The small: Charleston Internal Medicine, West Virginia

By Terry Coleman, administrative director, Charleston Internal Medicine

West Virginia-based Charleston Internal Medicine, CIM, is an independent practice with six physicians and two mid-level providers.  The providers pride themselves on the personal touch they bring to patients despite seeing 110-140 of them per day. Its use of PHM technology was the result of another initiative to improve care.

CMS selected CIM in 2013 to participate in a three-year project to transform healthcare in the Charleston area into the "Medical Neighborhood" concept. Among the goals were to decrease costs, improve the health of the local population by 15 percent, improve the patient experience by 25 percent and work with other practices in the area that are not part of the project to incorporate them into the medical "neighborhood."

While CIM had done proactive patient outreach to patients who were due for a wellness visit in the past, it was a manual and sporadic effort that involved printing letters, stuffing them into envelopes and mailing them.

As part of the CMS Neighborhood program, CIM gained access to an advanced PHM platform that became a game-changer. Rather than running a report in the EHR and reaching out to patients when the small staff had time, the technology now allows CIM to run three automated daily outreach campaigns, primarily using email. The campaigns include reminders for wellness visits, reminders to have lab tests performed after orders have been issued, and a campaign specifically targeted for diabetes care. CIM also runs other campaigns on an as-needed basis. In all, more than 7,600 communications were sent to more than 3,700 patients for various appointments.

Once patients are in the office, the PHM technology creates a care-gap list by patient and provider. This list makes it easy for physicians to discuss patient needs during office visits, helping CIM close more of those gaps.

Despite using only a small percentage of the PHM platform's capabilities, CIM saw outstanding results.

Between January and December 2014:

• Wellness visits for CIM's overall population were greater than 80 percent
• 82 percent of the 65+ population had annual wellness exams
• Adolescent wellness visits increased by 146 percent
• Breast cancer screening increased from 42 to 49 percent
• Cervical cancer screening increased from 32 to 49 percent
• Colorectal cancer screening increased from 34 to 64 percent
• The number of unfulfilled lab orders dropped dramatically

Two additional benefits from using the PHM platform include helping CIM achieve Level 3 PCMH status, and assisting the organization as it becomes part of an ACO. Management says CIM wouldn't be as well positioned for success without the PHM platform.