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Success Stories

Improving Ohio's Health: Patient Engagement = Better Outcomes


Effective Use of the Patient Portal; Creating a “Buzz” to Engage Your Patients

Director, Consulting Operations & HIE Outreach
and Kevin Waller, Director, Communications, Holzer Health System

“Improving Ohio’s Health” is an ongoing series of articles and webinars that are developed to help providers in the care management of patients with hypertension and/or diabetes.

This article explores the patient portal as one of the easiest ways to engage patients in managing their chronic conditions and identifies the importance of marketing portal use to patients by creating a “buzz” about the portal and thereby increasing a patient’s knowledge about improving their health.

This article on the patient portal focuses on:

Potential barriers to success that must be addressed early in a project plan

Practical advice provided by Holzer Health System staff on marketing and patient adoption tactics that led to their very successful and highly utilized portal.

Research showing why the portal should be the central technology tool for patient engagement





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Improving Ohio's Health: Patient Engagement = Better Outcomes
Kroger Pharmacists Join CliniSync Health Information Exchange


By Dorothea Howe, M.Ed., M.A.

Communications Director

It’s February and you’re a month into your New Year, New Me resolutions. Don’t get discouraged. It’s not too late to watch your waistline and budget by making sure you and your family are eating the healthiest foods at the lowest cost.

And believe it or not, your pharmacist can help.

Kroger pharmacists in 120 stores throughout Central Ohio can now electronically communicate with doctors’ offices to provide better patient care – whether it’s healthy foods for diabetics, immunizations for children, vaccinations for those who travel abroad, or smoking cessation for those who want to quit.

“Our goal is to leverage our convenient locations in a grocery store to be an important resource for Ohio’s health systems to improve the long-term health and wellness of patients in Ohio,” says Steve Burson, Pharmacy Clinical Sales Manager for the Kroger Columbus Division. “Kroger pharmacists are trained experts on proper medication use and immunizations. Plus, we have pharmacists specially trained on other services, such as health coaching and travel health."

Using referrals for patient care

CliniSync is a Hilliard-based nonprofit network that electronically connects different hospitals, health systems and practices with one another to securely exchange patient health information.

The referral pattern varies according to the needs of each person. For instance, a doctor who is treating a patient for diabetes, hypertension or any chronic condition can refer a person to a Kroger pharmacist to learn how to make the right food choices during a free, healthy nutrition tour.

Perhaps an individual who is starting to experience symptoms of chronic obstructive pulmonary disease (COPD) or another lung disease needs specialized coaching to stop smoking.

Maybe a family that is generally healthy just needs some tips on how to select more nutritious food that they can afford.

The CliniSync technology allows the doctor or clinician who made the referral to electronically see that the Kroger Pharmacy has followed up on that patient’s care, closing the loop around that patient so everyone is a part of that person’s care team.

The pharmacist also can access a patient’s health care summary to better understand an individual’s current health condition. Known as a Community Health Record, this summary allows a pharmacist to view treatment and care plans when necessary. They also can communicate directly with physicians using direct, secure emails within a closed network only accessible to that patient’s doctors.

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Kroger Pharmacists Join CliniSync Health Information Exchange
Prediabetic Screening and Coding


Prediabetic Screening and Coding: How to Easily Include Both into Your Chronic Care Management Program

by Cathy Costello, JD, CPHIMS, Director, CliniSyncPLUS Services

Diane Zucker, M.Ed., CCS-P

Anyone who has worked in a medical practice knows that one of the toughest types of patients to code correctly are patients who are prediabetic. What to do with these patients—how to make sure you are capturing all your charges correctly—is a real issue. The American Diabetes Association (ADA) has reported that 86 million American adults have prediabetes as of 2012. There is not a practice in the country that doesn’t treat patients with prediabetes.

New Code - New Approach to Chronic Care

What makes the coding dilemma easier now is that on October 1, 2016, CMS introduced a new ICD10 code specifically identifying a patient with prediabetes. This code, R73.03, should be used in place of R73.09, a non-specific code for abnormal blood glucose that was previously used to identify potential prediabetes in a patient. By establishing a more specific code, the process is simplified for tracking these patients within your EHR. It also assures correct payment by Medicare and commercial insurance plans/payers for care provided to patients who are at increased risk of diabetes.

Correctly identifying someone as having prediabetes is important for your chronic care management. All new payment models require practices to provide increased assessment of patients for existing and potential chronic conditions. Accurately coding patients with prediabetes will allow you to create a prediabetes registry and work with these patients to prevent the onset of type 2 diabetes. Additionally, using the prediabetes ICD10 code will give you a tracking mechanism for referring and monitoring these patients’ participation in a Diabetes Prevention Program (DPP).

The technical definition of the R73.03 Prediabetes is an interim diagnosis used to describe an elevated blood glucose level that is higher than normal but not yet high enough to be considered type 2 diabetes. With no intervention, the condition is expected to become type 2 diabetes within 10 years. A fasting blood glucose level of 100 to 125 mg/dl typically warrants a diagnosis of prediabetes, and the patient is then referred to a DPP to be educated about diet and exercise patterns for preventing the progression of prediabetes to type 2 diabetes. This definition is not age specific.


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Prediabetic Screening and Coding
Single Sign On Case Study


Single Sign On speeds up access to outside patient health records

by Dorothea Howe, M.Ed., M.A..

It’s not unusual for a patient to not fully comprehend or remember exact medical procedures and medications, especially when they’re complex.

Dr. Jay Wallin, Chief Clinical Information Officer at Central Ohio’s Mount Carmel East, posits a use case for why Single Sign On (SSO) to patient records is not only more convenient and faster than logging into separate portals, but offers diagnostic benefits of easy access to patient health records from other health systems, hospitals and facilities.

Patient doesn’t know history

Here’s a scenario: A patient presents at the Emergency Department at Mount Carmel East complaining of chest pain and tells the physician that he was at Fairfield Medical Center a week ago and had something done to his heart, Dr. Wallin explains. When the doctor asks about medications, the patient replies, “I’m taking a blue pill and a white pill.” Looking at Mount Carmel’s records on this patient, the physician doesn’t see anything about heart surgery.

“I’m not sure why he’s in my ER. I’m in a pickle,” Dr. Wallin quips. But Dr. Wallin can go directly into his drop-down menu for outside sources, click on Ohio Data Exchange, and find out what occurred at Fairfield last week. The patient has had a cardiac catheterization; the blue pill is Plavix and the white is Lisinopril. Now, the physician knows how to proceed.

Shared medical records speed up diagnosis

“From the clinician’s perspective, the record may look a little different but I’m still within my EHR,” Dr. Wallin says. “It’s magic,” he says with a laugh. He’s describing access to the patient’s Community Health Record, which contains test results, care summaries and other information from encounters at different hospitals and facilities within the CliniSync network. “If I don’t feel the need for outside information, I’m not going to go into the Community Health Record. I use it with clinical judgment,” Dr. Wallin says.

But when the Community Health Record contains pertinent information, it can lead to faster diagnosis and treatment, Wallin says.

“This has everything to do with something that happened outside of my institution, and I’m going to clinically use it and bring it forward,” he says. “I could make a more accurate diagnosis. Let’s say you had an MRI at Fairfield and it was negative for something. Well, I could cut out that diagnostic step. I could proceed to treatment faster.”

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Single Sign On Case Study


Improving Ohio's Health: Electronically Connecting the Community


Electronically Connecting the Community: Making Care Plans Easier

by Dottie Howe, MA, MEd, Director of Communications

This article is part of a series devoted to hypertension and diabetes in Ohio and the prevalence of these chronic conditions. It explores the exchange of patient health information through electronic referrals in a “medical neighborhood” made up of healthcare providers and social service entities in the Central Ohio region.

Four days a month, the indigent, immigrants, refugees, the uninsured and underinsured can access diabetes and hypertension screenings as well as other health and social services at a free clinic on Morse Road in Columbus, Ohio. Physicians traditionally have had a difficult time managing chronic conditions such as diabetes and hypertension in this patient population.

About 1,200 patients visit the Helping Hands Health and Wellness Center annually, which uses its electronic health record (EHR) system and additional functionality provided by the CliniSync Health Information Exchange (HIE) to overcome some of the related challenges to managing indigent and uninsured patients, especially those with chronic conditions. This electronic network connects hospitals, physicians and other providers across Ohio and is managed by the nonprofit Ohio Health Information Partnership.

The clinic now has the technological capability to electronically refer patients to other partners in the Central Ohio community, referred to as a “medical neighborhood.” This concept stems from the patient-centered medical home (PCMH) movement where the primary care practice is the hub of a coordinated care team involving other healthcare providers. While the medical neighborhood first sought to connect primary care with specialists, the community has expanded beyond ambulatory care.

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Improving Ohio's Health: Electronically Connecting the Community
Improving Ohio's Health: New Chronic Care Management Coding


New Chronic Care Management Coding: Proposed CMS Coding Changes for 2017

by Cathy Costello, JD, CPHIMS, Director of CliniSyncPLUS Services

This article is part of a series devoted to hypertension and diabetes in Ohio and the prevalence of these chronic conditions. It addresses changes in coding for Chronic Care Management and Transitional Care Management that CMS is proposing for the 2017 reporting year.

Let me guess: your practice looked at starting a Chronic Care Management (CCM) program. You thought it sounded like it might help with your diabetic patients and those with heart disease and COPD. You even went so far as to review all the technical requirements for starting one. But after you dug in, everyone in the office just rolled their eyes and said “Good idea; hard to execute.” Does that sum up your practice’s approach to CCM?
Well, look again. CMS heard about you and everyone else who hesitated to jump in to set up this brand new program and went back to the drawing board to develop a more user-friendly program.

We all know CMS is a big proponent of patient-centered care models. The cost of health care in the United States has climbed to $1 trillion. In 2014, almost 30 percent of that cost was attributed to hospital care.1 Approximately 15 percent of all hospital patients ended up being readmitted during 2014 according to CMS; so any program that can find new and creative ways to keep these hospital admission and readmission rates down receives a lot of attention by CMS.
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Improving Ohio's Health: New Chronic Care Management Coding


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