RoundingWell Release Notes - Early January 2017

Happy New Year! Happy New Release! 

We’ve been hard at work making RoundingWell work harder for you. This release introduces two big new features we’d like to tell you about.

Custom Patient Lists

We know how important it is for your RoundingWell workspace to be customized to your specific needs and workflows. Custom Patient Lists allow your organization to configure lists exactly the way you want.

  • Auto-matching patients - You define the rules for a list and when patients meet the ruleset, they show up on the list.
  • Configurable columns - Set only the columns that are relevant to a list.
  • Find in List - Easily locate the specific patient you’re searching for.
  • Custom Filter Menus (Coming Soon!) - Dial in a list just how you want with custom filter menus. Look out for this in an upcoming release.

For those of you who’ve been testing this feature, thanks for your feedback so far. We’re listening. If there's a patient list you'd like to see, contact your team lead or your RoundingWell account manager.

Insights - Pathway Adherence

Insights - Pathway Adherence

With payments being tied to quality more and more, the pressure for teams and organizations to perform is greater than ever. We’re committed to making RoundingWell help organizations achieve their performance and quality targets. That’s the idea behind our newest Insights feature: Pathway Adherence. Pathway Adherence measures how well your organization is following your pathways. 

Read more about everything in this release.

Illinois Rural Community Care Organization ACO & RoundingWell Partner to Enable Improved Patient Engagement and Care Coordination

RoundingWell to be deployed in January 2017 as part of a 3-year agreement to make a positive impact on quality and shared savings

NASHVILLE, Tenn. — December 20, 2016 — RoundingWell, an integrated care management software provider, announced today an agreement with the Illinois Rural Community Care Organization (IRCCO) to deploy RoundingWell in support of an ACO initiative across Illinois comprised of 24 critical access and rural hospitals, 35 rural health clinics, and 14 independent rural physician practices. RoundingWell’s care management platform will help IRCCO’s integrated clinician teams provide care for more than 24,000 Medicare beneficiaries.

“IRCCO has made great strides in the last year toward understanding and improving the health of our beneficiaries,” said Pat Schou, Executive Director, IRCCO. “RoundingWell is the final piece of the puzzle that will enable us to engage and coordinate care for our higher-risk patients by using standardized protocols that are accessible to all care coordinators at our 24-plus locations.”

John Smithwick, CEO of RoundingWell, emphasized, “This is a perfect example of the integrated care delivery models that we built RoundingWell to support. Dedicated care coordinators are working with clinicians from hospitals and primary care settings across Illinois to deliver collectively the very best care for the patients they manage.”

Eric Johns, VP of Business Development at RoundingWell, added “The RoundingWell team is very honored and excited about this partnership with IRCCO. Both organizations desire to improve patient care, and we are confident that with their coordinators, ACO members’ clinician teams, and our technology, we can make a positive impact on quality and ultimately assist them in achieving shared savings.”

For more information, visit or

About the Illinois Rural Community Care Organization
IRCCO is a statewide rural accountable care organization. It is comprised of 24 critical access and rural hospitals, 35 rural health clinics, and 14 independent rural physician practices providing care and services for more than 24,000 Medicare beneficiaries.

About RoundingWell
RoundingWell is integrated care management software for provider organizations’ accountable care, value-based, and population health initiatives. Picking up where EMRs stop, care teams use RoundingWell to coordinate care, engage patients, and measure quality. RoundingWell is offered as a subscription service to a variety of healthcare organizations, including hospitals, Accountable Care Organizations, and specialty care providers.

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.