ACO integrates decision support with its EHR to improve pop health efforts

Desert Oasis Healthcare is an accountable care organization that is part of Heritage Provider Network. It has been working hard at population health management and accountable care efforts.


In population health management, there always are very complex subpopulations – patients with comorbidities, or with poor medication adherence – that are time-consuming for primary care providers to manage effectively. And not every patient requires a specialist consult as a means to unburden the primary care physician office traffic.

“Desert Oasis Healthcare is an at-risk, high-performing integrated provider organization and our model is to use highly skilled pharmacists who are experts at medication therapy and disease state management in collaboration with our primary care network,” said Brian Hodgkins, executive vice president of clinical operations and HPN ACO at Desert Oasis Healthcare.

“We are a 5-star provider across the domains reflected in diabetic management, we get patients to goal quickly with the most appropriate treatment plan that can be adhered to by the patient so maintenance becomes an easier task.”

Brian Hodgkins, PharmD, Desert Oasis Healthcare

“The solution also required the need for technology to leverage a small team with a big population along with integration and connectivity that allowed the entire care team and patient a picture of the evolving treatment plan and clinical progress,” he said.


Desert Oasis Healthcare sought IT help from Rimidi, a vendor of clinical decision support tools. Rimidi is a cloud-based software platform that enables personalized management of chronic, cardiometabolic conditions across populations, with specific views for diabetes, heart failure, nonalcoholic fatty liver disease, cardiovascular disease, and obesity.

Created by doctors, Rimidi combines patient-generated health data with clinical data from the EHR to drive patient-specific clinical insights and actions.

“Achievement of clinical goals in an efficient process and quicker time frame is good for our entire health team community,” Hodgkins explained. “Rimidi is integrated with our NextGen EHR – not an easy task – and clinical data flows via cellular-enabled devices such as glucometers, scales and blood pressure cuffs back to our clinicians for rapid interpretation and intervention.”

The only steps missing now are unnecessary face-to-face visits as the data needed for best-in-class disease management has all been seamlessly shared in real time, he added. Face-to-face visits are now reserved for those patients that need to be seen – newly diagnosed or discovered diabetics with HgbA1c over 9, he said.

The addition of continuous blood glucose monitoring systems with Rimidi already is underway, which should only improve the system’s capabilities and reach, he predicted.

“Technology may take time to implement procedurally with efficient workflow, but the right partner will help you devise strategies to use the technology efficiently and effectively.”

Lindsey Valenzuela, PharmD, Desert Oasis Healthcare

“Trial and error in medicine is not a process that works well at the individual patient level,” said Hodgkins. “Diabetic care is subject to this because there is never a clear picture of blood glucose monitoring compliance and treatment plan adherence overall. Many primary care physician practices do not have time to download glucometer readings and trend results against the current drug regimen.”

The complexity of newer agents and their role in achieving good diabetic control also poses time consuming issues for primary care, he added.

“Rimidi brings a holistic data solution to the clinical team via a platform of predictive analytic modeling of blood glucose response to changes in therapy, while also automating all the data points for a clinician to make optimal interventions for the patient,” he explained.

“Essentially, you remove the need for in vivo experimentation in favor of in vitro, which lends itself to shorter times needed to get to clinical goals with greater patient satisfaction,” said Lindsey Valenzuela, administrator, population health and prescription management, at Desert Oasis Healthcare.


There are many clinical decision support tools on the market today, such as Argo Healthcare Solutions, Epic, Information Builders, LogicNets, medCPU, National Decision Support Company, Outcome Health, Pepid, PointRight, Talis Clinical and Wolters Kluwer.


Desert Oasis Healthcare’s ambulatory care team of clinical pharmacists working with a physician leader and support staff have achieved excellent clinical outcomes using the new technology platform, Hodgkins reported.

“The current iteration of this process also allows us to track and efficiently manage the other negative attributes of cardiometabolic syndrome, such as hypertension and hyperlipidemia, as well as to integrate the efforts managing chronic conditions where problematic disease states co-exist – such as in CHF,” he said.

“Connected blood pressure cuffs, scales and BGMs are a small beginning in the effort to connect patients to a care team in a manner that seeks their engagement and rewards them with better overall health,” he added.

The transparency offered through EHR integration means that all providers and clinicians interacting with patients can easily appreciate the thought process and management strategies implemented by the ambulatory care team, said Valenzuela.


For clinical trial results, implementation of the Rimidi platform achieved significant improvements – a 2.8% drop in HbA1c in a short 12-week period, lower total medical utilization, and higher satisfaction reported by patients.

And clinical pharmacists who support primary care use the technology platform to risk stratify patients with type 2 diabetes, monitor blood glucose data, and simulate the impact of medication adjustments on anticipated patient outcomes before prescribing.

“We are a 5-star provider across the domains reflected in diabetic management, we get patients to goal quickly with the most appropriate treatment plan that can be adhered to by the patient so maintenance becomes an easier task,” Hodgkins reported.

“We were able to demonstrate that using the technology tool, pharmacists were able to get patients to goal faster with A1c and lipid improvements above and beyond what was done with those pharmacists not using the tool,” Valenzuela added.

“Patient satisfaction also has improved with the use of cellular-enabled connected devices that mean fewer visits, less intrusion on their normal daily lives, while maintaining a close relationship with clinicians they trust and have 24/7 access to,” he said.


“There are a lot of innovators and tech solution developers in the marketplace right now vying for our attention,” Hodgkins observed. “Fortunately, we have leadership at Desert Oasis Healthcare that allows us to engage in rapid-cycle clinical improvement and test some of these tools and to sometimes fail in process improvement.”

Not all work as well as purported because of integration challenges, too difficult to manage at the user interface, or nebulous outcomes in a high-performing culture, to cite but a few reasons, he explained.

“You need to find a collaborator and partner who understands your model of care and where you are starting from in order to find that technological solution that gets your patients the outcome intended and not just the developer,” he advised.

A good collaborator will take a healthcare organization’s needs and insights and help develop their tool above and beyond their original platform providing a synergistic relationship, Valenzuela contended.

“Technology may take time to implement procedurally with efficient workflow, but the right partner will help you devise strategies to use the technology efficiently and effectively,” she concluded.

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

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