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How Do Electronic Health Records Benefit Chronic Care Management?

For years, patient health data was siloed. Patients and providers had to navigate a jumble of notes, prescriptions, and paper files, all scattered across various physical locations, making it difficult to get a complete, up-to-date picture of a patient’s health. This fragmented system posed significant challenges—especially for patients with chronic conditions who require ongoing, coordinated care among multiple providers. 

Electronic Health Records (EHRs) changed that. Now, providers and patients benefit from healthcare technology that supports a coherent patient health story across healthcare settings. EHRs centralize patient information and enable seamless communication so that every provider involved in a patient’s care has access to the same, real-time data. This connectivity is essential for Chronic Care Management (CCM), where effective coordination can mean the difference between proactive interventions and unaddressed gaps in care.

For providers, EHRs make it easier to trace the root cause of an issue, avoid errors, notice important trends, and find key information quickly and reliably. For patients, access to a digital health record means more autonomy, access, and participation in the care delivery process.

EHRs facilitate timely, coordinated, and patient-centered care, making them indispensable for managing chronic illness. In this article, we’ll explore the key functions and benefits of EHRs and their role in CCM.

What are Electronic Health Records (EHRs)?

Electronic Health Records (EHRs), also known as Electronic Medical Records (EMRs), are secure digital systems that store and manage comprehensive patient health information. They replace traditional paper-based records, improving continuity, accuracy, and accessibility in healthcare.

EHRs typically include:

• Patient demographics
• Medical history, diagnoses, and CPT codes
• Allergies, immunizations, and medications
• Vital signs and treatment plans
• Provider notes and condition information
• Insurance details and billing codes
• Lab results, imaging, and scheduling
• Appointment history 
• Patient communication tools

EHRs serve as a single source of truth for a patient’s health history and treatment, accessible to both providers and patients. 

Until 2009, EHR adoption was not common. The HITECH Act mandated the widespread implementation of technology in healthcare, including EHRs. The 21st Century Cures Act (Cures Act) furthered the push toward EHRs by promoting healthcare technology interoperability through standard Application Programming Interfaces (APIs). Today, nearly all acute care facilities and most office-based physicians have adopted an EHR. 

By centralizing health data, EHRs enhance communication among providers, reduce errors, and improve patient care.

Why an EHR system is essential for Chronic Care Management

Chronic Care Management is a preventative care program that provides ongoing, monthly care to patients in between appointments. Every month, a care coordinator reaches out to patients to help with appointment scheduling, medication refills, care plans and health goals, and community resources. CCM also includes a 24/7 care line for patients to ask health questions any time of day. An EHR system is essential for CCM for several reasons. 

CMS requirements and interoperability 

The Centers for Medicare & Medicaid Services (CMS) requires clear documentation of care in a certified EHR, reflecting the agency’s broader push for healthcare interoperability. Seamless data exchange between providers ensures that patient information is accurate, up-to-date, and accessible across care settings. 

This is particularly critical for CCM, where care coordinators as well as multiple providers may be involved in a patient’s care. Without an EHR, care teams risk working with incomplete or outdated information, which can lead to medication errors, duplicate tests, and gaps in treatment. 

Facilitating seamless care coordination 

EHRs play a central role in care coordination by keeping all providers informed and aligned. Without an integrated system, patients with chronic conditions may experience delays in treatment, conflicting prescriptions, or missed interventions.

EHRs consolidate data from multiple providers, ensuring that all care team members have real-time access to diagnoses, medications, and treatment plans. With built-in scheduling, task management, and automated alerts, EHRs help providers follow up with patients, track adherence to treatment plans, and schedule necessary check-ins.

Care coordinators can then access information from the EHR to determine which gaps in care, newly diagnosed conditions, prescriptions, or appointments they need to address with patients. 

Improving patient outcomes and reducing costs

A primary goal of CCM is to reduce unnecessary hospitalizations, lower healthcare costs, and improve long-term patient health. EHRs actively support these goals by enabling proactive interventions and continuous monitoring.

Many EHRs include patient portals, allowing individuals to access their medical records, track prescriptions, and communicate with providers—leading to greater involvement in their own care. Care coordinators also document non-face-to-face CCM services, such as care plan adjustments, patient education, and 24/7 access to support, so providers are aware of the care their patients have received and can incorporate it into the EHR if desired.

Seamless collaboration with CCM providers

An EHR also supports seamless collaboration with a Chronic Care Management provider, like ChartSpan. A CCM partner must have data-sharing capabilities with your EHR to ensure important patient information isn’t missed. At ChartSpan, we regularly share patient updates with our providers’ EHRs. 

For example, the medical record might indicate that a patient is taking a certain medication, but during a patient check-in, our care managers discover that the patient is no longer taking the medicine as directed. ChartSpan’s ability to share this information directly with athenaOne, Epic, or another EHR helps to close gaps in care and keep data current. 

7 benefits of Electronic Health Records for CCM

EHRs streamline workflows, improve care coordination, and enhance patient outcomes. They serve as the foundation of an effective CCM program, making it easier for providers to document care, track patient progress, and ensure compliance with CMS requirements. Here are seven key benefits of using an EHR for CCM.  

1. Improves care coordination 

Patients with one or more chronic illnesses often require a multi-faceted care approach with multiple providers. CCM supports this collaborative care model, even considering Social Determinants of Health (SDOH) and social services in its holistic view of preventive care. An EHR system offers a central hub for providers to access and update patient information, reducing gaps in care and improving care coordination. Any CCM documentation can also be stored in the EHR. 

2. Supports patient self-management 

A key tenet of the CCM model is empowering patients to become active participants in their health. EHRs support patient self-management by offering transparency. At any time, patients can access data related to diagnosis, treatment plans, test results, and upcoming appointments in a convenient and secure digital format. By putting this comprehensive health data into patients’ hands, they gain the tools to manage their conditions effectively, make informed decisions, and escalate health changes or concerns in a timely manner. 

3. Streamlines documentation 

An EHR offers a central repository for important health information. ChartSpan, for instance, can integrate directly into EHRs like Azalea Health and eClinicalWorks, among others, ensuring that any documentation required for CCM is reflected in the patient’s digital medical record. Clear reporting is not only beneficial for patient care coordination, but it’s also a CMS requirement for Chronic Care Management. 

4. Illuminates health trends 

Disjointed, analog patient reporting made it difficult to spot patterns, but EHRs have changed that. A complete and accurate record of patient data, all in one accessible location, makes the data analysis and visualization features of an EHR powerful. For patients experiencing one or more chronic illnesses, this function is especially beneficial. Spotting irregularities or changes to patient health and intervening early can help reduce acute events—a core goal of CCM. For example, a spike in A1C for a patient with diabetes or blood pressure for a patient with hypertension draws helpful attention in an EHR. Care coordinators can address the issue with patients and help them adjust their health goals to better manage their condition. 

5. Facilitates care planning 

Personalized care plans are essential for CCM. One of the core benefits of an EHR is that crafting an evidence-based treatment regimen, based on a patient’s unique conditions, is easier when all the data you need is easily accessible. EHRs can also help implement care planning, by alerting patients to upcoming screenings, needed medication refills, and other timely preventive care. Care coordinators can assist patients who aren’t comfortable logging into an EHR patient portal by following up on screenings, refills, appointments, and other care via phone or text. 

6. Supports accurate billing

EHRs help providers bill care correctly. The patient record serves as evidence of exactly which services were delivered, when, and by whom. Having a digital ledger of care also helps to prevent coding errors that often occur via manual data entry. Many EHRs can automatically apply certain billing codes, making it easier and faster to be reimbursed for services, including CCM. Some CCM vendors, like ChartSpan, can also send accurate CCM claims to the practice, so the practice can simply review and submit them. 

7. Improves patient communication 

Chronic Care Management hinges on regular contact with the patient. A digital health record offers a channel for patients to connect with providers and receive helpful education and other communication that supports their care. Features like patient portals and secure messaging make back and forth between providers and patients nearly frictionless. This is particularly important for high-risk patients with chronic conditions and supports the CCM requirement for 24/7 access to care. 

Extract more value from your EHR for CCM with ChartSpan

With direct integrations to many popular EHR systems, ChartSpan helps providers leverage their Electronic Health Records to benefit Chronic Care Management. Our tech-enabled approach embraces both the power of innovations like EHRs and the human connection of a dedicated care manager for patients with chronic illnesses.  Explore our Chronic Care Management services to learn why our partners trust us to support CCM in their healthcare practices. 

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