Medicine still depends on what happens between a provider and a patient. That hasn’t changed. What has changed is everything built around it: thousands of clicks, each one tied to a field, a measure, or a payer rule, and all of them competing for attention during a fifteen-minute visit.
Nobody can hold all of that in their head and still give the patient their full attention. We don’t think they should have to.
Start with the whole record
Certified EHRs are required to make patient records available through a standard format called FHIR. That matters more than it sounds, because a patient’s history stops being trapped in one visit’s screen. We can read the problem list, medications, results, and notes as a whole.
That’s how we catch the things no one has time to catch. A chronic condition may have been coded last year and not this year. A diagnosis may be coded less specifically than the chart supports. Either one can cost you the credit for the chronic disease care you are actually providing.
Suggestions, not automatic codes
Here’s a number that got our attention. When we first checked one practice’s billing against the ACO’s list, in early October 2026, only 6% of the dropped chronic condition codes had been recaptured.
The tempting fix is to add the missing codes automatically. We don’t do that, and we won’t. A list from last year is a memory, not a diagnosis, and coding a condition the note doesn’t support is exactly what risk adjustment audits look for.
So for each coded visit, we check the patient’s suspected diagnoses against that visit’s note. We only surface a suggestion when we can quote the words in the note that support it. The biller and the provider see the quote and make the decision. If the note doesn’t support the code, the code doesn’t go on the claim.
Those open conditions also appear on the prep sheet before the visit, which is the better place to catch them. If the provider addresses the condition with the patient, the documentation takes care of itself.
Getting the patient in, without burying the front desk
A chronic condition can only be recaptured at a visit, so the patient has to be on the schedule before the year ends. But handing a front desk more than a hundred new calls in one morning doesn’t get them made. It just gets the list ignored.
So we pace it. The calls go out only on days the physician isn’t in the office, when the front desk has room to make them. No more than 10 are added in a day, and open hospital discharge calls count against that 10, because those patients come first. Medicare patients are called first, then the patients with the most open conditions. If a patient already has a visit booked, no call is added, because the prep sheet carries the conditions into that visit. And when a visit gets booked, by anyone, the call closes itself. If that visit is cancelled, the call comes back.
Your staff get a list they can finish, and we can track how many of those conditions actually get coded.
A panel beside the note
We built Odin’s Chrome extension because a provider shouldn’t have to leave the note to get this help. It opens in the browser’s side panel, next to the note they are already writing. It runs beside Tebra today, with athenaOne and OpenEMR versions in progress. The panel itself is a small piece, because the real work is the data we pull out of the EHR and make available at the moment it’s needed.
- Before the visit: The panel shows the patient’s prep sheet, including what’s open and what to address. Anything can go into the note with one press, and items the note already covers are dimmed.
- While writing: If a note mentions an injection, the panel brings up the questions that documentation needs, fills in what the note already says, and offers recent lot numbers to tap.
- Before signing: It checks for what’s easy to miss, like a follow-up with no interval, a plan line cut off mid-sentence, or a next step that never made it into the Plan. It also catches dictation errors, like a drug name misheard or a blood pressure of 1122/68.
Some corrections can be fixed with one press and undone just as quickly. The rest are pointed out and left to the provider, because it’s their note.
Working with the EHR you have
Not every EHR has a discrete field for every measure, and not every practice has a template for everything. So the goal isn’t to make everyone document the same way. Free text, a template, or a dedicated field can all work, as long as the information ends up where it will count.
The reason for all of this is simple. If the software is keeping track of the measures, the fields, and the rules, the provider can keep their attention on the person in front of them.
This is the last post in a series. Start with why you can’t close a gap you don’t know is open, then read about the fax that closes a measure.