Laboratory Connectivity Challenges in the Age of COVID-19

By | Health Information Exchange, HL7, Integration, Interface Engine | No Comments

This year we are all having to communicate in ways we never have before, and also having to find new methods for processing those communications.  For laboratories and clinics across the country, there has also now been the need to report directly to state and local health departments to immediately deliver COVID-19 test results.


Thankfully, eTransX has been solving complex communication challenges for over 20 years!  We have been helping labs throughout the nation connect to multiple health departments, saving countless hours of manual reporting every week.  With this alone we have helped our clients save thousands of dollars and reduced headaches.  With decades of experience and our powerful eTX HEMI design studio, we have been able to quickly and efficiently bridge the gap where many traditional LIS providers are struggling to keep up.


If you are in need of a fast, tailor-made, and powerful solution for your company, please call us at 888-221-4971 or visit us at to see more information.  We’re happy to discuss your unique situation and how we can help!

eTXDesign Studio – Connectivity at Your Fingertips

By | Health Information Exchange, Integration, Interface Engine | No Comments

2020 has dramatically changed the way we interact and connect with each other both personally and professionally.  Thankfully, eTransX has been solving complex communications issues for over 20 years.  With our HEMI (Healthcare Enterprise Messaging and Integration) eTXDesign Studio we can empower your laboratory, medical practice, or surgical center to interface quickly.  Many times connections can be made in hours or days instead of weeks or months, while also saving thousands versus the traditional method of outsourcing this work.

Our eTXDesign Studio makes it easy for users to configure templates for inbound and outbound messages with no programming knowledge required.  Using the eTXDesign Studio, anyone can create message templates for HL7, Flat Files, Database tables, and API endpoints.  All templates created in the eTXDesign Studio are configuration driven, and can be reused for multiple different interfaces.  Our clients also get access to the comprehensive eTransX knowledgebase which includes templates for hundreds of file types and structures, allowing the export of templates to move quickly from test to production.

Laboratories and practices that use eTransX HEMI have taken what is normally an obstacle and turned it into a competitive advantage.  The eTXDesign Studio allows them to connect with new referral sources on their own time frame as well as adapt to new requirements, like reporting COVID19 test results to state and local health departments.  Click here or call 888-221-4971 to learn more about how eTransX can become a powerful partner in driving new growth for your company!

National Drug Abuse/Heroin Summit April 2-5, 2018

By | Uncategorized | No Comments

We would like to invite you to visit us at our booth (#707) at the National Rx Drug Abuse and Heroin Summit that will be held in Atlanta April 2-5, 2018. The National Rx Drug Abuse & Heroin Summit is the largest national collaboration of professionals from local, state, and federal agencies, business, academia, clinicians, treatment providers, counselors, educators, state and national leaders, and advocates impacted by prescription drug abuse and heroin use.

Key speakers at this year’s Summit include former President Bill Clinton; Jerome M. Adams

Surgeon General of the United States; James A. Walsh, Deputy Assistant Secretary

International Narcotics and Law Enforcement Affairs Bureau; Francis Collins, MD, PhD,

Director, National Institutes of Health (NIH), Anne Hazlett Assistant to the Secretary for

Rural Development, Elinore F. McCance-Katz Assistant Secretary, Substance Abuse and Mental Health Services Administration and many others.

We will be introducing our new Opioid Care Community software applicationat the Summit – the first of its kind software system to help communities of all sizes accelerate their efforts to solve the Opioid/Substance Abuse disorder crisis from prevention to treatment to recovery.

Our software is designed to support popular models for coordination opioid and substance abuse treatment and recovery – such as the Hub and Spoke Model and the Recovery Oriented Systems of Care (ROSC) – see diagram below of ROSC model.

Key benefits of using our outcome driven Opioid Care Community software system include:

Perform at-Scale– serve more clients with less staff with automation, reducing overall cost with better outcomes

Data-Driven- capture data to track and measure results – move the needle. You can’t manage what you can’t measure

Consistency – support consistency by using automated evidence based protocols. Set up standard templates based on best practices

Community Resource Directory– search for community based programs and services by location, service type and service availability in real time

Timely Data Sharing- break down silos of information between community services and easily and securely share client data between providers

Flexiblity- our software platform is designed to easily make changes to supporting future protocols, workflows, and data sharing processes

Specific software applications include:

Prevention – Coordinate prescriber and consumer education on guidelines and best practices. Coordinate programs to engage with youth on dealing with protective and risk factors

Early Intervention/Harm Reduction– Support rapid response programs to intervene with known Opioid use disorder individuals to help them into harm reduction and treatment programs

Treatment – Maintain an up to date listing of available treatment programs and facilitate matching individuals to the right programs based on their particular needs

Recovery – Maintain listings and facilitate transitions from treatment programs to recovery programs. Fully support the coordination of necessary wrap around services to help reduce relapses and promote full recovery.

Come visit with us next week.

If you can’t visit us at the Summit – call us for a free discovery session to help us better understand your needs for solving the opioid substance abuse epidemic in your community.


Chart: How the eTransX Opioid Care Community system supports the Recovery Oriented Systems of Care Model:



The Opioid Crisis in Philadelphia: Killy, Dilly, Philly

By | Accountable Health Communities, Care Coordination, Opioid | No Comments

Tomorrow the city of Philadelphia will hold a major parade to celebrate Philadelphia’s title as the home of America’s National Football Champions. Many fans will be sporting “Philly Philly” and “Philly Dilly” T-shirts related to the popular Bud Light commercials – which feature a king who prefers Budweiser to all other beers – and says the cheer “dilly dilly” to those bringing the King gifts of Bud Light (calling them true “friends of the Crown” while a citizen offering a homemade beer is sent to the “pit of misery”). 1

Philadelphia also holds a national title that no one will be celebrating tomorrow – the title of the having the nation’s highest per-capita overdose rate of any major city in the nation. 2  The opioid crisis is indeed a true “dilly” of a problem (e.g. “Killy Killy”) for a city that is desperately seeking answers to the crisis. 3

Philadelphia is not the only city in America that has a “dilly” of a problem in addressing the Opioid crisis. Opioid overdose deaths in America are now equivalent to a “9/11” crisis every three weeks. 4

A Real “Pit of Misery”

Those caught in the grips of an Opioid Use Disorder are living in a real life “pit of misery”. A recent blog post by Peter Wang shares his true story of living in real pit of misery in Philadelphia as a heroin addict. 5 In this blog post Peter states: “Five years ago, I was sleeping on the streets of Philadelphia with needles hanging out of my arm. Addicted to heroin and homeless, I felt incredibly alone. I felt like there was no way I could ever do anything with my life. I didn’t think there was any way I would ever turn it around.”

Like Peter, thousands of people are living in a pit of misery caused by their Opioid use disorder. To be precise, it is estimated that 21 million people in America are living with a substance use disorder. 6

True “Friends of the Crown”

Peter Wang’s blog post includes a happy ending as Peter shares how “true friends” helped him escape his pit of misery to become a productive citizen of the “kingdom”. These “true friends” included Peter’s mother, his girlfriend, and his church. 7 Those that are helping to fight the Opioid crisis in America are indeed “true friends” of the “kingdom” of America.

Join Us in Sharing this “Philadelphia Story”

Our company eTransX has been focused on being a “true friend” for those caught in the Opioid crisis by developing information systems solutions to help solve the crisis. We want to invite the readers of this blog post to join us in this quest to fight the Opioid crisis by sharing this “Philadelphia Story” with your friends and family, and exploring ways you can personally help fight the Opioid crisis in your community.

The Philadelphia Opioid story serves as a wake-up call to every community in America that the Opioid crisis is real and growing rapidly. Now is the time to take action to solve this crisis across America.
“Never doubt that a small group of thoughtful, committed, citizens can change the world. Indeed, it is the only thing that ever has.” Margaret Mead

Richard Taylor is the director of Business Development for eTransX ( an information technology company based in Brentwood TN that has been leveraging information technology to address complex challenges for over 18 years. Most recently, eTransX has teamed up with other partnering organizations to offer technology and services to help communities address the Opioid crisis.

For more details on eTransX’s Opioid solution offering go to:



1 Youtube link for the Bud Light Dilly Dilly commercial:

2 Based on 2016 opioid death statistics from the CDC,

3 Hit Hard by Opioids, Philadelphia Makes Most Radical Move Yet, Tribune News Service, Jan 24, 2018 as reported in

4 Quote by NJ Governor Chris Christie in 2017:


6 CBHSQ (2016), Results from the 2015 National Survey on Drug Use and Health (HHS) as retrieved from:


Charles Dickens’ A Christmas Carol and the Opioid Crisis

By | Care Coordination, Opioid, Population Health | No Comments

The current movie – The Man Who Invented Christmas – centers on the events that inspired Charles Dickens to write his famous book A Christmas Carol. In doing some additional research on this topic, I was struck by several interesting parallels between the characters and message of Dickens’ A Christmas Carol and today’s Opioid crisis.
At the time his book was written in 1843, inequality and poverty in the Britain’s Victorian Era were rampant as the country was shifting from an agricultural economy to an industrial one. This transition led to thousands moving from the country to the city in search of work. Factory owners were exploiting children as a cheap source of labor. Hunger was widespread, and many lives were being lost. Efforts to address this inequality did not seem to be a high priority with the general public or with those in authority.

These circumstances led Dickens to write his “Carol” as a strong condemnation of greed and disinterest – centered on the transformation of the book’s main character – Ebenezer Scrooge. Dickens’ story of Scrooge’s journey has provided an optimistic message of personal change of heart that has proved popular across generations of readers. 1

Similar to the poverty epidemic that devastated families and lives in Victorian England, the opioid epidemic is devastating families and lives in cities across America. Just like modern times, there were differing views on how to solve the problem. In regards to poverty, the prevalent solution was to punish or imprison individuals for not working instead of providing services to help meet basic needs while they could find new jobs or learn new skills. Today, a similar discussion is heard, in regard to solving the Opioid crisis (e.g. arrest more addicts or provide more treatment services). Unfortunately, just as in Dickens’ day, there are some individuals who regard the rising number of Opioid overdose deaths as a positive development (e.g. “decrease the surplus population”).

Like any good story, there are villains and heroes. In Dicken’s day, the villains were greedy factory owners paying minimal wages and promoting poor working conditions that contributed to poverty and early deaths. In today’s opioid crisis, some greedy opioid pharmaceutical companies and unscrupulous opioid treatment providers are seen as villains that have played a role in contributing to increased Opioid abuse and overdose deaths.
Through Ebenezer Scrooge, Dickens introduced the idea that employers should take more responsibility for the well-being of their employees. Dickens’s message was that an employer’s workers are not of value only to the extent to which they contribute to a product for the cheapest possible labor cost. Instead, they are of value as “fellow-passengers to the grave, and not another race of creatures bound on other “journeys.” Employers owe their employees “as human beings” – no better, but no worse, than themselves. 2

The impact of the publication of Dickens’ A Christmas Carol in 1843 was immediate and widespread. The increase in new charities and changes in employer attitudes and policies started a major movement to address poverty and inequality in Victorian England.

Just as Dickens’ used A Christmas Carol to provide a spark for addressing poverty in 1843, the U.S. Surgeon General’s 2016 report Facing Addiction in America is seen as a similar landmark publication for addressing America’s Opioid epidemic.

In the Surgeon General’s report, the message is clear – addiction is a health issue, not the result of any individual’s moral shortcomings, and must be addressed through a public health approach integrated with the community at large. This means shifting the focus away from punitive policies toward a comprehensive strategy that combines health and social services. 3

Just like Dickens’ Carol, the Facing Addiction in America report offers a new perspective and motivation for America’s employers and communities to act collaboratively to address the tragic consequences of Opioid use disorders.

At our company, eTransX, we have teamed up with other companies to help find solutions to address today’s Opioid crisis that is devastating families across our country.

This holiday season, we ask you to join us in the spirit of A Christmas Carol to explore new ways to work with your community to help address this devastating crisis. Every day we further hesitate or delay addressing the growing opioid crisis is another step forward to catastrophic loss of life and economic costs to a community. As in Dickens’ A Christmas Carol, we need businessmen and community leaders to step forward to help solve the opioid epidemic.
“Never doubt that a small group of thoughtful, committed, citizens can change the world. Indeed, it is the only thing that ever has.” Margaret Mead

Richard Taylor is the director of Business Development for eTransX ( an information technology company based in Brentwood TN that has been leveraging information technology to address complex challenges for over 18 years. Most recently, eTransX has teamed up with other organizations – Insightformation (, Restoration One (, and Analysts ( to offer technology and services to help communities address the Opioid crisis.

1 Why and How Charles Dickens Wrote the Classic Story of Ebenezer Scrooge, Robert McNamara, Dec 4, 2017,

2 The Real Reason Charles Dickens Wrote A Christmas Carol, John Broich, TIME, Dec 13, 2016

3  Shifting Our National Approach to Addiction, Health Policy Hub, Nov 23, 2016,

MACRA Care Coordination Software

By | Care Coordination, MACRA, Value-Based Care | No Comments

Last week we talked about how MACRA legislation is a game changer for how providers will be paid in the future for their Medicare patients.  This week we will focus on the value and benefits of using care coordination software solutions to maximize MACRA payments and care delivery productivity.

Specific opportunities for using care coordination software to maximize revenue include:

  • building and managing “whole person” longitudinal care plans
  • automating data collection and workflows
  • automating interactions with patients and with other professional care team members
  • automating the selection and management of community based services to help patients ‘

While some EMR software vendors will be able to support the need to capture and report quality metrics – support for care coordination – particularly for complex patients – will likely require separate care coordination software.

In selecting a care coordination software solution, we would like to point out two key considerations to keep in mind.   First, there are benefits in selecting a solution that can scale to support the more advanced MACRA alternative payment models – even if a practice begins in the basic MERIT based payment model and transitions later to a more advanced model.    Second, it is important to select a platform that can fully support the creation and management of robust longitudinal care plans as a foundation for maximizing patient outcomes that in turn should maximize MACRA payments to the practice.

Recently, Chilmark Research – an independent healthcare software evaluation company – Chilmark concluded that many software vendors where two to three years away from offering fully featured longitudinal care plan software solution.  Chilmark defined a robust longitudinal care plan as a solution that can support eight core components (see exhibit A below):

Longitudinal Care Plan Chart

Exhibit A: Eight Core Components of a Robust Longitudinal Care Plan

Source:  Longitudinal Care Plans, Chilmark Research, Dec. 2015.

Eight “core” elements of a Robust Longitudinal Care Plan:

  1. Patient demographics
  2. Members of the care team
  3. Any care management programs the patient is in
  4. Active problem list
  5. Active medication list
  6. Goals, including those for self-management
  7. All health interventions and their current status
  8. Risk factors for the patient

eTransX’s  XCare Community system fully supports all eight core components out of the box today.  The old adage of “pay me now or pay be later” applies as you evaluate and select your software application solutions for maximizing MACRA payments.   By starting now with  a robust care coordination software solution that will support your current and future MACRA deployment  options can potentially save you significant money and time in the long run.

For more information on the XCare Community system – contact Richard Taylor at 615 620 7524 or

Accountable Health Communities Software

By | Accountable Health Communities, Care Coordination, Value-Based Care | No Comments

CMS recently announced a 5-year, $157 million program to fund Accountable Health  Communities (AHC) under the CMS Innovation Center.  The purpose of this new program is to assess whether systematically identifying and addressing health-related social needs can reduce health care costs and utilization among community-dwelling Medicare and Medicaid beneficiaries.   For the first time in its history, CMS is making a significant amount of money available to help communities address the social determinants of health.  CMS has referenced several key reasons for this landmark program 1:

  • Many of the largest drivers of health care costs fall outside the clinical care environment.
  • Social and economic determinants, health behaviors and the physical environment significantly drive utilization and costs.
  • There is emerging evidence that addressing health-related social needs through enhanced clinical-community linkages can improve health outcomes and impact costs.
  • The AHC model seeks to address current gaps between health care delivery and community services.

The foundation of the AHC model is a comprehensive screening process for health-related social needs.  These needs include but are not limited to housing needs, food insecurity, utility needs (e.g., difficulty paying utility bills), interpersonal safety (e.g., problems of intimate-partner violence, elder abuse, child maltreatment). Using the data gathered through this social needs screening process, the AHC model aims to address these underlying health-related social needs through three tiers of approaches, with each tier linked to a payment method. 2   These three tiers are referenced as Tracks 1,2,and 3 in the AHC program     The primary focus of each track is shown below:

  • Track 1: Awareness – Increase beneficiary awareness of available community services through information dissemination and referral
  • Track 2: Assistance – Provide community service navigation services to assist high-risk beneficiaries with accessing services
  • Track 3: Alignment – Encourage partner alignment to ensure that community services are available and responsive to the needs of beneficiaries

While Track 2 and 3 applications were closed in May, CMS has reopened applications for Track 1 with new provisions to make it easier for communities to apply for Track 1.   Under all tracks, the AHC model will fund award recipients, called bridge organizations, to serve as “hubs”.  These bridge organizations will be responsible for coordinating AHC efforts to 2:

  • Identify and partner with clinical delivery sites
  • Conduct systematic health-related social needs screenings and make referrals
  • Coordinate and connect community-dwelling beneficiaries who screen positive for certain unmet health-related social needs to community service providers that might be able to address those needs
  • Align model partners to optimize community capacity to address health-related social needs

The eTransX XCare Community system offers an ideal software platform for any community that would like to pursue the implementation of a  Track 1, 2, or 3 AHC model.  Our flexible software as a service solution can support the social needs assessments and the ability to share information with the healthcare community and social service organizations.

As mentioned earlier,  Track 2 and Track 3 applications are now closed,  Track 1 applications are still open for interested communities until Nov 3, 2016.

CMS modified Track 1 application requirements for the new Track 1 funding opportunity. The modifications include: – reducing the annual number of beneficiaries applicants are required to screen from 75,000 to 53,000; and increasing the maximum funding amount per award recipient from $1 million to $1.17 million over 5 years.  CMS believes these two key modifications to Track 1 will make the program more accessible to a broader set of applicants. Applicants that previously applied to Track 1 of the AHC Model under the original FOA must re-apply using this FOA to be considered for the Model.  CMS anticipates announcing Track 1 cooperative agreement awards in the Summer of 2017. 4   eTransX would be glad to assist any Track 1 applicants in providing information related to software requirements for their Track 1 application.


Footnotes: 1 source; CMS AHC Track 1 Program Webinar slides, 09-14-16

2 ibid

3 ibid

4 ibid.

MACRA MIPS Software platform

By | Analytics, Care Coordination, Population Health, Value-Based Care | No Comments

MACRA is a game changer for providers.   It represents the most significant change in healthcare payments since Medicare was introduced 60 years ago.   The baseline for calculating MACRA payment adjustments starts January 1, 2017.   The purpose of MACRA is to lead healthcare providers from a fee-for-service payment model to a value-based care model where reimbursement is determined by patient outcomes that includes quality of care, utilization of care, improved patient outcomes, and improved cost control.

The MACRA payment program has to be budget neutral so there will be winners and losers.  Under MACRA, providers will have to choose to operate under a merit-based incentive program (MIPS) or transition to an Alternative Payment Model (APM).  While there are a few exceptions for providers new to Medicare and/or with low Medicare payment volume to participate in MACRA,  most providers will be impacted by MACRA.

Under the MIPS default option,  there is a potential for a maximum plus or minus 4 percent or payments in the first year (2019). A bonus payment (not to exceed 10 percent) for exceptional performance is part of this program for the first five years. An overall MIPS score will be calculated according to performance in four measures (weighted by performance, with potential changes in weight by year):  Quality =50%, Cost (Resource Use) =10%, Advancing care information (interoperability, etc.  = 25 percent, and Clinical practice improvement activities (care coordination, etc.) = 15 percent.

Under the Alternative Payment Model (APM), Medicare providers will be paid based on value of services rather than service volume. Providers meeting the criteria for this track cannot move to the MIPS track. Physicians receiving a significant portion of their payments through eligible APMs can be exempt from MIPS—and they receive a lump sum payment of 5 percent of covered services.

In regards to software requirements – some requirements can be met with a certified EMR system – while other requirements such as care coordination and interoperability will require software beyond most EMRs.   eTransX’s XCare Community system provides a solid robust software as a service platform that can be used to maximize value based payments under either MIPS or Alternative Payment Models (APM).

A robust MACRA software plaform will not only need to support capturing and reporting metrics and sharing information electronically,  it will also need to support robust team based  care coordination to maximize payments and performance bonuses.   For example, to maximize performance, patients will need to be an integral part of their care and really understand their care plans.  The care plans should be evidence based and personalized.   In addition to the physician,  the care team for the patient may include a nurse, a pharmacist, and a social worker who are all managing a group of patients with chronic conditions to make sure their needs are being met, such as arranging transportation, solving prescription problems, planning meals and exercise…this will require a robust care coordination software platform.

Providers can start generating value based payments now with the eTransX XCare Community system – through programs such as the Medicare Chronic Care Management program and/or Transitional Care Management program.   In addition, using the XCare Community system now – will help practices improve their patient outcomes and quality metrics in 2017 which will serve as the basis of future value based payments under MACRA.

Now is the time to start evaluating your software options to maximize MACRA payments.

Comprehensive Primary Care Plus Software

By | Care Coordination, Uncategorized, Value-Based Care | No Comments

If you are a primary care practice operating in one of 14 selected CPC+ regions  (see list below) you may be eligible for a unique opportunity to earn significant additional revenue from multiple payers (e.g., Medicare, Medicaid, and Commercial) by participating in the Comprehensive Primary Care Plus (CPC+) program that will start January 1, 2017 and last for five years.

Time is of the essence as interested primary care practices must submit an application to CMS by September 15, 2016.

Who is eligible?

Eligible CPC+ practitioners are those who have a primary specialty designation of family medicine, internal medicine, or geriatric medicine, and for whom primary care services accounted for at least 60 percent of billing under the Medicare Physician Fee Schedule and have a minimum of 150 attributed Medicare fee for service beneficiaries in one of the 14 CPC+ Regions (see below).

Practices owned by hospitals and health systems are eligible to apply to CPC+.

Practices within an IPA are eligible to apply to CPC+. Practices within an IPA must apply separately to participate in CPC+, as CPC+ is a practice-level transformation

Primary care practices currently participating, or considering participation in Tracks 1, 2, or 3 of the Shared Savings Program, that meet the eligibility requirements of CPC+, may participate in both initiatives. Practices participating in Shared Savings Program Accountable Care Organizations (ACOs) can participate in either track of CPC+.


Practices within ACOs participating in the ACO Investment Model (AIM), Next Generation ACO Model, or other shared savings programs may not participate in CPC+.

Also not eligible for CPC+: FQHCs, Rural Health clinics, and concierge practices, or any practice that charges patients a retainer fee as of January 1, 2017, may not participate in CPC+.

CPC+ Regions

1. Arkansas: Statewide

2. Colorado: Statewide

3. Hawaii: Statewide

4. Kansas and Missouri: Greater Kansas City Region

5. Michigan: Statewide

6. Montana: Statewide

7. New Jersey: Statewide

8. New York: North Hudson-Capital Region

9. Ohio: Statewide and Northern Kentucky: Ohio and Northern Kentucky Region

10. Oklahoma: Statewide

11. Oregon: Statewide

12. Pennsylvania: Greater Philadelphia Region

13. Rhode Island: Statewide

14. Tennessee: Statewide


Additional details for eligibility can be found at the CPC+ website:

Two CPC+ Options – Track 1 and Track 2

Practices will have two program options – Track 1 and Track 2.   Care delivery requirements for each track are:

Track 1

Existing care delivery activities must include: assigning patients to provider panel, providing 24/7 access for patients, and supporting quality improvement activities.

Track 2

Existing care delivery activities must include: assigning patients to provider panel, providing 24/7 access for patients, and supporting quality improvement activities, while also developing and recording care plans, following up with patients after emergency department (ED) or hospital discharge, and implementing a process to link patients to community based resources

CPC+ will accommodate up to 2,500 practices in each track for a total of 5,000 practices across all regions and encompass approximately 20,000 clinicians and 25 million patients

CMS expects practices that participate in CPC+ will do so for the full five years of the model. However, participation in CPC+ is voluntary and practices may withdraw from the model without penalty during the five-year program period.

Practice Additional Revenue Projections

Additional revenue can be significant for participating practices

For Track 1 and Track 2 participants – projected average payments are shown below (per beneficiary per month)

Track Care Management Fees PBPM Performance based Incentive Payments
1 $15 average $2.50 PBPM
2 $28 average $4.00 PBPM

These payments are in addition to fee-for-service payments.

Per 1,000 patients, the maximum payments for care management fees for Track 1 participants would be $210,000 and $384,000 for track 2 participants.

Technology requirements  and eTransX

Use of advanced technology will be critical for maximizing revenue in the CPC+ program – particularly for Track 2 participants.

eTransX  offers Comprehensive Primary Care Plus software and seeks to partner with practices applying to participate in the CPC+ Model Track 2 leveraging our comprehensive, modular XCare Community software system.

Our Comprehensive Primary Care Plus software offering  can act as a total solution or fill in the gaps for those products and/or services that you do  have.  Specific CPC+  Track 2 functions addressed by our XCare Community system (software-as-a-service) offering include:

  • Developing a personalized care management plan for patients with complex medical, behavioral, and psychosocial needs.
  • Managing referrals and services orders with community based service organizations to coordinate services for patients with complex needs.
  • Risk-stratifying practice site patient populations: identify and flag “patients with complex needs”
  • Capturing and tracking certified quality measures results at the practice level to support continuous feedback
  • Systematically assessing patients’ psychosocial needs and developing and maintaining an inventory of community resources and supports to meet those needs
  • Documenting and tracking patient reported outcomes
  • Developing and manage follow-up care plans for patients after discharge from emergency department (ED) or hospital stays.

Please call us today to find out more on how eTransX can help with your CPC+ initiative.

Richard Taylor 615 620 7524 –

Advanced Health Models: Healthcare’s Future?

By | Care Coordination, Population Health, Value-Based Care | No Comments

05-11-16  by Richard Taylor, Director of Business Development for eTransX Inc.


Recently,  the Advanced Health Model workgroup of the ONC’s Health IT Policy Committee issued their initial findings and recommendations*.  This workgroup, chaired by Paul Tang, MD, the chief innovation and technology officer at Sutter Health’s Palo Alto Medical Foundation, is charged with finding ways to facilitate the effective use of health IT to support and scale advanced health models.

Their findings and recommendations can be summarized as follows:

1.  Recognizing the significant impact of the social determinants of health

Providers seeking to improve individual health outcomes are increasingly acknowledging the reality that an individual’s health is shaped largely by life circumstances that fall outside the traditional health care system. An extensive body of research has shown that social, psychological, and behavioral factors, such as family support systems, stress, housing, nutrition, income, and education explain far more about an individual’s health outcomes than the results of medical care.

  1. Expanding the traditional medical “continuum of care”

The Advanced Health Platform (AHP) Workgroup recognizes that improving health will require a broad expansion of the traditional medical “continuum of care” to encompass all of the entities and individuals within a community that influence an individual’s health. The IT solutions and systems that are used to support a holistic approach across all of these entities must evolve as well to enable truly seamless services to the right individual at the right time.

  1. Defining a new  “Advanced Health Model”

The AHM workgroup has sought to describe a range of emerging, community-level interventions that strive to bring together clinical, social, psychological, and behavioral data to improve and to coordinate health across settings for individuals. In many cases, these Advanced Health Models start within the medical system but seek to bridge gaps with a wider set of relevant services. In other cases, these models may be driven by community-based organizations seeking to incorporate clinical services to meet individuals in their preferred setting, such as where the individual lives, or another community setting. Rather than prioritizing clinical outcomes dictated by the medical system, these models seek to drive sustainable health improvements by focusing on person-centered goals and priorities that matter most to the individual.

  1.  Utilizing technology to support Advanced Health Models

Selecting and implementing technology to support AHM models requires recognizing a wider  ecosystem of technology solutions beyond the traditional electronic health records system used in clinical care. In the clinical setting, these include technology applications that may exist outside the traditional EHR, such as care management modules and population health management and analytics applications,  as well as third-party services, such as those offered by health information exchange organizations. Meanwhile, organizations such as schools, food banks, and social services agencies that are focused on supports that are non-clinical in nature may have a wide range of software solutions that support case management. At the community level, technology platforms that link human-services information and deliver consumer education are also integral to improving health.

Advanced Health Models that bring together these disparate systems frequently rely on an additional layer of information management that can match, normalize and aggregate data to support individuals and inform targeted service provider decision-making.

An Ideal IT Platform for supporting Advanced Health Models

eTransX offers a robust IT Platform to support Advanced Health Models.  This platform is the XCare Community system a hosted software as a service application.   This platform was designed from the ground up to support a fully integrated care coordination solution that connects healthcare providers with community based social service providers.

For any organization seeking to implement an Advanced Health Model, the eTransX XCare Community system provides a robust IT platform that can be integrated with existing healthcare delivery systems already in place.


* Source:  Advanced Health Model Workgroup June 2, 2015 Hearing summary,  6/21/15