Tracking patients between visits: A new health care model

Troy Parks , News Writer

As the health care system transitions to value-based care, new models of care will be a critical part of the new Medicare payment system. Learn how one physician is using a new model of care to track patients in between face-to-face visits in his practice.


Imagine your patients, as you probably do every day, out in the world living their lives. You may wonder if their treatment is working, their medication is causing any side effects, their blood pressure is rising or any number of possibilities that could be percolating unknown—but you can’t find out until they come in for their next visit or call your practice or head to the hospital with an emergency.

“Patients are like submarines … out there submerged,” said Lawrence Kosinski, MD, a gastroenterologist and founder and chief medical officer of SonarMD. “We can’t see them; we don’t know how they are [because] they only come in when they’re in trouble. Which means that, number one, they have to recognize that they’re in trouble and, number two, realize that they can’t fix it themselves …. So we need a sonar system to ping them.”

Two years ago, Dr. Kosinski created SonarMD, a web-based platform that pings patients once a month with a set of validated questions, which allows his practice to get out ahead of any complications or progressing medical issues before an emergency occurs. And his practice has been using it since June of last year.

Dr. Kosinski led the development of an initiative known as Project Sonar, which is an intensive medical home for the management of Crohn’s disease created in partnership with Blue Cross Blue Shield of Illinois. SonarMD is the platform that coordinates with their electronic health record (EHR) system to help identify emerging health issues before they result in hospitalization.

“What we’ve created is a sonar system that pings patients in between their face-to-face visits,” Dr. Kosinski said. “One of the main issues that results in high complication rates in the patient population is that they don’t recognize they’re deteriorating when they’re deteriorating. They don’t call the physician; they don’t reach out for help, and bad things can happen to patients in the long-run.”

“If we ping them in between visits with a structured set of questions,” he said, “we get to intervene before anybody realizes things are getting bad.”

Working with Blue Cross Blue Shield of Illinois, Dr. Kosinski’s practice enrolls all of their inflammatory bowel disease (IBD) patients in SonarMD. “[The insurer] pays us a monthly management fee for these patients, and part of that payment goes to the medical practice, and part of the payment goes to SonarMD to manage the platform [and] the data,” he said.

The patient has an initial enrollment visit, and a nurse care manager works with the patient to set up an action plan for the goals they want to accomplish. “We assess barriers to attaining those goals,” Dr. Kosinski said. “It creates a team-based approach of physicians and nurse care managers interacting with patients.”

The pings go out automatically on the first Monday of every month with a set of questions to identify and track symptoms and developing conditions. It takes patients about one minute to answer all of the questions, and SonarMD calculates a “Sonar Score.” If the score is rising, that means something may be wrong, and the nurse care manager coordinates with the physician to contact the patient or bring the patient in for a visit.

Since they began using the SonarMD platform, Dr. Kosinki’s patients have responded at a rate of approximately 80 percent. 

“We built parameters into an algorithm so that the scores change colors at certain levels,” he said. If the physician needs to be brought in, the nurse care manager goes into the EHR and sends a message to alert the physician that a patient’s score is rising. The nurse care managers monitor about 100 patients each.

“We’ve demonstrated a 10 percent decrease in cost of care in these patients over a year,” he said, “driven largely by a 50 percent decline in inpatient costs. So we’re keeping them out of the hospital, we’re keeping them healthy, we’re keeping the costs down, and the patients are happy.”

SonarMD started with IBD patients, but Dr. Kosinski and his colleagues have expanded it to irritable bowel syndrome and are now working on expanding it to End Stage Liver disease and Gastroesophogeal Reflux disease. “Our goal is to be able to handle over 50 percent of the encounters for a gastroenterologist so we can actually function as an alternative payment model (APM),” he said.

Making sure that SonarMD fits into the new payment system as a qualified APM is a challenge, he said.

“We’re trying very hard to do everything we have to stay in the game,” Dr. Kosinski said, speaking as a member of the governing board of the American Gastroenterological Association. “It’s very important that we are part of the solution to the problem.”

Listen to a podcast interview with Dr. Kosinski, and watch in the coming weeks for an interview with Robin Zon, MD, who will discuss her oncology APM and MACRA.