mHealth Helps Compass Medical Get a Complete View of Patient Care

A Massachusetts-based health system that saw a more than 50 percent decrease in office visits during the height of the coronavirus pandemic is using mHealth to make sure patients are still getting the care they’re supposed to be getting.

Compass Medical, a six-office, 90-provider healthcare network serving roughly 80,000 patients in the southeastern part of the state, is tracking care visits that trigger electronic notifications on a connected health platform supplied by PatientPing. The platform enables the health system to coordinate and manage care for a wide range of patients – including those with multiple chronic care needs – who might be visiting the hospital instead of their primary care provider.

“They were just going to the hospital, coming home and then nothing more was happening to them,” says Dhrumil Shah, MD, Compass Medical’s chief medical information officer. “We started to see a huge gap between what we were doing in our exam rooms and what was going on in the hospital. Mostly we didn’t know what our patients were doing there.”

The problem is familiar to many medical practices and has been around long before COVID-19 cast it into the spotlight. Providers often aren’t getting the full health record of the patient, and they’re spending lots of time trying to gather that information – hospital visits, interactions with other care providers, prescription information – for care management and coordination.

Aside from costing time and office staff effort, the process creates gaps in care, which can affect a patient’s long-term health and prevent primary care providers from identifying care management opportunities or suggesting preventive health and wellness measures.

“There are a lot of opportunities that we just miss out on” says Shah, who estimates that his office staff spends six to eight hours a week just trying to follow up on patient hospital visits. It’s especially vital, he says, “with the high-risk populations where you can really make a difference.”

And it will be important going forward as primary care providers try to iron out the wrinkles in a post-pandemic care environment where telehealth and in-person visits exist side-by-side and patients need to be coaxed back into the healthcare ecosystem.

Compass Medical first adopted the technology in 2018 to manage its chronic care population, and has more recently expanded the platform to better manage patients discharged from the hospital. They’ve also launched a transitional care management program, which aims to close those gaps and identify more opportunities for patients moving from one care setting to another.

And with COVID-19 still restricting in-person care, they’ve launched a telehealth service as well, to expand access to care and help patients who are skipping care altogether because they can’t or won’t go to the office or clinic.

“We went to telehealth to help our hospitals,” Shah says, noting that Compass Medical is affiliated with one local health system and works with five others in the region. “It tells our patients and the hospitals that we can offer care to patients who don’t need to be in the hospital.”

Additionally, using an mHealth platform that captures and tracks all healthcare encounters allows Compass Medical to spot patients in need of care, and to push services and resources to them rather than waiting for them to either contact a doctor or become sick enough to require a hospital visit.

“We’re getting better and quicker data on our patients that we wouldn’t have had before, which helps us provide better and quicker care,” Shah says. “We really see that in the high-risk population that makes up 5 percent to 20 percent of our patient population. That’s where you can really make a difference in care.”

The system basically collects all the available data on patients in one place, allowing doctors and nurses to jump online and check out where a patient has been, what tests have been done, what diagnoses have been made and anything else that would go into the health record. It’s designed to reduce silos of care and data and create a comprehensive health record.

Shah says the platform also improves relationships with hospitals and other care providers. It allows them to chart how their patients are being treated in those care sites, and gives them the data they need to forge better care transition programs.

“This definitely helps us to build care management and case management opportunities with these hospitals,” he says.

Using this platform, Compass Medical has boosted follow-up care to its transitional care management patients by enabling providers to contact patients after they’ve left the hospital or care site and push resources to them quickly. This not only maximizes care opportunities and reduces the chances of a return to the hospital or adverse health issue, but also maximizes billing opportunities and ensures a smooth continuity of care.

It also gives primary care providers a better idea of their patients’ health and improves patient engagement and self-management.

“We’re able to capture the entire healthcare journey of the patient,” says Shah.