Phytel has announced the launch of its Atmosphere platform, which integrates population health data with a patient communication engine to help providers proactively improve chronic and preventive care.

Executives say the scalable, software-as-a-service platform allows care teams to deliver appropriate care more effectively to patients. Combining analytic reports with interventional capabilities, Atmosphere's open-architecture offers the ability to securely plug in consumer health, education, digital coaching and other apps relevant to population health management.

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With 30 percent of U.S. adults living with two or more chronic conditions, 10 percent of patients accounting for 70 percent of healthcare expenditures, half of Americans projected to be obese in 2030, and a third of them projected to have diabetes by 2050, the numbers tell a scary story.

Phytel CEO Steve Schelhammer says a technology that focuses on "identifying patients in need of care, and then automating the steps needed to reengage" those patients is key to helping reverse those worrisome population health trends.

Atmosphere, offering physicians and their care teams information at the point of care, while also prompting them with actionable information to help ensure proper follow-up treatment, represents a way to extend the reach of providers "beyond the walls of the practice, by leveraging digital health coaching and multimodal communications to patients and their families," says Schelhammer.

The core elements of Phytel Atmosphere include:

• protocol-driven registries that automatically trigger messages to patients for recommended care
• applications that help providers stratify individual health risks and create personalized, automated interventions;
• patient self-management programs that include health risk assessments and individualized online care plans;
• automated communications that follow a patient's hospital or ER discharges to help prevent unnecessary readmissions;
• dashboards that measure an organization's effectiveness in its quality improvement initiatives;
• automation tools that identify the patient groups and processes required to qualify for Medicare's PQRS rewards and streamline the application for those incentives.
• Automated communication that proactively reminds patients about upcoming appointments with their providers.

Schelhammer says the platform will be a crucial tool as physician groups and healthcare systems move toward accountable care models and develop patient-centered medical homes.

"Everybody is starting to wake up to the fact that they really need to find ways to engage the provider in population health management," he says. Atmosphere offers a way to do that, making use of the "enormous data assets that we've accumulated, as well as our relationships with thousands and thousands of providers."

[See also: Phytel well-positioned for PPACA.]

Providers using components of Phytel's suite of care management solutions include Jackson, Mich.-based Allegiance Health, Richmond, Va.-based Bon Secours Health System, Elmhurts, Ill.-based Elmhurst Clinic and Green Bay, Wis.-based Prevea Health.

"We see Phytel as an integral piece of our effort to build the patient-centered medical home," said Kimberly Freese-Beal, MD, of Allegiance Health. "Phytel helps us do that with lean resources, through automation, and by delivering information to providers and staff. Its solutions enable us to reach patients who are not getting recommended care.

"As we tailor our care to better meet our patients' needs, Phytel's risk stratification capability will allow our care managers to quickly identify the patients who need more intensive care management," she added. "And the quality dashboards that show variations in practice and allow our doctors to more clearly converge toward evidence-based medicine will be very helpful from a quality perspective."

[See also: Catholic Health Partners enlists Phytel for population health management.]

Ashok Rai, MD, president and CEO of Prevea Health, said Atmosphere's ablity to mine patient information has led to "better real-time data, specifically in primary care settings" and "the ability to organize and approach in a much more proactive manner, rather than reactive.

To truly effect a shift in approach to population health, "it takes a redesign of our own processes and how we approach healthcare," Rai added. "As we do that, the tools we use need to be redesigned with us. Typical EMR products are all transactional based – they're only about the patient that's in front of you." With Atmosphere, he says, Phytel has helped harness "actionable" data that can help make a difference on a larger scale.