South Cove Community Health Center Uses Electronic Health Records to Increase Patient Follow Ups

Leads to Increased Cancer Screening and Better Diabetes Management

The nation’s 62 Regional Extension Centers (RECs) have helped hundreds of thousands of health care providers, doctors, health clinics, and small rural hospitals across the nation learn the best practices for implementing and using electronic health records, or EHRs.  Working closely with partners in their cities and towns, RECs are helping drive innovation by assisting healthcare providers to spur practice transformation and provide better health care to their patients.

The REC at the Massachusetts eHealth Institute at MassTech (MeHI) External Links Disclaimer helps eligible providers in Massachusetts implement EHR systems and achieve meaningful use. MeHI has partnered with 3,051 primary care providers to adopt, optimize and transform their practices using health IT tools.

One example is the South Cove Community Health Center, a Federally Qualified Health Center (FQHC), which implemented an EHR interface with their lab vendor at Beth Israel Deaconess Medical Center (BIDMC), with the guidance of the Massachusetts League of Community Health Centers, and through funding provided by MeHI and ONC. South Cove’s work is a great example of what can be accomplished to improve health, health care and control costs when an EHR is used. In 2009, South Cove successfully transitioned entirely from a paper system to an exclusive electronic system using their EHR. South Cove uses its EHR to better track patient care by identifying those patients that are due for follow-up and wellness visits. It also closely tracks high-risk patients, which is often an arduous and time-consuming task.

From 2012-2013, South Cove saw a dramatic increase in the number of colorectal cancer screenings, thanks in part to a new reference lab interface to their EHR. The new interface helped drive increased screenings for patients between the ages of 51 to 75, from 58 to 73 percent.  While the initial goal was to broadly improve their internal Quality Assurance and Quality Improvement program, these results were a welcomed byproduct of their newfound ability to keep tabs on patients through the EHR interface and drive outcome improvements.  Their reporting requirements changed in 2012 to include three new measures, including colorectal screenings.

Due to this new EHR interface, South Cove staff is able to receive real time numeric and text based results directly into the patient’s progress note. For example, if a pap smear or an in-house colorectal screening comes back positive or abnormal, the staff can see this information flagged as ‘Abnormal‘ in the lab section of the EHR. The provider can then proceed with the appropriate treatment and ensure that the patient returns for follow up visits. Having an interface that submits results directly into the EHR makes it easier for South Cove’s quality improvement team to accurately track what follow up was ordered, when it was ordered, if the result came back, or if an issue exists with the lab sample or in  scheduling.

South Cove also increased diabetic control in 2,900 of their diabetic patients from 73 to 79 percent over the same timeframe through the use of the new electronic interface. This technology brings several benefits for the tracking of diabetes care, including:

  •  All numerical results are now part of the patient note, with abnormal or large A1C difference results flagged in the EHR;
  •  The interface breaks up the last category of 9.0%+/no test and allows for a report to run for patients with no test A1C; and
  • South Cove can keep track of patients who are ‘high-risk’ diabetics in real time, because they can sort and analyze the data and spend more time on those diabetic patients with A1C > 9.0%.

In short, the electronic lists generated by the system are much more accurate and actionable with numerical data than they were in the past.

Through ONC’s and MeHI’s efforts, health care providers and FQHC’s like South Cove are provided with the financial resources and support services which help them move them from paper-based medical record systems to a certified EHR. By adopting an EHR, these providers have been able to improve workflow efficiencies and care coordination, deliver higher quality care to patients, and reduce health-care costs.

To further achieve these goals, South Cove’s next step is to become a full participant in the Massachusetts Health Information Exchange (HIE), called the Mass HIway, which will allow them to share electronic information among health care partners statewide. “Participating in the HIE should make it much easier to collaborate with other agencies in terms of electronically receiving results, imaging, screenings, and progress notes into our EHR. This will really complete the journey of going paperless and allow our providers to have access to important information that might change the way they treat the patient,” stated Brook Hailu, South Cove’s quality improvement program manager.

Massachusetts’s REC will continue to offer a variety of programs and services designed to help clinical providers transition into a practice that meaningfully uses EHRs and facilitates practice transformation.

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