Transforming Care Coordination for a Multi-Specialty Practice

The Challenge: Specialists Working Blind

A multi-specialty practice serving 45,000 patients across cardiology, endocrinology, and primary care was facing a critical coordination problem. Specialists were treating patients without access to their complete medical histories, leading to redundant testing, potential drug interactions, and missed opportunities for proactive intervention. The practice knew they were leaving revenue on the table but lacked the infrastructure to identify and close care gaps at scale.

The Breaking Point:

• Cardiologists couldn't access primary care visit notes
• Endocrinologists unaware of recent ER visits for diabetic patients
• No systematic way to identify patients needing chronic care management
• Manual record requests taking 7-14 days per patient

The MedSync Solution: AI + Clinical Expertise

Stream Health deployed an integrated solution that pulled comprehensive patient records from all available sources and subjected them to NP clinical review. The platform automatically flagged 12,000+ patients (63% of eligible population) as warranting gap-in-care analysis, routing them to appropriate care management programs.

What Made This Work:

• Complete Data Access: Records consolidated from 1,300+ sources including previous providers, labs, pharmacies
• Clinical Validation: Every summary reviewed by a licensed NP for accuracy
• Automated Workflows: Gap-in-care alerts pushed directly into existing EHR
• Zero Training Required: Seamless integration with current clinical workflows

The Transformation: From Reactive to Proactive Care

Within the first 90 days, the practice transitioned from reactive symptom management to proactive population health management. Specialists now had complete patient contexts at their fingertips, enabling more informed treatment decisions and closing critical gaps in care.

Financial Results:

• $2.1M new annual revenue from previously unbillable services
• 12,000 patients enrolled in RPM/CCM programs (63% of eligible population)
• $350 average reimbursement per gap-in-care analysis

Clinical Impact:

• Cardiologists identified 2,400 patients with uncontrolled hypertension requiring intervention
• Endocrinology prevented 180+ diabetic complications through early gap identification
• Primary care closed 5,000+ preventive care gaps (overdue screenings, vaccinations)

Operational Efficiency:

• 7-14 days → 48 hours: Time to obtain complete patient records
• 63% automation of care gap identification (previously 100% manual)
• Staff redeployed from records management to patient-facing care

Results based on anonymized data from a typical 45K-patient multi-specialty practice. Individual results may vary.