When you can’t kick a cold, who do you go to? Primary care physicians are there for you when something’s feeling off and are also often the first to notice underlying health issues. The Comprehensive Primary Care Plus (CPC+) model is a means to help strengthen primary care, promote health, and lower healthcare costs.

What is CPC+?

CPC+ is a multi-payer initiative led by the Centers for Medicare and Medicaid Services (CMS) designed to improve primary care with two five-year rounds that are location specific. It provides practices with a comprehensive learning system and data feedback that can help guide a practice’s decision-making and deliver better care.

Many tools, but challenges persist

Each year brings new advances in medical technology and new understanding of challenges in healthcare. The progress of science is so visible that it’s easy for physicians, patients, and public-policy experts to believe all the tools necessary to build a healthier society are already in hand. 

In reality, many difficult and complex challenges remain. Conditions that have clear, adverse impacts on the quality of life — including diabetes, high blood pressure, obesity, and poor nutrition — remain widespread. 

Healthcare organizations have a significant opportunity to improve the outcomes with the advent of innovative delivery and payment models tapping into the advances in technology and its adoption. To do this, organizations need a solution.

Our enhanced Population Health solutions help practices understand disease patterns, better assess risk, and improve patients’ engagement and compliance. At eClinicalWorks, we are constantly driven to innovate and find ways to further benefit practices interested in Population Health.

Matt Cady, Chief Innovation Officer at Florida’s Adult Medicine of Lake County, says that before his practice began using eClinicalWorks to track patients moving among care settings, they had a system in place: Post-It® Notes and spreadsheets.

In other words, in spite of having the cloud-based eClinicalWorks EHR, when it came to keeping track of patients moving from a hospital setting to home, they were still, in effect, using paper records. Each provider knew what was going on with their patients, but communicating that information to colleagues was cumbersome and time-consuming.

When Florida medical practices talk about snowbirds, they aren’t talking ornithology. They are referring to the large subset of patients who spend the winter in the Sunshine State and scoot back North in the spring. Such patients pose one of the thorniest problems in medicine because keeping track of their health — from the specialists they have seen to whatever medications they are taking — can be a real challenge.

What kind of medical practices need an advanced tool for determining patient risk, projecting the likelihood of adverse health events, and processing each patient with the highest possible degree of specificity in coding for reimbursements?

Maximizing their clinical effectiveness while holding down costs is never easy, but for today’s medical practices, one sure guide is to follow the spending. And the evidence points overwhelmingly to one area — chronic medical conditions. 

Healthcare has tremendous power to do good, but its very complexity can also bring complications. Nowhere is that clearer than when patients are moving from one care setting to another.

Dr. Martha R. Rodriguez used to have nightmares. Except she had them during the day. At the office.

“We were inundated with lists from the insurance companies,” said Dr. Rodriguez, founder of MMR Healthcare in Boynton Beach, Florida. “Every day we would get a new list — these patients have missing eye exams, these patients are missing mammograms.”

Dr. Rodriguez admits that her knee would sometimes shake when she was faced with yet another list of patients who were out of compliance with recommended exams, because she knew that the data on those lists were sometimes 90 to 120 days out of date.

According to the Centers for Disease Control and Prevention, 60% of American adults have at least one chronic illness, and 42% have two or more such illnesses — with heart disease, cancer, and diabetes leading the list of maladies that require ongoing medical attention and limit daily activities in some way.

Defying a trend

If you happen to be in the Salt Lake City area and visit any of the 18 locations run by Granger Medical Clinic, you’ll see a lot that looks familiar, including a busy front office and the range of primary and specialty services you’d expect from any growing medical facility.

Look more closely, and you’ll see an organization that’s just a bit different in key ways.

While more and more U.S. doctors are giving up owning their own practices, and joining larger, hospital-owned networks, Granger continues to proudly assert its independence.

That classic line from “Office Space” — “I’m going to need you to come in on Saturday…” — works great on the screen, but it’s usually not something folks like to hear in real life. Except this weekend in Dallas at the eClinicalWorks National Conference!

From all 50 states and overseas, our customers and employees are arriving in sunny Orlando! From sunrise until long after sunset, crews have been hard at work choreographing tomorrow’s kickoff of the 2016 eClinicalWorks National Conference here at the Orlando World Center Marriott! Our social media wall is already abuzz with photos and posts, of plane departures, bus arrivals, smiling faces, and shout outs. And our social media and selfie contests are already under way. Check pages 12 and 13 of your Conference program book for complete details and post, post, post — to #eCW16 and #eCWSelfie.

Our product experts are onsite and at the top of their games, ready to unveil the new features and functionalities that are now being rolled out across our U.S. and international markets. And eCW team members and technicians are putting the finishing touches on tomorrow’s much-anticipated Keynote from CEO Girish Navani, which promises to deliver a high-energy introduction to four unforgettable days of learning, networking, and sheer fun.

A desire for more coordinated care has led to the advancement of accountable care organizations (ACO) and similar models. These organizations have set out to improve the delivery of healthcare, while reducing costs and leveraging evidence-based care to collaborate with care teams and patients. At the forefront this movement is Minnesota’s Children’s Health Network (CHN), where we visited for our final Season One episode. We joined Chad Johnson, CEO, Dave Overman, President and COO of Children’s Hospitals and Clinics of Minn., and Dr. Kelly Lemieux, Pediatrician with Wayzata Children’s Clinic and chair of clinical operations for CHN to discuss the benefits of population health technologies, like CCMR, and their ability to enhance care.

In an age where connectivity is constantly accessible, the term “Big Data” has quickly become a buzzword favored by any business seeking information about its customers, products and even its performance. But this seemingly ambiguous term has a place in the healthcare industry as well. “Big Data” is more than a buzzword for doctors, researchers and patients – it means easier access to health information, predictive medicine, quicker diagnoses and better treatment.