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Health IT Success Stories

NO/AIDS Task Force Uses EHR Data to Categorize Patients by Risk Level and Provide Better Care

"Use of HIT enables the practice to stratify and target patients based on disease-specific calculated risk score with an aim to engage patients meaningfully in their care and to achieve better health outcomes."

For over 29 years, the NO/AIDS Task Force (NATF) has offered a full spectrum of care at low or no cost to thousands of men, women, and families affected by HIV/AIDS in Louisiana. NATF customized its EHR system to include a care plan template and successfully harnessed the EHR system’s capabilities to organize its patient population by risk level, enabling the delivery of higher quality care.

Recognizing a Need for EHRs

During Hurricane Katrina, NATF realized the importance of having electronic access to medical records and in 2008 the Task Force secured funds to implement EHRs for its patients. Since then, NATF has progressively implemented changes to achieve meaningful use of its Electronic Health Record. In 2009, NATF clinic was recognized as Level 3 Physician Practice Connections – Patient Centered Medical Home by NCQA.

Continuous Quality Improvement (CQI) Committee Recognizes Need for Goal Alignment

As NATF was preparing for Meaningful Use, it was also seeking National Committee for Quality Assurance (NCQA) Patient Centered Medical Home (PCMH) 2011 recognition. The NATF CQI Committee determined it was necessary to integrate the different goals and objectives of obtaining Meaningful Use Stage 1 and PCMH 2011 status. To meet certain objectives, NATF applied for and received a Quality Improvement award from the Crescent City Beacon Initiative in New Orleans to develop innovative quality improvement approaches to address health care and decrease cost for its patients.

Using EHRs to Target Chronic Conditions

Upon receiving the grant, NATF periodically ran reports of patients with specific disease conditions and identified hypertension, diabetes, HIV and cardiovascular disease as conditions to target, develop risk stratification models for, and engage patients in their care through care plans at the population level.

Identifying High Risk Patients

Using patient vital sign data and clinical lab test results from the EHRs, NATF was able to give each patient a risk score, classifying them as low, medium, or high risk, for each of the targeted diseases. Currently, each disease has its own registry that displays a list of patients and their risk score in the EHR. By clicking on the ID number of an individual patient, a provider can instantaneously gain access to fields used in calculating the risk score and see a patient’s most recent labs and vital sign values. This gives the provider a better idea of why any individual patient is appearing on the disease-specific registry and helps inform the care plan.

Check-in personnel assist with the process of identifying high-risk patients by checking their risk score on the disease registries and making special note of them on providers’ schedules. This helps providers connect patients to Nurse Care Managers, who work with patients on health goal development and provide care referrals as necessary. Nurses are responsible for identifying medium-risk patients during regular visits by scanning the disease registries.

Identifying patients at increased risk has helped NATF provide the most appropriate quality care to its patients. For instance, in every quarter since the implementation of the risk stratification process, NATF has documented consistent performance above NCQA goals for the measurement of diabetic indicators.

Looking Forward: New Capabilities on the Horizon

As NATF continues to develop its risk stratification capabilities, it has plans to implement the following activities in the near future:

  • Include smoking status in risk calculation scores;
  • Train nurses to review the benefits of Aspirin use with identified at risk cardiovascular patients;
  • Use risk stratification models with Body Mass Index data to identify patients at risk and schedule them to meet with a nutritionist; and 
  • Generate provider specific patient lists organized by risk and disease.

Lessons Learned: Key Elements of Success

In reflecting on the program to date, NATF attributes its success to several factors:

  • Created and built custom business intelligence software based reports;
  • Trained CQI staff to use the business intelligence software system prior to developing risk stratification reports; and 
  • Designed the EHR system to include care plans.

NATF has found the ability to electronically organize patients based on risk to be incredibly helpful in improving healthcare quality. NATF notes that embedded risk stratification models within the EHR system will increase adoption and use to deliver better health care outcomes. The Task Force whole-heartedly encourages future research activities to develop effective risk stratification models for outpatient primary care clinics.