RoundingWell Release Notes - Late Aug '16

We're excited to share our latest updates! We are committed to improving your RoundingWell experience with new features, enhancements, and bug fixes. This release introduces a CCM Activity Report to the Patient History section. Please see the release notes below.


Today we’re introducing the CCM Activity Report for our clinical teams working with patients who need Chronic Care Management, CPT Code 99490. RoundingWell supports key aspects of billing requirements for CCM through patient engagement, care coordination documentation, and time tracking. With the CCM Activity Report, you'll be able to see a full log of all time tracked activity for a CCM patient in a completed month. You can access the CCM Activity Report in the patient's History. You can also print or copy and paste the report into an EMR. Key information in this report includes: 

  • Total Time Tracked
  • Clinician Time Tracked
  • Patient Engagement Time Tracked
  • Completed Check-Ins (Includes Date/Timestamp and Duration)
  • Completed Tasks (Includes Clinician Name, Date/Timestamp Completed, Duration, Related Risk, and Notes) *excludes completed tasks with no time tracked
  • Completed Assessments (Includes Assessor, Date/Timestamp, and Duration)

Read more about everything in this release.

RoundingWell Release Notes - Early July 2016

Patient Activation Measure (PAM) comes to RoundingWell

In our last release, we introduced Assessments in RoundingWell, a way for clinicians to electronically capture screenings and health assessments. Assessments launched with the PHQ-9 Depression Screening. Today, we’re adding another assessment: the Patient Activation Measure by Insignia Health. Backed by many clinical studies, the PAM is a validated measure to gauge a patient’s activation level. Activation not only supports more personalized patient-centered care, but activation is a strong predictor of patient outcomes. 

Benefits of PAM in RoundingWell:

  1. PAM is available to patients directly via RoundingWell Engagement and patient activation is automatically measured on a quarterly basis (image 1)
  2. Clinicians can capture PAM assessments electronically at any time (image 2)
  3. PAM Level and Score are calculated automatically and displayed in the Patient Sidebar (and coming later on Patients, Risks, and Tasks lists) (image 3)

Note: Your organization must have a license for PAM in order to take advantage of the PAM features in RoundingWell. Call or email your RoundingWell Account Manager if you’re interested in licensing the PAM!

Full release notes available here.

The Rogosin Institute Selects RoundingWell as its Care Coordination Platform to Facilitate Innovative CMS Kidney Care Model

RoundingWell now supports four of the 13 CMS ESCO participants

NASHVILLE, Tenn. — June 29,2016 — RoundingWell, an integrated care management platform, today announced its participation in The Rogosin Institute’s Rogosin Kidney Care Alliance ESCO (End-Stage Renal Disease Seamless Care Organization) within the new Centers for Medicare & Medicaid Services’ (CMS’) innovative Comprehensive End-Stage Renal Disease Care (CEC) Model.

"The achievement of truly integrated care that improves health and quality-of-life outcomes for end-stage, dialysis-dependent kidney patients is the goal of the ESCO, and we are privileged to be participating in this effort,” said Barry Smith, MD, PhD, President & CEO of Rogosin. "RoundingWell is providing care management software that is essential to the facilitation of such patient-centered care, both in and out of the dialysis clinic. With its care model supported by this technology, the Rogosin Kidney Care Alliance is poised to improve both care management and patient outcomes."

With the addition of Rogosin, RoundingWell now supports four of the 13 ESCOs participating in CMS’s CEC Model.

“We’re thrilled to be partnering with Rogosin to help them operationalize the CEC Model,” said RoundingWell CEO John Smithwick. “Our platform enables the next generation of care delivery – one that is integrated, team-based, and patient-centered. RoundingWell is committed to seeing our customer partners be successful as we pursue our mission to transform the delivery of care.”

For more information, visit,, and



About The Rogosin Institute
The Rogosin Institute is a world-renowned not-for-profit medical treatment and research center for kidney disease and its complications. Rogosin also provides treatment programs for patients with high cholesterol and has innovative research programs in cancer and diabetes. The Rogosin Institute is affiliated with NewYork-Presbyterian Hospital, Weill Cornell Medicine and is a Sponsored Member of the NewYork-Presbyterian Regional Hospital Network.

About RoundingWell
RoundingWell is integrated care management software for provider organizations’ accountable care, value-based, and population health initiatives. Picking up where EMRs (electronic medical records) stop, care teams use RoundingWell to track their populations, coordinate care, and engage patients. RoundingWell is offered as a subscription service to a variety of health care entities, including hospitals, Accountable Care Organizations (ACOs), Medicare Advantage plans, and specialty care providers.

RoundingWell Release Notes - Early June '16

Add New Assessment

We’re happy to announce the newest feature in RoundingWell: Assessments. Many of our customers (oncology, renal, home health, health systems, etc.) have expressed strong interest in the ability for clinicians to capture assessments electronically.

Electronic assessments have many advantages over paper-based assessments, such as:

  • Capturing responses electronically is faster than paper.
  • Electronic assessments can be scored automatically.
  • Assessment results can trigger other steps in a workflow: Alerts will appear in your risk feed and pathways can be queued up.

Today, we’re launching Assessments with the PHQ-9 Depression Screening. Here’s how it works:

  • You can capture an assessment for any patient by clicking Add New Assessment on Patient Overview and selecting PHQ-9.
  • After completing the assessment, close the assessment modal window and you’ll see that the assessment is processing. After a moment, you’ll see that the assessment has completed its processing. Click “Refresh the page” to see if any risks were identified.
  • Completed assessments are logged to History will be listed as a completed check-in.

Read more about everything in this release.

The Impact of Care Coordination On The Healthcare Industry

It may be hard to believe, but the United States has one of the poorest health outcomes among first-world countries. This is surprising to due to healthcare’s high spending in our country, which currently totals $2.5 trillion a year – the most per capita in the world. Sadly, the high spend does not result in better care.

Care management software sits critically in between patient, community, and health system. Research and evidence are pointing to the importance of putting patients at the center of this reform if we ever hope to improve outcomes and control costs.

Healthcare outcomes can have many influencers. The quality of the care delivered, including the consideration of evidence rather than intuition, the accessibility of care, and the affordability of care are just a few. Most importantly is the patient, and the countless behavioral, environmental, and psychosocial factors that make each of the patients distinctively unique.

Hypotheses now overwhelmingly point toward the fact that patient-centered, evidence-based care is fundamental to health reform. Nevertheless, consistently defining, and more significantly, putting the concept to action in daily care delivery is challenging. The “one-size-fits-all” approach towards patient behavior modification has previously been unproductive, and is the exact opposite of the widely-known term “patient-centered care.”

The World Health Organization (WHO) reports that approximately 70 percent of health outcomes are related to the aforementioned factors and that, until we can effect, understand, and change behavior based on modification of these factors, our costly healthcare efforts will continue to be substandard. In order to grasp accountability for healthcare outcomes, understanding the patient’s part (or lack thereof) in achieving evidence-based practice is crucial.

Changing behavior is not easy. This difficulty is only increased by the time constraints faced in the current care delivery system. To effectively evaluate and adjust behavior, health systems will have to find mechanisms to identify, stratify, engage, modify, and measure a patient’s individual characteristics and ensuing behavior as related to health outcomes — all, of course, while being comprehensive and cost-efficient.

A trusted method in achieving this with care coordination is through coordination supported by software specifically designated for the tough task. Coordinated care has reliably been a milestone in bringing about a successful and caring health system, yet quality assessment in this field needs improvement in delivering actionable, outcome-focused measures.

The accelerated movement to outcomes-based reimbursement has pushed health care systems to fully understand how to manage an individual patient’s health and healthcare across the care continuum in order to be successful. That means that engaging the patient as an active, accountable participant in the process is crucial.

A strong care plan, which serves as a guide during the involved and complicated process, should incorporate a person’s medical and psychosocial needs, evidence-based interventions to address those needs, and the patient’s individual values about receiving treatment. It spells out the process designed to meet those goals, and holds those accountable while doing so.   

Successful care coordination platforms assess a patient’s inclination to change, monitoring and measuring a patient’s response to evidence-based treatment, and identifying in real time where break-downs occur. By giving all members of a care team access to this information, a harmonized and systematized delivery of evidence-based, patient-centered care is attainable — and even likely.

Care coordination software solutions are the feasible answer to operationalized, evidence-based care. Coordinated care captures not only treatment plans initiated, but the individual patient preference, modifications to accommodate for both factors, and move toward mutually established goals.

With the end goal driving improvement in health and healthcare, care coordination gives providers the ability to convert evidence into action, evaluate the practice and adjust on an individual basis to achieve a defined outcome.

Kristin Stitt is an Advanced Practice Nurse with experience in analytics, system management, implementation science, predictive modeling, and care coordination. After working as an analyst in the airline industry, she migrated to healthcare, serving in a variety of roles in private practice and an integrated ACO, as well as private industry. She recently completed a Doctorate of Nursing Practice in Systems Management at Vanderbilt University, focusing on the utilization of system data and clinical evidence to concurrently guide administrative and clinical decision making in ACO population health initiatives.



RoundingWell Release Notes - Early May '16

Find in List

We mentioned a few weeks back that we had a little bit more work to do on Tasks to get it all the way into its new and improved state. By now you’re used to the new filters like Group, Assignee, and Date. The final element is Find in List, and we have a feeling you’re going to like it.
Find in List is a way for you search the current task list you’re viewing. When you type a keyword term into Find in List, any tasks from the current task list matching that term will be displayed.

Read more about everything in this release.

Music City Kidney Care Alliance Selects RoundingWell for Care Coordination

-- Release sourced from Dialysis Clinic, Inc. --

Medical Community Forms Partnership to Transform Kidney Care


Music City Kidney Care Alliance established within Middle Tennessee

NASHVILLE, Tenn. - April 14, 2016 - PRLog -- In an effort to demonstrate that the delivery of kidney care can be improved from the current patient experience and offered at a reduced cost to Medicare, Dialysis Clinic, Inc. (DCI) has joined forces with a select group of community health partners to establish the Music City Kidney Care Alliance. The newly formed six partner alliance will demonstrate an improved, continuous model of care for people with kidney disease under the new Medicare Demonstration.

These healthcare providers and suppliers are considered Participants in the End Stage Renal Disease (ESRD) Seamless Care Organization (ESCO), and together they are clinically and financially responsible for all care offered to patients under this new model, not just dialysis services or care specifically related to a patient's kidney disease.

The Music City Kidney Care Alliance ESCO spans the Middle Tennessee area. Its Participant Owners, who are responsible for improving the care provided to more than 500 patients, include:

  • Adel Saleh, MD
  • Alive Hospice, Inc.
  • Aspire Health Medical Partners of Middle Tennessee, PC
  • Nephrology Associates, PC
  • The Surgical Clinic, PLLC
  • Dialysis Clinic, Inc.

Reducing cost is one area of potential improvement for the kidney community along with improving coordination of care. Dialysis patients have complex health needs that are typically addressed by a variety of health care providers. More often than not, the care that a patient receives is not coordinated among providers.

The ESCO is utilizing dynamic health information technology to enhance communication and care coordination. "Our path to success for the Music City ESCO is with an integrated care model," said Robert Taylor, MD, Music City ESCO Chief Medical Officer. "RoundingWell is providing the care management platform that's helping the Music City ESCO participant-owners provide patient-centered care, both in and outside of the dialysis clinic. With the care model and the technology in alignment, the Music City ESCO is poised to deliver improved outcomes and reduced costs."

In addition, the ESCO represents a multispecialty group of providers working together to transform the care that dialysis patients receive. "Collaborative care is essential in providing the quality of care patients deserve, and we believe the Music City Kidney Care Alliance is a model to follow," said Anna-Gene O'Neal, Alive Hospice President and CEO and ESCO Participant. "One of the important aspects of this partnership is offering comprehensive care that meets patients' needs and goals when dialysis is no longer effective or desired. Alive Hospice applauds DCI for its deep concern for patients' quality of life as they pursue curative treatments, and, when the time is right, helping them transition into specialized care for the last months of life."

Patients participating in the ESCO will retain their full Medicare benefits and the freedom to choose their own providers. They will not experience a change in their health insurance coverage or benefit options.

Medicare patients receiving dialysis treatment in a DCI facility participating in the Music City Kidney Care Alliance ESCO have been mailed notification letters, alerting them to the new model of care. Participating DCI dialysis clinics include:

  • DCI Clarksville Highway
  • DCI Cumberland
  • DCI Dickson
  • DCI Home Training
  • DCI Lebanon
  • DCI Med Center
  • DCI Madison
  • DCI Murfreesboro
  • DCI Southern Hills
  • DCI Summit Medical Center
  • DCI Shelbyville
  • DCI Waverly

"We have implemented care coordinator positions within the ESCO to streamline care for new and high-risk dialysis patients and developed partnerships to coordinate patient needs that were once difficult to manage," said Doug Johnson, MD, Music City ESCO Executive Director and Chairman of the Board. "We believe this innovative approach will improve the care that kidney patients receive. We look forward to evaluating the success of this Medicare demonstration model with the Centers for Medicare & Medicaid Services (CMS) and sharing our results with the community."

More information about the Music City Kidney Care Alliance ESCO can be found at:

More information about the Medicare demonstration can be found at:

The statements contained in this document are solely those of the authors and do not necessarily reflect the views or policies of CMS. The authors assume responsibility for the accuracy and completeness of the information contained in this document.