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Perform High-Quality Chronic Care Management
That Exceeds The Requirements For
Medicare Reimbursement.



  • Physician-written clinical workflows for 34 of the top chronic conditions, such as diabetes, heart failure, obesity, asthma, and COPD.  Contact DSHI or an updated listing of chronic disease workflows.
  • Comprehensive workflows empower a medical assistant to perform a physician-level medical history, capturing relevant symptoms, biometrics, co-morbidities, self-monitoring, lifestyle factors, and psychosocial and behavioral data, as well as medication reconciliation and a functional needs assessment.
  • A physician-written expert system processes the medical history into a physician-friendly format (CCM note) that includes objective measures (for trending) and a comprehensive care plan.
  • Gaps in care are identified in the CCM note.
  • Calculates Disease Control Score, an objective measure that is calculated using a wide variety of data such as biometrics, symptoms, symptom severity, co-morbidities, and behaviors.  Allows you to quickly identify which patients are doing better and which ones need attention. 
  • Calculates Patient Effort Score, an objective measure that reflects the patient's adherence with the treatment plan. Quickly identify educational opportunities to get the patient back on track. 
  • Assigns a Priority Score (1-7) an objective measure assigned to each CCM note. Indicates how quickly the note should be reviewed by the provider.  Identifies acute opportunities where clinical intervention could avoid an ED visit or hospitalization.  Priority Score also identifies situations where intervention could be managed via telemedicine.
  • Extensive medical library supports verbal and web-based education.  Links in the care plan provide the medical assistant with instant access to targeted educational content from a 28,000 topic medical library.
  • Creates a personalized web-based interactive care plan.  Our Virtual Health Coachallows patients to educate themselves when they want, and perform self-assessments to check for improvement in their Patient Effort Score.
  • Time audit logs encounter start times and duration in the CCM note.
  • Free web-based training every month.



  • No change in primary care provider work flow.
  • Providers don't need to learn or operate new software.
  • Obtain objective data to support transition to value-based care.
  • Reduce ER utilization and admissions.
  • Patients love the Virtual Health Coach.  Use our new Library API and incorporate the coach content on your own portal.
  • Lower cost when medical assistants deliver expert CCM services.
  • Up-to-date: Physician-written, evidence-based content updated quarterly.
  • Available as a quick-to-deploy widget for integration with any third party application, such as an EMR or CRM solution.
  • Available as an API for custom integration with any third party solution. 
  • Secure and dependable: Accessible via the web anywhere, anytime.