In November 2019, the AMA and NCMS began a collaborative effort on diabetes prevention in NC, which was also part of a larger multi-organizational effort, Diabetes Free NC. The collaboration between AMA/NCMS was directed at physician education and outreach, and increasing physician referrals to diabetes prevention lifestyle change programs. These programs are offered virtually through NCSU and in-person at YMCAs, independent pharmacies and local health departments. Referrals could be sent using several modalities; The NC DPH Navigator, NC Care 360, NCMSF OCHI Platform or direct referral.
Our Community Health Initiative endeavors to form a coalition that fosters single source collaboration between Community Based Organizations (CBO’s) currently providing services that improve health, with local healthcare providers and social support networks. OCHI leveraged its core IP as a certified EHR to offer features no other DDP workflow product could deliver. NCMS, along with partner CBOS worked closely with OCHI to create a customized platform that served, not only to manage the DPP program, but the participant’s schedule and progress assessments. In addition, OCHI enabled the bidirectional transfer of data which provided efficient communication between referring providers and the CBOs. Specific value was experienced for providers wanting to refer from their practice EHR and CBOs electronically sending progress assessments back to the providers EHR
OCHI, LLC (OCHI) is a North Carolina based software company that has designed and operated Intellectual Property (IP) for patient care management workflow automation. This IP has been developed using a certified EHR patient management system developed by the OCHI principals (the “Chart(x) EHR”), and then configured for several Use Cases (Use Cases) that include Chronic Care Management and a solution for linking community-based organizations with referring physicians for provision of care management related services. OCHI has also created a Use Case for management of patients requiring Behavioral Health Integration Collaborative Care (BHI CoCM).