How pop health EHR modules led to better care and an 'exponential increase in income' at one practice

Photo: MMR Healthcare

MMR Healthcare in Boynton Beach, Florida, had limited access to data, so it was difficult to obtain a clear, holistic view of the practice’s collective patient health.


For example, staff members were swimming in redundant and time-consuming lists from insurance companies and were trying to work with a read-only electronic health record system. This was a big problem because the practice serves a large geriatric population of more than 4,000 patients who often suffer from many chronic conditions.

While staff members had bits and pieces of population health data, like hierarchical condition category (HCC) scores and specific diagnoses, they were missing the top-level view of the overall health of their patients.

“My 36 employees, all working in their respective silos, only had a limited perspective,” said Dr. Martha M. Rodriguez, founder of MMR Healthcare. “I would bring the list of patients in need of screenings to one department and the list of patients in need of exams to another.

“This process started all over again at the beginning of each new month,” she continued. “Instead of spending time with patients, my staff was stuck analyzing lists of specific information that could range anywhere from two to 300 pages long. It was almost a crime.”


“eClinicalWorks’ population health solutions presented the opportunity for my practice to be proactive instead of reactive,” Rodriguez said. “We operate under a risk model, and every little mistake costs us money. The population health solutions offered to help us analyze the data and insights already at our fingertips to better care for our patients.”

Staff no longer would have to use data that was 90 to 120 days old, but would be able to make real-time decisions to enhance patient care and save money, she added. 

“By allowing insight into the top five causes of hospital admissions, we were able to completely eliminate admissions for congestive heart failure.”

Dr. Martha M. Rodriguez, MMR Healthcare

Instead of seeing chronic conditions escalate because of the time it took to look through old insurance claims, staff could use the tools to know in the moment what chronic conditions a patient had already been checked for, which ones needed to be monitored and which ones patients could be at risk of developing, she said.

“We could finally be ahead of the curve and stop health issues before they happened,” said Rodriguez. “Specifically, eClinicalWorks’ HCC module offered to help my practice use demographic data and diagnoses to calculate risk adjustment factor scores, saving us both time and money. We were able to identify coding gaps, calculate risk in real-time and analyze trends within our population.”

The chronic care management module presented the opportunity for MMR Healthcare staff to know which patients were enrolled in the practice’s different programs, and to easily submit claims, she said. 

The transition care management module could help the practice maintain the highest quality of care between visits and help reduce missed appointments and medications.

“As the CEO and a full-time practicing physician, these solutions offered me great freedom,” Rodriguez said. “These tools provided greater insight into my day-to-day operations and equipped my practice with the resources needed to work together as a team, while keeping patient care at the core of everything we do.”


There are many vendors with electronic health records systems on the health IT market, including Allscripts, athenahealth, Cerner, DrChrono, eClinicalWorks, Epic, Greenway Health, HCS, Meditech and NextGen Healthcare.


MMR Healthcare was able to create a new infrastructure to manage patients’ data and overall health using eClinicalWorks’ population health solutions, Rodriguez explained.

“The solutions also allowed my practice to become a concrete team,” she noted. “I always say that healthcare is a team sport. We need to work together efficiently to arrive at effective solutions for optimized patient outcomes. The HCC, CCM and TCM modules have made this possible, in part by giving everyone on my team a dedicated role and helping us better manage patient care between visits.”

These modules also helped create clear goals and a roadmap of where the practice was, and where it needed to go to better understand and care for patients, she added.

“Most recently, when the CPO module came out, we were excited to be able to record and follow home health use for the first time,” she said. “This module has made the healthcare landscape accountable. Historically, until this module was available, it was impossible for a practice of my size to control and follow home health certifications and recertifications. This has always been like a loose cannon.

“The first thing I did was educate myself and my teams on all of the modules’ capabilities and possibilities,” she added. “The vendor was available and willing to answer questions during this training period – and they still always are. The beauty of these modules is their comprehensiveness and flexibility, allowing us to learn continuously by receiving new data in real time to adapt our approach for better patient outcomes.”

Rodriguez stresses the importance of education and teamwork because everyone – vendors, providers and payers – all have an important role to play in making these modules a success, and each have a responsibility to do their part and hold each other accountable.

“The same goes for my staff,” she said. “Within my practice, I created teams who own each of these modules. The modules provided very clear goals, rules and steps to guide these teams in how to provide the best patient care and grow the practice. With everything in one easy-to-access place, I now have the confidence that my staff has the data and resources they need to do their best work possible.”


Using the modules, MMR Healthcare has increased its HCC score significantly, translating to an exponential increase in income for both the insurance companies and the practice.

“We also are seeing these modules address major crises in healthcare,” said Rodriguez. “For example, 86 million Americans have prediabetes who will later become diabetic. With tools like eClinicalWorks’ population health modules, we are able to better screen for prediabetes and prevent the condition from worsening.

“These modules expose patterns in population health data, allowing us to create programs and mechanisms to better understand disease and treatment trends, and prevent or reduce the impact of future healthcare crises,” she added.

Since implementing the CCM solution, MMR Healthcare has not had a single hospital admission from its CCM patients. With these advanced tools at their disposal, staff are able to prevent worsening conditions and address potential issues before they happen.

“More importantly, during the pandemic this model of care created a close connection between patients, their family and our provider team, while simultaneously increasing our revenue – positively benefiting all parties,” said Rodriguez. 

“At the start of the pandemic, I never would have thought it was possible, but with the help of the vendor, we were able to continue providing the same high-quality care as we had been before the pandemic.”

The TCM solution also has produced results. Since all of the data and analytics are in one place, and easily viewable across teams, staff members were able to brainstorm and kick-start programs, she noted.

“We can also easily track the progress of the programs to see what is working and what needs to be improved,” said Rodriguez. 

“For example, by allowing insight into the top five causes of hospital admissions, we were able to completely eliminate admissions for congestive heart failure,” she explained. “This is huge, because congestive heart failure often has the highest cost for hospital readmission. Therefore, these tools are directly saving both our practice and our patients a significant amount of money.”

Looking forward, staff members are now working to eliminate hypertension with these population health modules.

“Hypertension often leads to cardiovascular disease, the leading cause of death in the United States,” Rodriguez said. “We are using these modules to create a hypertension clinic and transform the way that hypertension is treated and resolved. Without the metrics the modules provide, it would be quite difficult to move forward in tackling this issue. These metrics and dashboards help us make sure that patients keep appointments, schedule follow-ups and adhere to medication.”

Rodriguez’s goal is that by the end of 2021 her practice will be able to demonstrate that it can eliminate hypertension as a leading cause of death. She believes that the practice could not reach that goal without the vendor’s modules.


“I cannot stress the importance of population health tools and shared data enough,” Rodriguez advised. “The relationships we build with our patients are unique and incredibly important. If providers want that relationship to be preserved, they must take the responsibility to identify and change the current gaps in care by using tools that provide population health insights.

“These are critical to care coordination, the elimination of duplicated efforts and treatments, as well as improving the overall healthcare system,” she added. “If we want to eliminate these issues and more, we need access to shared data. We need to be able to see a patient’s care history from all of their providers and identify specific care gaps from a patient’s overall health regimen.”

All providers need to use tools like this in order to liberate data and connect the healthcare industry, she said. Everyone must take responsibility for creating a truly interoperable system, and this starts with healthcare leaders discussing how to achieve this as a top priority in moving the industry forward.

“We have the resources we need to make these changes,” said Rodriguez. “Now it is just about doing it. We need to work together using healthcare technology to aid us in our work as physicians. Ultimately, we have the brainpower and innovation to figure out a way to have all our systems talk to one another.

“This is the critical next step that needs to happen, and it will become a reality if we work together to gather, share and analyze data collectively as an industry.”

Twitter: @SiwickiHealthIT
Email the writer: [email protected]
Healthcare IT News is a HIMSS Media publication.

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