounds like that’s making an impact. Can you think of a particular patient story where Transition Care Management has really made the difference?

Dr. Rodriguez: Well, we have many stories, but we have one, and it’s one that I like to talk about because it’s such a frequent one. Most people like to go out to eat on Friday nights, and a lot of people go to Chinese restaurants on Friday nights. Well, we all know the amount of salt that can be — nothing against Chinese food — but it’s high in salt. So, people are at risk for changes in volume, like CHF patients. It can cause them to go into a crisis because they go to a Chinese restaurant. Using TCM, we were able to identify patients at risk for volume issues, such as CHF, and we were able to create programs to change that. We educate the patient on what to do before going out to eat. We educate the patient on what to do on the next day after eating. So, we have found that by giving them emergency kits, for instance, like giving them a water pill to have at home, before they go, and to weigh themselves the next day and use it if needed, all of those things have changed everything about the patients’ admissions.

Siladi: How critical is a team-based approach to success in Transition Care Management? And in what ways does the Transition Care Management tool facilitate that team-based care?

Dr. Rodriguez: Well, I believe that healthcare as a whole cannot be accomplished without a team effort. We all know that, for instance, LeBron, isn’t he a star basketball player? Can he win a championship by himself? He can’t. So, no matter what I know, I can’t do it all. I can see the patient, I can educate him, I can transfer my passion, but I cannot go home with him. So, a team is critical to carry through what needs to be done in-between visits, and the team players are very important. And we need to recognize that. But what we really need is one place where all the teams can put their scores, you know. You cannot be on a team and playing a game and there are 10 different scoreboards. That makes getting to the final score very difficult. With the usage of a tool we’re able to record everything in one place and the whole team can see it at the same time. That’s transforming.

Siladi: Now, Transition Care Management is often looked at as maybe being retrospective. The patient was in the hospital, they were discharged, now we have to care for them. Are there ways in which this tool is helping you be proactive in care for your patients?

Dr. Rodriguez: Oh absolutely. For instance, one of the frequent reasons for admissions to hospitals in the elderly is urinary infections. So, if the patient is admitted for a urinary infection, we identify that in the tool, we put a system in process. For instance, we may give a patient a suppressive therapy with an antibiotic. So, by identifying that this is a problem, using the tool, then we can create a program to eliminate it as a problem.

Siladi: Excellent. Well, it sounds like we’re really pushing the envelope with patient care, really improving those outcomes and reducing admissions. Thank you so much for your great work and thank you so much for your time speaking with us here today. If you’d like to learn more about the Transition Care Management module, check out or speak with your Strategic Account Manager. And check out our other episodes on iTunes, YouTube, and For the eClinicalWorks Podcast, I’m Adam Siladi, thanks for watching.

CCM: Easing the Burdens of Chronic Illness

Published on Thursday April 11, 2019

While MMR Healthcare had always provided chronic care, in 2014 they begun using the CCM module from eClinicalWorks. They partnered with a local pharmacy college, increased contact with vulnerable patients in-between visits, and avoided unnecessary hospitalizations and readmissions. While few patients with chronic illnesses are cured of them, the CCM program has helped educate patients, keep them in closer touch with the practice, and improved their quality of life.

Adam Siladi: Patients with chronic conditions need to manage their health every day, but without the support of their care team, it can be difficult to keep those conditions under control and to identify potential complications before they become critical. Fortunately, the focus on value-based care and Population Health is providing support for clinicians who are managing these patients to drive better outcomes. And that’s why we’re here speaking with Dr. Martha Rodriguez from MMR Healthcare here in Boynton Beach, Florida. Dr. Rodriguez, thank you so much for being here today. Now, you are CEO and president of MMR Healthcare. What was your strategy to get started with CCM. Why was that something that was critical for you?

Dr. Martha Rodriguez: Well, CCM, in my opinion is really a concept that carries through the solution to healthcare. Because it’s the one concept that creates and emphasizes on the team effort. So, when Chronic Care Management came out as a benefit, and we were reimbursed for identifying and following closer patients with these conditions, it really has made a huge difference in healthcare.

Siladi: How did you actually implement that program? Did you start a pilot project? Did you select a specific, small group of patients to get started? What was your strategy there?

Dr. Rodriguez: Yeah, when we become PCMH recognized in 2014, actually in October 2014, we started Chronic Care Management. It wasn’t known as such then because it became a benefit in 2015, but we used the team concept to identify patients at risk. And so we created a pilot actually where we involved a pharmacist from the area, we involved two nurses and our care team here, and we identified a set of patients that we followed through. And we were able to see how the team effort and closer follow-up was able to change the patients’ outcome.

Siladi: And was that something that was scalable for you as you moved out of that pilot project into actual participation? Was it easy to grow your participation there?

Dr. Rodriguez: Our participation was easy to grow, but what was more timely was the amount of money that was being saved. We get that data from the insurance companies because we practice a lot of managed care, so with the use of CCM we were able to see that we were saving millions of dollars a year in healthcare costs, because by following the patients closer, we were able to prevent things that could happen that would have escaped us otherwise.

Siladi: You mentioned a close collaboration with pharmacists and other care team members. Did you have to bring in additional employees to participate in CCM or did you get started with who you had right now?

Dr. Rodriguez: When I got started I used who I had, and the pharmacist that I brought on the team didn’t really charge us anything because he was excited about the concept of interdisciplinary growth. Afterwards, I did have to hire more staff because the program grew to such a degree, but the financial rewards were much higher than my investment.

Siladi: That’s a great point. You know, you have to bring people. At a certain point, you know, if the program participation grows you will need more staff. At what point did you find that you needed more people? How many patients per coordinator did you find was the right amount?

Dr. Rodriguez: Well, it depends on the patients, but I believe that about 20 to 30 patients that are critical should be followed by one coordinator. But it depends, because when you have a team — for instance, we have the pharmacy students. The pharmacy students call the patients almost every day if they have to, so it reduces the amount of coordination that we need from a coordinator, and they can target their efforts to another patient. So, it depends on how the team is structured, but it also depends on the patients.

Siladi: And speaking of the patients, you know, we often hear with new programs like Population Health, Chronic Care Management, etc., that we need to get provider buy-in, but Chronic Care Management actually has a component where the patient needs to give consent. How did you speak with your patients to convince them that this was something that would benefit them?

Dr. Rodriguez: Well, very easily, because the patients were not used to really getting in contact with us in-between visits. And that’s where we really lost so much room. When we started the program I gave cellphones to the coordinators. So, just the fact of having an in-house number that they could call directly for any issues was a very big selling point. Because, you know, they never have to go through the front desk again for a prescription or an appointment. They had to select the person whose cellphone they had to reach out for anything. That really made a difference and made it very easy to sell the program.

Siladi: Increasing that access, then, was the carrot to get the people involved? Now, how do you keep patients in the program after enrollment? Are there people who join the program and was to disenroll?

Dr. Rodriguez: Well, my wish is always that they disenroll because I want them to get better! But Chronic Care Management is a lifelong commitment. When you develop a chronic disease, usually it doesn’t go away. So, with the chronic care program what we can do is keep that chronic disease controlled. And it’s that follow-up, constant, continued involvement that keeps it from progressing. So, the patients don’t disenroll because they don’t have the disease, they might disenroll because they move or because they’ve gone to a lower level of intensity. But usually I like them to continue in the program so that they have that continued education, continued involvement that ties them to the practice.

Siladi: Now, there is a patient copay for CCM services, and there are some providers out there who feel a strong conflict with trying to charge a patient a copay for something like that, that they would have been doing anyway previously. What are your thoughts on that?

Dr. Rodriguez: My thoughts on that — as physicians we have a responsibility to educate the patient about the benefits of the program. First of all, most of the secondaries cover that copay if it’s a fee-for-service patient. But besides that, the amount of copay that it is, is nothing compared to the benefits that the program brings. So, as we present it to the patient, if we don’t have the time to do it ourselves we can have the coordinator educate the patient, because in reality the benefits far outweigh the costs.

Siladi: Is there a specific story that you can think of for your practice that shows how valuable Chronic Care Management has been for your patients?

Dr. Rodriguez: OK, so we had a patient that had — he died already — but he had a cardiomyopathy, and he was having a lot of problems with fluid retention. So, he was being hospitalized often. So, one day we told him to go home and get all of the medications that he had in the house and bring them to us. And the pharmacist and I made an appointment with him to meet with him. Here he comes with luggage — he actually brought a suitcase full of medications. Well, we found that by doing that, and identifying this patient at risk, and involving the team, is that he was taking two different water pills when he felt like it, and not taking the potassium when he didn’t feel like. He was taking two beta blockers because he didn’t know they were the same. And all of those things were happening without our knowledge. When we identified them and we involved him in the team, we educated him about letting us know immediately when there was a change, then everything changed.

Siladi: In other words, being able to see more about what’s going on with the patient outside your setting of care lets you identify that critical issue.

Dr. Rodriguez: Gaps in care.

Siladi: How does Chronic Care Management help prepare or accelerate the transformation to value-based medicine?

Dr. Rodriguez: Well, Chronic Care Management is the key to value-based medicine, because it is Chronic Care Management that stops the escalating of chronic conditions from getting worse. If you identify a patient when their condition is manageable and you don’t let it get worse, then the team can really prevent the cost that getting worse brings. So, it’s an incredible investment on both the patient’s and our part, because it’s what really brings value.

Siladi: How do you document the Care Plan? Since Care Plans are a prerequisite for the CCM program, are you using the eClinicalWorks Care Plan module, or are you using your traditional Progress Note? What’s your strategy there?

Dr. Rodriguez: We have a mixture. We use both. We use the Care Plans from eCW, and we use also the Progress Notes. But we try to use the tool, because since we have a team, it’s better to have everything in one place, so we try to document everything in the tool.

Siladi: Were there any patterns or insights that you didn’t anticipate that you’ve learned after participating in CCM?

Dr. Rodriguez: Well, when I participate in CCM I learned what a fool I was, you know, how much I didn’t know about my patients, and how much I thought they were doing that they weren’t doing. It was the CCM program that helped me identify the gaps in care that were incredible, and so impactful. Using the CCM program, we really, really knew what was happening between visits, what was really happening that we didn’t know.

Siladi: Well, Dr. Rodriguez, thank you so much for sharing your thoughts and your insights on the Chronic Care Management program with us. We’re glad to hear that you’ve had so much success and that your patients have really experienced better outcomes as a result of it. If you’d

like to learn more about the Chronic Care Management program, you can check out or check out our other podcasts on iTunes, YouTube, and For the eClinicalWorks Podcast, I’m Adam Siladi, thanks for watching.

“A team is critical to carry through what needs to be done in-between visits, but what we really need is one place where all the teams can put their scores. You cannot be on a team and playing a game and there are 10 different scoreboards. We’re able to record everything in one place and the whole team can see it at the same time. That’s transforming.”

Dr. Martha R. Rodriguez, MMR Healthcare


Topics From This Episode

Transition Care Management

eClinicalWorks offers providers the tools and insight needed to provide the continuity and quality of care for patients moving between acute and ambulatory settings while meeting regulatory and compliance requirements of the Centers for Medicare & Medicaid Services. Manage patients, track appointments, reconcile medications, and better understand who is being hospitalized and why.

HEDIS® Measures

Healthcare Effectiveness Data and Information Set (HEDIS®) is an essential tool for Population Health planning, offering a set of performance measures designed to improve the delivery of quality care, evaluate access to care, evaluate high-risk patients, measure compliance with treatments, and evaluate provider performance and patient satisfaction.

Chronic Care Management

CMS’ Chronic Care Management program reimburses medical providers for providing non-face-to-face care to patients with multiple chronic conditions, with the goal of achieving and maintaining better health outcomes and controlling costs. Learn how eClinicalWorks’ CCM module can help your practice deliver evidence-based care in keeping with the CCM program.

HCC Coding

The Hierarchical Condition Category Risk Adjustment Model calculates risk and predicts healthcare expenditures for individual beneficiaries. The eClinicalWorks HCC Module identifies coding gaps based on historical data, displays Risk Adjustment Factor scores, and uses a dashboard for trending analysis, enabling comparison of RAF scores from current and previous years.

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