How Population Health Data Is Transforming a Florida Practice

TCM: Tracking Patients in Real Time for Better Care

Published on Monday March 11, 2019

Patients are most vulnerable when transitioning from an acute care setting back to their primary care provider and home. Reducing readmissions requires proactive management of patients — reconciling medications, ensuring the home setting is safe, and keeping in close contact with the patient. With Transition Care Management from eClinicalWorks, Adult Medicine of Lake County is tracking patients in real time, getting actionable data at the point of care, and lowering readmission rates.

Adam Siladi: One of the most vulnerable times for patients is the transition from an acute setting of care back to the primary care setting. And the Transition Care Management program is intended to place more emphasis on that process, to help patients succeed in that difficult time. Here to talk with me about the Transition Care Management program is Matt Cady from Adult Medicine of Lake County. Matt, thank you so much for being here to talk to us. Tell us about the TCM program and why it’s so important for your practice.

Matt Cady: Like you had mentioned, upon transitioning out of the hospital back into the primary setting, a patient, like you said, is incredibly vulnerable. The family can be involved, there may be discharge orders, referrals, and a lot of things that are needed. So, the sooner we can get ahold of that patient, reconcile the medications, and make sure they’re on a firm foot getting back home, reduces the chances of their being readmitted. They found that within the first, not only three days, but the first couple of weeks, is the highest chance of readmittance. It’s the time for them to get back, get settled, and then really prevent that. So, TCM gives us a way to track that it, but then also really make a dent on cutting back on those readmissions.

Siladi: And of course we’re here to talk about the eClinicalWorks solution to help you manage Transition Care Management. But if you don’t participate in TCM — because I know there are a lot of offices out there that don’t do it — what is the risk if you don’t participate?

Cady: We have both the risk to the patient, which would be a higher chance of readmission to the hospital, and really I don’t think a lot of patients enjoy going back to the hospital; the risk to the practice, though, would be the higher cost of that patient going back to the hospital and any future complications that may arise from that. A lot of practices that I’ve seen will try to manage it on paper and have a very cumbersome solution to it, and when we migrated to the eClinicalWorks solution, we did it for ease of use. 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.

Siladi: And you mentioned overall cost of care, that’s more and more critical as we move toward this idea of value-based healthcare. And does TCM align with any of the other activities that you’re doing here at Adult Medicine of Lake County?

Cady: Yup. Just recently, actually, we combined our TCM team with our CCM team. And what we had found is that upon discharge from the hospital, that a patient could receive up to three phone calls from three different staff members. So, with this recent move, upon being discharged, your TCM coordinator will call you. If you’re eligible for CCM, you’ll be enrolled into CCM, but you’ll keep that same care coordinator from the hospital into that. If you’re not eligible for CCM, we have what’s called a patient outreach program. But either way, once you’re discharged, the same person who’s talking to you now will talk to you for the next three months, just to make sure you’re settled and the chance of readmission is reduced as heavily as possible.

Siladi: You know, having that constant point of care, it’s a huge concept right now. Patient-Centered Medical Home places a lot of emphasis on that continuity concept, so it sounds like you’re putting that into place for good use here. But what are some of the challenges in trying to actually participate in the TCM program? What did your group struggle with at first?

Cady: Our absolute biggest struggle was getting the information. Who was in the hospital, when they were admitted, what they were discharged, when they were discharged, any new medications. The local hospital system has not really been forthcoming with even an HL7 feed or any sort of a consistent one. So, any data we could get was spread around the office. Once we launched the TCM module, it gave us a way to consolidate it, because we’re happy to get any data we could. So what we had prior to this was a lot of data collection but not a lot of data activity. We would have data that was two weeks old, which is — any TCM opportunity is missed. We’re now able to get data in real time and our staff’s able to act on it in real time.

Siladi: Who was collecting that and how were they tracking it?

Cady: They tracked it over a series of spreadsheets and Post-it® Notes. And so, if the provider didn’t actually go by her podium, she may not have known it was a TCM appointment and some other critical things. Now, using the TCM module, throughout the office everyone is well aware of it — from the billing standpoint to the provider standpoint, and even for any care coordination over the phone, they understand what the patient is going through.

Siladi: What impact has this TCM module that’s built into eClinicalWorks had on the way your staff and your providers manage the patients who are in that TCM program?

Cady: One of our biggest concerns upon discharge was a medical reconciliation. Anything that you may have been prescribed there that may or may not conflict with what’s at home. So, given the TCM module, we were able to make sure, office-wide, that the medical reconciliation was done almost immediately, because it’s a box, a table to be checked off, and we can see it immediately. Then our next phase concerned are we able to get them in here within the allotted time, and looking at that report in the dashboard tells us how much time we have left. So scheduling up front is able to know that this is a priority patient and this one may not be based on the sensitivity.

Siladi: And has it improved the ability for you to fill gaps if someone is out of the office, or make sure that that information isn’t lost?

Cady: In essence, our TCM department would close on sick days and vacation days, because no one could understand the spreadsheets and the Post-it® Note system. Here, it is very seamless across the office. We have multiple people adding data and almost everybody extracting data out of that module.

Siladi: So, it’s really turned it into a team-based process for you, instead of just locking that in with one person who, like you said, if they’re out of the office, everything stops.

Cady: The other thing I would say it’s a much more proactive process now. We’re proactively seeking that medical record, so it’s more proactively seeking that appointment versus trying to say did somebody do it, was this done? We’re proactively knowing what needs to be done and when it needs to be done by.

Siladi: Thinking ahead to the next step, critical concept, like I said, as we move toward value-based care, because we’re all about preventing things from becoming problems, rather than addressing them after they’ve been an issue. So, with that in mind, how do you manage those timeframes, right? With Transition Care Management you have to contact the patient within two days of their discharge, and then you have to see them within seven to 14 days after discharge.

Cady: Correct.

Siladi: How are you making sure that that happens, especially when people say ‘Oh, I couldn’t get in touch with the patient,’ or they’re not responding. What are some of the things you’re doing there?

Cady: Probably the biggest impact was office-wide visibility. So, if the care coordinator reached out to the patient, and then when the patient called back and the front desk took the call and said ‘Oh, I think I need an appointment,’ they may put that appointment two to three weeks out. When they can now see that person is a TCM patient, and they know to book it in an allocated TCM slot, we can see them within 24 hours and 48 hours. So, getting office-wide visibility was a huge impact. The other thing that I saw was the need to start doing home visits. So, upon discharge, if a patient is home-bound, we will actually go to their house with a full battery of testing and do the TCM at their house, just to make sure that they’re settled and that they’re ready to resume their normal activities.

Siladi: Now, there’s also TCM analytics that come with the eClinicalWorks TCM module. What kinds of information are you seeing in that analytics dashboard and what are you doing about it?

Cady: That was probably one of the biggest eyeopeners over the last year. When you look at the reports section of the TCM module, it gives you your top diagnoses or reasons for admits. And I think prior to the dashboard, if you were to survey the office you’d have a spectrum of why they thought they were being admitted. Having it consolidated and having real data behind it, it really opened our eyes that two of our top diagnoses were very easily preventable. And as a result of having that data we’ve now launched programs to help reduce and attack those top two diagnoses, and over the last eight months have been very successful at it.

Siladi: Which of those programs have you found to be the most beneficial?

Cady: Our top diagnosis ironically was falls. And so, what we realized was they kept falling, and nobody was doing anything about it. So, what we did is we partnered up with a local DME [durable medical equipment] company and a home health company. And so, 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 a DME or a change in medication, we’re actually able to get some good insight and actually reduce the problem.

Siladi: So, Matt, those initiatives that you’re doing, the fall-risk follow-up, the congestive heart failure program, those must have a cost associated to them. How is this playing into your value-based care participation?

Cady: We look at it almost as a form of preventive medicine. If we can keep you from being readmitted, or possibly stop a fall that causes a broken hip, or possibly stop another life event with the heart, how do you attach a cost to that? We’ve run numbers on what an admission cost for a hip fracture — and you compare that to what it costs for us to go to the house and address what may cause that hip fracture, and there really is no comparison. So, as we move into the value-based care and more into Population Health, this is an essential component to that.

Siladi: Now, if you have more questions about Transition Care Management, you can go onto or speak with your Strategic Account Manager. And don’t forget to check out our other podcasts on iTunes, YouTube, and For the eClinicalWorks Podcast, I’m Adam Siladi, thanks for watching.

HEDIS®: Quality Care and Leverage in Contracts

Published on Monday March 11, 2019

Accurate risk-stratification is essential for any practice to succeed with value-based care. Adult Medicine of Lake County enjoys high HEDIS® scores — which both reflects quality care delivery and has given them leverage in negotiating managed-care contracts. The practice no longer waits weeks for patient data and can better track their snowbird patients in-between appointments. Better data means better tracking and the ability to expand service to their patient population.

Adam Siladi: Value-based care relies upon two major concepts: Estimating the amount of resources that are going to be required for a patient’s care and also ensuring that we maintain a reasonable level of quality of that care while trying to reduce costs. And quality measures like the HEDIS® measures set are intended to help practices to stay on top of that very aspect. Here to talk with me about his practice’s experience with the HEDIS measures and eClinicalWorks HEDIS dashboard is Matt Cady from Adult Medicine of Lake County. Matt, thanks so much for taking your time today.

Matt Cady: No problem.

Siladi: So, Matt, what do you see as far as the trajectory for quality metrics like HEDIS in this value-based landscape?

Cady: I see that it’s the beginning of a way to judge a practice’s effectiveness, and going into the future, I do think a lot of payers will judge who gets contracts and who doesn’t get contracts based on their HEDIS outcome, based on their Star rating. I think it will be a criteria that both patients and payers will assess their healthcare decisions on.

Siladi: Is that right around the corner, is that far off in the distance?

Cady: No, we see — I would say you can see it as soon as 2021. And, in fact, since I’ve taken over the practice, we had to renegotiate quite a few contracts and relationships that we have. And I can tell you, one of the biggest leverages we had in negotiating those was a prior success with our HEDIS scores. In talking to, for example, Blue Cross Blue Shield — we have a 4.7 score — gave us a good amount of clout to really negotiate and get the contacts we needed to provide some great patient care.

Siladi: So, quality measures. I think everyone’s familiar with quality measures in some regard, you know, making sure we’re monitoring blood pressures, making sure A1c’s are done, screenings are completed on time. What were some of the challenges to tracking that information before you started using the eCW HEDIS tools? How were you managing that?

Cady: I think that, like a lot of practices, at the very beginning we were very retroactive. We waited for the gap reports to come from the payers, which were typically anywhere from 30 to 60, 90 days old, and we would react to them. We’d realize that 90 days ago in that patient encounter we didn’t document something properly, and then we’d have to wait for the patient to come back in to capture it, and the problem with that is, having a heavy snowbird population, where our population migrates back and forth from New England and up north, is we had to make every visit count. We may not get that patient back before the end of that year, so we had to make sure we could capture as much data at a time, so having a report come 60 days later did me very little good. Using the HEDIS dashboard, we were able to actually track it in almost real time. With the weekly refresh, we are able to see our efforts this week, and the impact them make by next week to realize, in our system, is our training effective and are we really documenting properly?

Siladi: So, you’re not being buried under paper, just not even from your side, but the payers. They’re sending that gap report, sometimes they even send a representative to practices once a month. That takes time of your your day, where you could be taking care of patients or addressing other patient needs or things like that. So, you’ve been able to reduce that?

Cady: To be honest with you, unfortunately the reps still come by, but I can tell you it’s elevated our conversation. We’re no longer talking about something that happened 90 days ago and why it wasn’t documented. A lot of those conversations revolve around our current dashboard and the struggles we’re facing now, so it’s a much more valuable conversation. Talking about something that happened 60 days ago, or what could have happened, versus about what I need to do next week is definitely two different conversations.

Siladi: How have the HEDIS tools from eClinicalWorks allowed you to change the way you track and monitor patients who are being considered for these measures?

Cady: So, one of my big things is having the right information at the point of care, and what you see now — and I think it’s very common — is that the provider will go with their laptop with eClinicalWorks on it, a printed spreadsheet with some HEDIS measures on it, and some Post-It® Notes and please don’t forget! And that to me was very overwhelming, to walk in to a 15-minute appointment with numerous different types of media. So, using the HEDIS dashboard, and also the CDS and the practice alerts, we were able to populate what the provider needed to know at the point of care very seamlessly. Since we’ve now fully implemented the dashboard and the alert system, I would say if you were to talk to our providers, HEDIS is no longer one of the biggest probably barriers or intimidating things that they need to do. They actually don’t even think about it now. The MA’s able to look at what alerts are due, which are what HEDIS measures are currently, they’re able to trigger an Order Set that loads it into the chart, the provider’s able to come in and push the Order through, and it’s very seamless now. There are no longer spreadsheets, there’s no longer tracking. And a week later we’re able to judge the effectiveness of it.

Siladi: Has there been any impact on the way or the methods that you communicate with patients after using this tool?

Cady: One of the big ones is, having a very migratory population that goes up north, is sometimes we need to reach them wherever they are. And so, using Patient Portal, they were able to elect their preference. We’re able to look at, say, the non-compliants in a colonoscopy or breast exam, and push all of them a message through Messenger immediately with just a click or a couple of clicks of a button. When we had the spreadsheets, we had to dedicate usually a whole Friday afternoon with our front-desk staff to do reminder calls. We’d call their home, their backup in New England, we’d call their cellphone, which — it was always a nightmare. And now, using eClinicalWorks, and having the patients select how we communicate, has streamlined everything. We’ve not had to take the office down to do reminder calls. It’s in essence automatic now. We can look at the non-compliant list, we can populate a Messenger campaign, and it’s off to the races.

Siladi: So, it sounds like it’s having a positive impact there and saving you some time when you’re reaching out to patients, but of course the real proof is in the pudding. Has this had an impact on your scores?

Cady: Absolutely. Scores and patient outcomes. We’re no longer as focused on administrative duties and we’re much more focused on providing care at the right time and the right place now. As far as an impact, across the board with all the payers we’re at least a 4.5 if not higher, and actually received a pay increase from Medicare based off our quality report. So, we’ve actually seen a huge increase and again, with the renegotiating contracts, it gave us a lot of leverage to go after the contracts we wanted.

Siladi: It sounds like it’s like a virtuous cycle: The better you’re able to track these things, the more resources you’re given, which allows you to then maybe expand services or do more things that you weren’t necessarily able to do before for your patients.

Cady: Absolutely. And I think looking forward to the future, it puts you in a position that you’ll need to remain as a competitive, independent practice. I think as practices try and either ignore HEDIS or look at it as a bare minimum, they’re going to realize that the contracts that are offered to them in the future becomes heavily reduced, and then, in which case, their ability to remain independent also becomes reduced. Having a strong HEDIS team and a strong reporting gets you the recognition you need from the payers to allow you to remain independent and do what you need to do.

Siladi: Matt, thank you so much for your insights here today. If you want to learn more about the HEDIS tools that are available from eClinicalWorks, you can check out or speak with your Strategic Account Manager. And of course don’t forget to check out our other podcast episodes on iTunes, YouTube, and For the eClinicalWorks Podcast, I’m Adam Siladi, thanks for watching.

CCM: Beyond the Four Walls and the 15 Minutes

Published on Monday March 11, 2019

With Chronic Care Management from eClinicalWorks, Adult Medicine of Lake County went from zero CCM patients to 800+ in 10 months. They are addressing patients’ needs beyond periodic, 15-minute appointments. CCM coordinators stay in touch with patients, building real relationships. Clinical staff enjoy better visibility into patient cases. Many patients who would previously have been hospitalized are now treated at a walk-in clinic. And compliance and patient satisfaction rates have skyrocketed.

Adam Siladi: As healthcare moves toward value-based care, it becomes increasingly apparent that patient care is needed not just inside the doctor’s office but that the patient has needs outside of that setting, as well. The Chronic Care Management program is one way to address those requirements while supporting practices who are trying to provider top-notch, value-based care through Population Health. Here to speak with me about his practice’s experiences with Chronic Care Management is Matt Cady from Adult Medicine of Lake County. Matt, thanks so much for taking your time here to speak with us.

Matt Cady: Thank you.

Siladi: So tell us about the Chronic Care Management program and what that has meant for your practice.

Cady: As we’ve talked about, I had taken over the practice about a year ago, and one of our first goals in embracing the Population Health is we knew we had to expand the care past these four walls, past that 15-minute encounter, and the CCM program is a vehicle to do that that’s very easy. In fact, I believe most practices probably are already doing it, they’re just not billing for it. So, upon taking over the practice, what we realized is that our referral team was spending a lot of time coordinating referrals for some of our most chronically ill patients with these chronic conditions, spending time on the phone with both the patient and the other provider’s office, to make sure that appointment happened just the way it had to. So, at that point in time, all we did was just launch the CCM module. We then had our clinical staff help us in Care Plans, and relatively quickly we had a very comprehensive CCM program, and it was our first step in expanding care beyond these four walls.

Siladi: You painted a picture of what was going on in the practice before you got started with Chronic Care Management — at least with the tools in eClinicalWorks. Was this even on the radar for the practice, and what was the state of the organization when you got started?

Cady: The practice was in an ACO and a lot of the value-based contracts and was probably under-performing. The reasons were many, but we found the biggest initiative to attack that was, again, expanding care beyond these four walls. And by having our CCM team be able to talk to a patient at their time, on their terms, at their convenience, has made a huge impact. We’re able to learn so much more about the patient and the barriers that stand in their way and we’re able to address those outside of the 15-minute appointment. I do think that it then makes the 15-minute appointment when they do come in for the office visit that much more impactful, because the patient is not forced to feel they need to tell us everything that’s happened since the last one, because we’ve already documented it through the CCM calls and encounters since that last appointment. So, when they come in it’s a much more valuable conversation, it jives into much more of the conditions much quicker because we’ve already accumulated so much data in-between visits. That also goes with the specialists, too. We find a lot of our older population was having a hard time coordinating appointments and just making it happen. My CCM team ensures that appointment happens and then follows up after the appointment to make sure we’re all on the same page. So, compliance has gone up and patient satisfaction has skyrocketed.

Siladi: So, with coordination of care between your office and the specialists, is this just a matter of the CCM coordinator just ordering a referral and faxing that over to the other office, or are they getting on the phone with that specialist’s office, arranging for the appointment? How far does this go for you guys?

Cady: They’re on the phone. What we found with so many new healthcares being introduced right now, that we had a little bit of trouble making sure that that patient’s [provider] knew it was accepted at the other referral. And so, my coordinator will make sure that it’s done. There may be transportation concerns, there may be copayment concerns. But my CCM coordinator is able to flesh out all those concerns before the appointment to make sure the appointment happens, and happens like we wanted it too.

Siladi: Beginning a new initiative can be very nerve-wracking for a practice. They might not think that they have enough resources, they might think that it’s a difficult process to even just get the technology in place. How easy is it to get started with Chronic Care Management, both in eClinicalWorks and as a practice?

Cady: Well, starting with eClinicalWorks, it actually probably couldn’t be easier. It’s just a simple click of a button under Product Activation, and then the famous eClinicalWorks log out/log back in, and then it appears in the right-hand panel and it’s ready to go. Almost immediately upon activating it, you’ll be assigned a product implementation specialist who can reach out to you, go over concerns and the reports, and the robust dashboard. So, from an eClinicalWorks perspective, it’s very, very easy to do. From a practice perspective, I’d say it would almost be as easy to do because we found that most practices are already doing CCM, they’re just not documenting and billing for CCM. So, upon having it in the right-hand panel, any staff member is able to click time, and bill time against that patient —

Siladi: Clinical staff?

Cady: Yes, clinical staff! Any clinical staff is actually able to book time against that patient, and they’re spending that time anyway. They’re on the phone with the patient explaining a medication. They’re on the phone making sure they understood the need for the referral. So, they’re doing it anyway, I just find that a lot of the practices aren’t taking the time to document it — through the intimidation. Using the product implementation specialist and the activities a practice is already doing, it’s probably one of the easier programs to implement.

Siladi: How scalable is Chronic Care Management from your perspective?

Cady: We had actually explored a couple of CCM options when I had first started, and selected eClinicalWorks for mostly that reason. It’s incredibly scalable. We were able to go from none to

40 to 200 to 800 with just the amount of adding staff. And the staff that I’m adding is only in my Care Management team. I’ve not had to increase my billing team, my administrative, or any compliance costs, because it’s all within eClinicalWorks. So, it’s been relatively easy. Everything is tracked within eClinicalWorks, from my consents to my billable time to what’s been claimed. So, it’s very, very easy and very scalable. Again, we went from zero to 40 to 200 to 800 in about a 10-month period.

Siladi: What about that process of taking the time that you’re tracking — because you mentioned that your staff can collect that time — translating that into a claim. What’s that process like?

Cady: I think last month we probably dropped in the high 600s claims, and it took probably 13 minutes. And the beauty of it is, is eClinicalWorks was able to look at the time that has been documented, it suggests the code relative to the time. I simply go through, review the claims and the proposed codes. If I agree with them, I can make a quick run, and then within an hour my billing team sees these claims and is ready to submit their billing. So, again, we went from zero to 40 to 200 to 800 patients, and my billing staff hasn’t changed at all.

Siladi: Now, you mentioned that as you’ve scaled that up, really the only change to your staffing was additional coordinators. You said that you started out with your existing referral coordinator, who was already doing much of that, maybe just changed her role a little bit. At what point do you need to start bringing somebody on. In other words, how many patients do you usually have per coordinator in your office?

Cady: OK, there are a couple of different numbers there that we could explore. One of the first ones is we’ve counted around the 75 mark becomes — you can justify a full-time job. At about 75 completed claims, when you do the math, it can justify a full-time job. At about 100, or just over 100, it becomes its own little profit center. On average, most of my people will manage just over 200 patients and will generate just over about 100 to 150 claims a month of completed calls. Right now we currently have six and we look forward to adding more to that team. The numbers, I would say, are probably practice driven. As you see the need, what we did is at the 75-member we then hired somebody, it became a full-time position. As we then ramped up again and hit somewhere in the 65 mark, we hired another person and transitioned. We’ve ramped up, hired, and then moved those patients to that person and it’s been relatively seamless.

Siladi: How has participation in the Chronic Care Management improved patient care? And where do you see the impacts of that program?

Cady: Probably out of everything we’ve done this year, it’s probably the biggest impact on patient care and also patient satisfaction. I’ll do the patient satisfaction first. On a daily basis, we’ll have feedback from the exam room at the provider level of how much they enjoyed having the CCM coordinator be a part of their care circle. It happens on a daily basis. The ability that the patient has, a name and a phone number to someone that can answer, that knows their name, that understands their condition, and is that inside of our office, has been huge for them, absolutely huge. From a patient outcome perspective, we’ve seen it in a couple of different ways. We’ve seen a much higher compliance with referrals, because we were able to remove any barriers that were standing in the way, whether it be transportation, copays, conflicting schedules. We’ve had other practices not call on patients, and when our CCM coordinator uncovered that they hadn’t been reached out, and we made sure they got the appointment they need. We’ve also had a much higher compliance with medications. We were able to explain to the patient why they were assigned a new medication, why that medication is important. We were able to find out maybe they weren’t able to refill that medication, in which case we could work with them on getting it refilled. So, it definitely gave us much more insight to what the patient’s going through on the journey to getting them to a better health.

Siladi: What does that interaction between the coordinator and the patient look like? Is there a script that they follow? How do you spend that, upwards of 20 minutes of time or more each month with the patient?

Cady: So we set out to not make it feel formal. We figure every other interaction with our office here is a very formal, structured one, so we actually don’t give our CCM coordinators a script at all. We also hire them with a strong clinical background but with the right personality. Because really, at the end of the day what I’m looking for is a connection with their CCM coordinators, so that way, if there is a concern from either the patient or a caregiver, they feel very comfortable reaching out to our CCM coordinator. We’ve even found that some of them have become so attached that when they come through they’ll ask to say hi to their coordinator. We have a couple of patients who have even brought friends by to meet their coordinator. In a prior podcast we have talked about that we have an exam room set up as a dining room to have a nice conversation, and a lot of times we’ll bring the care coordinator into that conversation with the family, because she’s worked with the family over the last couple months on anything from advanced directives, to a new diagnosis, to dad or mom, and it definitely makes the patient feel much more part of this practice.

Siladi: What are some specific examples when Chronic Care Management has made a difference for patients?

Cady: Specifically, I can think of — we were able to identify one of our highest reasons for admittance was congestive heart failure, and the problem we were having is we didn’t have a way to monitor the patient in-between visits. So, any retaining of water, gaining of weight, loss of weight, we were flying blind. At best we could hope that the patient had their appointment every 30 days and we could capture as much of it there. With having access to CCM, and having my care coordinators talk to not only the patient but any caregivers at the house, we were able to identify these people retaining water much earlier on in the scenario. As such, we came up with a program where they’re able to utilize our walk-in clinic instead of utilizing the ER, and in the last six months we believe that 100% of these people would have gone to the ER at some point in time, and potentially once it had become severe. In constant contact with these patients, we’re able to find out as soon as we’ve gained one to two pounds, not eight to 12 pounds. And at that point we’re able to bring them in to either our office or walk-in clinic and address it right then before it becomes a life-changing incident.

Siladi: And you’ve actually implemented a special program in that walk-in clinic to address that issue. What strategy are you guys using?

Cady: So what we’ve done is we’ve partnered up with a home health company and one of our main cardiology referral sources and the reason being is we feel that the patient needs constant contact. So, with home health being there either every day or every other day, and my care coordinator filling in those gaps, the patient is almost constantly in contact with somebody, and on the days that they’re not, the other two teams are talking. So, my care coordinator is talking to the home health, who’s talking to the cardiologist. So, whether it’s my caregiver or the home health, once they identify that we have retained a couple of pounds, the decision is made right then and there: Is he going to go to the ER, is he going to go to the walk-in? And we’ve said, again, we assume that 100% of these patients would have gone to the ER before. Now about 30% of them go to the ER. The other 70% we’re able to treat it in office before it becomes severe — leading to better patient satisfaction, because no one looks forward to going to the hospital, and being a massive cost savings. So, it’s turned out not only better for the patients but also for the practice.

Siladi: It sounds like a significant reduction in negative outcomes there for the patients, or potentially negative outcomes for the patients, at the same time increasing the relationship, the amount of contact you get with those patients in the office. Hopefully, we get to hear more about the impact that this has had for your practice and keep up the great work. Thank you so much.

Cady: Thank you.

Siladi: If you’d like to learn more about the Chronic Care Management program, you can check out or speak with your Strategic Account Manager. And don’t forget to check out our other podcast episodes on iTunes, YouTube, and For the eClinicalWorks Podcast, I’m Adam Siladi, thanks for watching.

HCC: Improving Coding With Every Encounter

Published on Monday March 11, 2019

Adult Medicine of Lake County has taken the guesswork out of coding by implementing Hierarchical Condition Category (HCC) coding for all patient visits. More accurate patient information supports quality care. With all six of the practice’s providers having ready access to a list of care gaps for each patient, the encounter is more productive, and Adult Medicine is eliminating that end-of-the-year rush to close gaps in care.

Adam Siladi: As the healthcare industry moves toward value-based care, one of the most important considerations is risk adjustment. And accurately risk-adjusting patients relies on Hierarchical Condition Categories, HCC. Here to speak with me about HCC and why it’s so important today is Matt Cady from Adult Medicine of Lake County. Matt, thank you so much for being here.

Matt Cady: No problem.

Siladi: So, Matt, tell us a little bit about the role of HCC in healthcare today, and what kinds of practices need to pay attention to that right now.

Cady: Well, we’re of seeing it kind of be all practices. And the reason being is we’re heavily graded on the over-65 Medicare population, our capitated patients. But we’ve already started to see indicators that other payers are going to require us to do it across the spectrum of demographics. So as a practice we now have implemented HCC coding for all patient encounters. Utilizing the dashboard we have to track it, and the reason being we never want to put the provider in a position of did they need to or did they not to. So, we have forced the habit with all of them to — everybody is HCC, according to the highest specificity possible.

Siladi: So, standardizing that workflow no matter what patients you’re seeing seems to make it easier for your doctors. Now, is this something that is mostly important in an ACO or do you also need to pay attention to it outside of an ACO?

Cady: I would say until just recently it was probably more ACO focused and managed care, but just recently we’ve had CIGNA reach out and they are actually asking us to go through their full panel. So, as a practice, like I said, we’ve now implemented it across all patient care.

Siladi: Now, HCC, as you said, relies very heavily on specificity of coding. But the other challenge with HCC is that you don’t just have to code those once and forget about it, you have to recapture those codes each and every year. So, what is the risk for providers who aren’t paying as much attention to this, for people who don’t recapture those codes each and every year?

Cady: On the larger level, you’re not informing the payer of the condition of the patient. So, the way that would translate down to the practice, is the practice may not be allocated enough money to take care of that patient accurately. So, if we don’t accurately tell the payer what we’re encountering here, they don’t know how to accurately budget for that patient, in which case the practice could suffer a serious decline in revenue, and, with managed care, actually be put into possibly a deficit by not accurately reporting the conditions.

Siladi: Is there a chance for people who are behind to catch up? Or is it like, once that time period is past, you’re not able to rectify that?

Cady: Most of the time you’re going to have to capture it twice a year. And really, we look at HCC as a trend. Once the practice is engrained in it, and doing it, you should see the nice trend upwards. It’s not something where you can just have them come in for a quick visit and code. It’s really something that’s got to go company-wide and you have to have full staff buy-in on it.

Siladi: What are some of the biggest challenges to using HCC, or succeeding with HCC?

Cady: Probably visibility into things that we don’t know about, maybe something that a specialty is treating that we are unaware of, or really just getting through all of the different specificities in a timely fashion.

Siladi: Are there any things that eClinicalWorks is offering that help you gain some of that visibility?

Cady: You’ve addressed both of them. The first one was the interoperability. Using that, we’re actually able to see what are coded and on the Problem List at other practices, and that’s been huge. So, we may have sent a referral over, and you’ve uncovered something else and are now treating it, but we need to accurately report that to the payer also. And we’ve actually seen this in two forms. One form is you may treat somebody for a condition we were unaware of and the payer will reach out to us to confirm that you actually had that, because we have not reported it. We’ve seen a severe drop-off in those, because now we’re seeing what our specialties are coding. The other problem we’ve run into is if we don’t code accurately, the specialty is going to treat the patient and it won’t be reflected in the monetary. And so then the issue arises that the patient is what we call a deficit with a managed care plan. So, it’s very, very critical that the primary care provider accurately reports all the conditions to the highest level.

Siladi: That’s really interesting too because I’ve heard a lot of practices say they get these regular reports, or somebody comes in from the insurance company and says, you know, here’s a list of codes that we want you to look into. And you’re saying this is coming because maybe they see that from the specialist, not on your side, and now your office is having to spend time rectifying that, or reconciling that information. And by using interoperability, along with this HCC mindset, maybe you’re actually reducing the amount of work you have to do overall and not playing as much catchup, so you can focus on patients who are there in front of you.

Cady: The other thing, just to touch on that, is we’ve actually found specialties that have miscoded things. And by using the interoperability we were able to reach out to them and say hey, we need you to double-check this, this is not what we’re seeing, and we were able to collaborate on, actually, that patient’s condition.

Siladi: And so how has the eClinicalWorks HCC module helped you to overcome some of those hurdles?

Cady: One of the biggest ones is for the fact that every year we have to — patients start at zero again. So, by using the gaps, we’re able to see what we coded last time, instead of having to use the IMO search every single time with that patient. The other one, really neat feature, is to be able to real-time calculate the RAF score. That has been such a valuable tool, because it lets us know if we’re higher or lower than last year. For some reason, if we’re lower, what it’s going to tell us is that we missed a code. If we’re higher, we know we’re trending in the right direction, as long as the patient care is right. So, it really gives us everything we need right at the assessment screen, which is at the point of care.

Siladi: So, providers often worry changes in their workflows. How did you get your providers to buy into using this HCC module to keep up with these codes?

Cady: It was actually relatively easy for us. Because of being in Florida with a heavily Medicare population, our ACO was basically demanding we got better at HCC coding. And what we lacked was a tool. We had the faxes that came in on a daily basis like you mentioned, with codes that other people, and that they had suggested, but we really lacked something at the point of care to be able to do it. And in using this, the doctors knew they had to, and it gave them a tool that was very easy to use. Right there in the assessment screen they’re able to see the gap list and calculate the RAF score in real time, which is almost a confirmation that we did good, or the possibility that something was missed.

Siladi: Now you mentioned playing catchup, and I know that sometimes late in the year, maybe August, September, some time like that, groups get a list of all these codes that they haven’t recaptured and things like that. Now they have to scramble to get patients into the office. How has the HCC tool from eClinicalWorks changed that for you?

Cady: Like I said earlier, it’s a trend. So we start the year trying to be on the right trend. Being in Florida, we have a huge snowbird population, so I don’t always have the ability to play catchup at the end of the year, because you may not be here at the end of the year. So one of the most important things for us is we have to catch it at every visit. And so, putting that gap list right there at the point of care assured that I can make every visit count, I can avoid the catchup game, and the massive fax inbox.

Siladi: eClinicalWorks also includes a dashboard with the HCC tool. What types of information do you see on that dashboard and how does that help you manage your patient population?

Cady: So, at lunchtime we have a provider meeting, and we actually use the dashboard as a teaching tool. We’re able to see all six providers on the dashboard, and it gives us a good line of trends if we’re trending up or down. And what we can do is compare against their peers and also prior encounters with that patient. And it tells us if we’re either doing a good job or maybe if we need to do some retraining with one of our providers.

Siladi: And Matt, with all of this information about HCC, where do you suggest providers or practices start if they want to be successful with it?

Cady: Again, it’s such a small impact on workflow, it’s really, going into 2019, and I’m sure by 2020, it’s almost a necessity. I would say activate it and just start looking for the blue gaps button under the assessment screen. It’s there and it’s incredibly easy to use.

Siladi: Matt, thank you so much for your time here to explain the importance of HCC and how you can be successful with that. If you’d like to learn more about the eClinicalWorks HCC module, you can check out some information on or get in touch with your Strategic Account Manager. You can also check out our other eClinicalWorks Podcast episodes on iTunes, YouTube, or For the eClinicalWorks Podcast, I’m Adam Siladi, thanks for watching.

“If we can keep you from being readmitted, or possibly stop a fall that causes a broken hip, or possibly stop another life event with the heart, how do you attach a cost to that? We’ve run numbers on what an admission costs for a hip fracture. Compare that to what it costs for us to go to the house and address what may cause that hip fracture, and there really is no comparison.”

Matt Cady, practice administrator, Adult Medicine of Lake County


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 helps users manage patients, track appointments, reconcile medications, and better understand who is being hospitalized and why.

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.

Subscribe to our podcast easily with your smartphone on iTunes®.