Providing the tools for Primacy Care Transformation

By Howard Beckman, MD, FACP, FAACH, FNAP. Chief Medical Officer, EagleDream Health

In a series of articles in the April 2017 issue of the Journal of General Internal Medicine, Ellner and Phillips1, then Shrank2, and finally Hochman and Asch3, argue for the need to transform primary care to meet the needs of our population in a cost effective manner. Ellner and Phillips argue that the principles that should guide this transformation include 1) Payment must support the primary care functions and reward value, facilitating a paradigm shift away from visit based care, 2) Relationships will continue to serve as the bedrock value in primary care and will be increasingly enhanced by teams, improved clinical operations and technology, 3) Generalist physicians will increasingly focus on high acuity and high complexity presentations with primary care teams increasingly collaborating to manage conditions that specialists managed in the past, and Primary care teams will develop an increasing ability to support health and wellness.  Shrank argues that consumerism will mandate avenues of change such as retail healthcare, direct and concierge care and home based diagnostics and care. Finally Hochman and Asch describe the need to identify and treat “High Cost High Need Populations (HCHN) possibly in dedicated HCHN clinics.

What is the underpinning for all these approaches to work successfully? I suggest that accurate actionable data analytic systems whether sitting on top of an EMR or embedded in it is the overwhelming first step in organizing any of these solutions. While identifying the current high need high cost (HCHN) patients is not difficult, determining who the next generation of HCHN patients are is not so easy. Accurately identifying this important sub-group and predicting the resources needed to reduce risk is the answer to successfully risk adjusted contracting. Analytic systems that can accurately predict who those patients are allows the primary care team to begin interventions BEFORE catastrophic outcomes and expenses ensue. The quality of risk profiling embedded in contracting for a capitated population is the critical first step  in provider organization success in the world prospective population based care.

Similarly, for disruptive approaches like retail clinics to provide meaningful service, they need to be integrated into an information system that allows their cross sectional visits to be meaningfully incorporated into the longitudinal care of each patient. Otherwise, we are simply creating yet another silo successful in generating income at the system’s expense while offering no systematic efficiency or improved quality.  The patient’s past history, personal preferences and tust, developed over months or years through a relationship with a health care team is either ignored or lost. The same is true for concierge care. To be efficiently delivered, one needs access o specialist and diagnostic information to be able to manage care be it through social media, email, text or whatever comes next.

Finally, for the primary care teams to function as teams there needs to be the ability to view each other’s work, communicate before and after patient’s synchronous or asynchronous contacts, and co-manage care electronically. While this would seem obvious, none of the major EMR entities have solved the dilemma of how to effortlessly integrate all this information.

In addition, this work leaves pre-transformation needs of managing contractual measures with insurers or self-insured employer based plans unaddressed. The needs for managing both claims and clinical data seems overwhelming to most practitioner organizations.

What I have learned over the past year serving as the Chief Medical Officer of EagleDream Health (EDH) is that not only is the platform to jointly manage claims and clinical data possible, it is currently available. EagleDream Health currently offers an effortless analytic system that blends claims and clinical EMR data into an accurate actionable format that is easy to use and offers transparency to administrators, practitioners and the health care team. The program has modules that employ state of the are analytics to enable customers to 1) prospectively estimate the costs of a panel of patients, 2) identify the population at highest risk now and next year’s HCHN patients, 3) provide practitioner performance reports on contracted measures down to patient names and contact information, 4) identify those overdue and near due for needed preventive and chronic disease management services, 5) provide lists of patients that need specified care management services, and provide the cost per episode for the services provided.  But there is more! Also available are the cost drivers for each diagnostic group. To the degree those cost drivers are determined to be low value, the organization has quickly defined waste identification and management programs because the variation in those services by provider is available. In addition, our network management module allow rapid identification of to which out of network services primary care practices  are referring AND the most commonly referred to practices. In each case, the amount of dollars lost is provided so that organizations can determine which projects have a potential ROI worth pursuing.

EDH is interested in exploring whether partnering would be in your best interest. To schedule a conversation and demo of our product, please contact Michael Howard, our SVP for Business Development at


  1. Ellner AL, Phillips RS. The Coming Primary care Revolution. J Gen Intern Med. 2017;33:380-386.
  2. Shrank WH. Primary Care Practice Transformation and the Rise of Consumerism. J Gen Intern Med. 2017;33:387-391.
  3. Hochman M, Asch sM. Disruptive Models in Primary Care: Caring for High Needs, High Cost Populations. J gen Intern Med. 2017;33:392-397.

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