Physicians Leverage AI to Introduce Solution to Effectively Manage Chronic Disease and Hospital Readmissions

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EcoSoft Health and DSHI Systems have combined their expertise to create a smart solution that enables hospitals to improve patient recovery post-discharge and reduce costly readmissions.

Prevent Hospital Readmissions

Improve patient recovery post-discharge, and reduce costly readmissions

The real breakthrough was combining the power of a CRM application with physician-authored medical intelligence. This allows our customers to escape the pain of generating their own content to evaluate and manage poly-chronic patients.

EcoSoft Health and DSHI Systems jointly announce the immediate availability of Ecosoft Health PRM, a chronic disease and transitions of care solution for use by healthcare organizations. The product was engineered to unburden providers by empowering clinical staff to work at the top of their license. Care teams, care managers and patients all benefit from consistent and systematic follow-up.

The solution is powered by physician-written Artificial Intelligence for thirty-two of the top discharge diagnoses. This AI component is integrated into the EcoSoft Health PRM workflow engine to assess patients after care. Evaluations reveal patients whose status may be worsening due to chronic disease or a medical complication. Patient responses are monitored in real-time, and when a problem is detected, a notification is sent to the care team suggesting an intervention. A physician-written expert system synthesizes the medical history into a physician-friendly post-discharge follow-up note that includes clinical history, objective measures and a comprehensive care plan. This gives the care team more time so they can focus their efforts on providing care to those who need it most.

"This joint offering creates a best-of-breed solution for healthcare providers faced with the challenge of meeting CMS Readmission Reduction guidelines as well as positioning for value-based care models,” says Jay Fruin, founder and CEO of EcoSoft Health. “The EcoSoft Health framework and the proven DSHI Clinical Assessments enable providers to scale-up their post-care follow-up implementations across all conditions and care events.”

Assessments managed by EcoSoft Health PRM can be delivered by a medical assistant at point-of-care or over the phone. The web-based solution is designed to operate on both desktop and mobile devices.
EcoSoft PRM will:

  •     Guide a medical assistant to perform a comprehensive medical history for 49 conditions
  •     Score patients for readmission risk, disease control, and patient adherence
  •     Send notifications when an intervention is needed to avoid an unnecessary hospitalization
  •     Record the medical history in medical terminology and store it in a structured format
  •     Provide real-time dashboards to visualize patient status and trends
  •     Provide real-time dashboards to visualize population health and predictive analytics
  •     Provide a unique patient engagement tool for early symptom recognition and self-management

“The successful management of chronic disease and transitions of care requires both patient and provider engagement,” says Stephen Schueler, MD, President of DSHI Systems. “The traditional problem facing chronic care management has been discovering a way to engage providers without compromising their work flow. Working with EcoSoft Health, we have created a solution that provides actionable data in the form of a status report that can be quickly reviewed by the provider. The real breakthrough was combining the power of a CRM application with physician-authored medical intelligence. This allows our customers to escape the pain of generating their own content to evaluate and manage poly-chronic patients.”

About EcoSoft Health
EcoSoft Health offers a unique proprietary Patient Relationship Management platform that gives healthcare providers the flexibility to deploy customized digital patient engagement strategies in a variety of care settings. The software-as-a-service platform can readily adapt to use cases ranging from marketing to patient screening, on-boarding and surveying. Designed to stand alone or integrate with in-house systems, the platform is a cost-efficient and minimally disruptive addition to a provider's technology portfolio.

About DSHI
Founded in 1989, DSHI Systems is a physician led clinical content and technology company, headquartered in the heart of Florida's space coast. DSHI provides physician-written and peer-reviewed clinical content that empowers health coaches and medical assistants to be experts in the delivery of post discharge follow-up services and chronic care management.
Our mission is to improve the management of chronic disease, unburden providers, and reduce readmissions.
For the past 18 years, our solutions have been used by the Department of Veterans Affairs, hospitals, health systems, group practices, home health, and other healthcare organizations to provide valuable services to more than 50 million people.

DSHI Contact – Darin Southard, 404-386-2922, dsouthard(at)

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