Community Health Record

Connects health plans, providers, and community-based organizations via a common shared longitudinal health record.

VALUE

Comprehensive, longitudinal view of information from a variety of medical, behavioral health, and social data sources

include the broader clinical, social and behavioral health team

Meet CMS interoperability requirements

DIFFERENTIATORS

Integrated with key data sources for health information including SDoH and unique data sources, including jail and housing data

Provide access to the entire care community on single platform with SSO integration to EHRs and other systems

Role-based community health record dashboards

Support for interoperability requirements and data exchange

Integrate, exchange and visualize comprehensive health information across the community

Features

  • State-of-the-art infrastructure to support standards-based and custom information exchange
  • Role-based views
  • Comprehensive integration of information across medical, behavioral health, social and other data sources for unique 360-degree insight
  • Advanced EMPI to ensure proper matching of information across data sources
  • Validation and clean-up of data quality
  • Tools to continuously monitor quality of interfaces
  • Comprehensive protected health information framework to manage and audit access to sensitive and protected information
  • Configurable workflows to manage patient consent requirements and workflows
  • Shredding of document-based information into structured fields to support advanced analytics

What our Users Say

Case Study:

Integrated community health record supports transitional case management and connects residents to community-based sources of care

Health care providers are using SyntraNet's Community Health Record to systematically and equitably identify homeless individuals residing in Safer Ground hotels who need intensive clinical care and case management. Leveraging the SyntraNet Community Health Record, they achieved the following outcomes measured over eight months between Oct 2020 and June 2021.

Connect residents to care

  • 105 residents enrolled in Medi-Cal (nearly 100%)
  • 100% of residents were assigned primary care provider or medical home
  • 51 residents enrolled in personal care services
  • 28 residents enrolled in the health homes program
  • 12 HIV/Hep C positive residents connected with their HIV/Hep C care team

Identify and address gaps in care

  • 692 comprehensive assessments completed
  • 30 advance directives completed
  • 240 flu vaccinations administered
  • 259 VODs completed
  • 1310 COVID tests completed
  • 600 COVID vaccinations administered

Avoid unnecessary utilization

  • <10% of ER visits attributed to ambulatory sensitive conditions
  • Prevented ~ 150 ambulatory-sensitive ER visits

SyntraNet's Integrated Community Health Record helpsĀ organizations meet CMS interoperability requirements

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