New Software Helps Docs Identify, Contact At-Risk Patients

Phytel is unveiling a hosted, next-generation suite of care management tools that integrate with electronic medical record (EMR) data to help doctors and case managers more proactively identify and contact patients at risk for health complications.

Not only do the new Phytel Atmosphere tools allow analysis of populations of patients and identify gaps in care based on evidence based medicine--such as diabetic patients that haven't had annual foot exams--the tools provide automatic outreach capabilities, such as calling, texting, or emailing patients, based on their communication preferences, said Russell Olsen, VP of product development at Phytel.

The new capabilities can be helpful to healthcare providers planning to participate in healthcare reform's emerging accountable care organizations (ACOs), which will be reimbursed by payers, including Medicare, for the quality of the care and patient outcomes, as well as more traditional fee-for-service providers who are also looking to boost quality, said Steve Schelhammer, CEO of Phytel, which is based in Dallas.

The Phytel Atmosphere offering is provided via a software-as-a-service model. The software suite includes medical protocol-driven registries that automatically trigger messages to patients for recommended care; tools to help healthcare providers stratify individual health risks and create personalized, automated interventions; patient self-management tools, including health risk assessments and individualized online care plans; an automated patient communication engine; dashboards for measuring an organization's effectiveness in its quality improvement initiatives; and automation tools that identify the patient groups and processes required to qualify for Medicare quality of care incentives.

The tools give chief medical officers (CMOs), chief medical information officers, and other healthcare leaders the ability to "visualize" the details of patient compliance to recommended care, said Schelhammer.

"If you ask CFOs details about revenue cycle and accounts payable, they know the numbers," said Olsen. "But ask a CMO about diabetic patient compliance, and they'll give you a squishy answer," he said. The tools provided by Phytel "bring these measurements to the forefront," he said.

Robert Fortini, VP and chief clinical officer at Bon Secours Medical Group, a hospital-owned physician group with 350 doctors in the Richmond, Va., region, has been using Phytel's Patient Proactive Outreach, an earlier version of the Phytel's care management systems for about 18 months.

That system is helping Bon Secours identify gaps in patient care by using administrative and claims data, Fortini said. When gaps in care are identified, the system initiates automated outreach, such as calling diabetic patients to remind them to schedule an appointment to have their glucose checked.

While the use of the earlier Phytel patient management product over the last year or so has helped the medical group book 17,000 care visits with patients that might've otherwise been missed for chronic care or preventative care (such as blood tests for diabetics and mammograms for women over age 50), the newer generation of Phytel's product using EMR data is "exciting" to Fortini.

That's in part because Fortini thinks gap and risk analysis will be more accurate--for instance, being able to identify patients needing interventional care based on the results of lab tests, such as abnormal readings in recent blood work. That results data would be part of a patient's EMR, but not necessarily evident in claims data, he said.

The new Phytel care management system works with about 50 different EMR and practice management systems, said Olsen.

The new version of the software can also provide graphical displays of patients at risk, mapping out patients who are most likely to end up being readmitted to a hospital after discharge if key interventional and followup care is missed, for instance.

"This literally gives you a roadmap for cutting risks," Fortini said. His organization is planning to upgrade to the new Phytel platform, he said.

"With healthcare reform and all the changes coming with it, watching for care gap in the transitions of care for patients, and being able to provide outreach is vital," Fortini said.

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