Medical Net Systems: Patient Centered Medical Home, Practice Management Software, EMR Software, Electronic Medical Records

For various conditions, tracking chronic disease patients’ medical data between office visits is a means to prevent clinical exacerbations and improve patients’ health.  Congestive heart failure (CHF) is a major cause and cost of hospitalization.  The average hospitalization cost ranges from $14K to $20K depending on whether the failure is primary or secondary.  It is well known that a CHF patient’s weight can gradually increase before a patient goes into clinical failure.  The Joint Commission mandates that on discharge CHF patients are told to take daily weights and report increases to their physicians.  However there is no structure to insure that this occurs.  EncounterSuite’s Tracking the Chronic Disease Patient at Home (TCDPH) module provides that structure.

Using TCDPH, the patient becomes in essence, an activated patient and the physician office becomes a prepared proactive practice team as described in Wagner's Chronic Care Model. Here's how.

When a patient is diagnosed with CHF, the physician can place the patient in TCDPH for weight and set upper and/or lower limits for that patient. 

Once in the program, the patient enters his weight in his PHR.  If the patient’s weight is outside the patient’s limits, an entry is made in the practice’s Outside Limit Alert Report in the Inbox.  From the report the physician can review the previous communications with the patient, the patient’s chart, and the patient’s data in the PHR.  The physician can contact the patient and intervene appropriately.  From the report, the physician can write orders and document the communication with the patient for the chart.  

Physicians can tailor TCDPH so their efforts are maximized by adjusting the data entry frequency for each patient.  Physicians can closely monitor brittle patients on a frequent basis.  Stable patients may not have any data entry frequency set.  Such stable patients can use TCDPH to enter unstable data points in their PHR which then automatically inform their physicians of their status change. This flexibility makes TCDPH manageable for a busy physician office. 

When patients fail to enter their data on time, they are listed on the Non-Compliant Patients Report in the Inbox.  From this report, staff can contact those patients and document their communications in the chart. 

In additions to weights, TCDPH can follow blood pressure, blood sugar, peak flows, and abdominal girth.  Additional parameters can be easily added.

All parties benefit from the TCDPH.  Patients are more involved with their healthcare and are monitored more closely.  Physicians are able to intervene earlier and prevent clinical exacerbations resulting in healthier patients.  Physician organizations can manage chronic disease populations and have more professionally satisfied physicians and a powerful marketing tool to acquire new business.