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Health Information Technology (HIT) and Data to Inform Quality Improvement (QI)

Zufall has utilized an electronic health record system (EHR) since 2009. In the past three years, the health center has continued to expand its HIT infrastructure and capacity to address the needs of patients and the organization. Zufall has enhanced its eClinical Works (ECW) EHR system by expanding and upgrading servers and backup systems, purchasing the updated version of ECW and adding dental.

All Zufall providers, including behavioral health providers, use the electronic record for all charting and to share information contained in the medical records. ECW’s patient portal is available to all patients enrolled in the center and automatic appointment reminders through texting and voice mail has been successfully implemented.

Physicians, clinical staff and providers obtain access through ECW and the internet to “Uptodate,” a decision support application that provides real-time access to guidelines on diagnosis, therapy and patient education by condition. Clinicians also have access to the state’s Prescription Drug Monitoring Program via web-based applications.

Zufall has access to local hospitals’ patient portals, and our providers and case managers are able to view patients’ records. However, Zufall and its partner, Saint Clare’s Hospital mental health service, do not have a fully integrated medical record and are not yet able to electronically exchange information.

The data obtained from the EHR and behavioral health clinicians is analyzed and used to make primary care decisions and screening/preventive health plans on an individual basis. Patient specific data is used to focus services via the van or the health center visit. Since 2013, we have seen improvements in hypertension and diabetes control, and in cervical cancer screening rate in the cohort of patients colocated at Saint Clare’s behavioral health programs.

As part of the Accountable Care Organization (ACO) reports, we receive a high-risk list of Medicare recipients who were recently admitted to the hospital, have high-risk conditions or are high utilizers. We use this information to target interventions to improve their outcomes.

General QAPI activities at the center focus on more than 20 clinical measures and outcomes. Zufall includes behavioral health patients in the population health reports that are submitted to its funders, the federal government and accrediting organizations. Examples include universal depression screen and referrals, SBIRT rates, BMI and counseling on nutrition and physical activity, tobacco use screening and cessation counseling, cervical and colon cancer screening, hypertension and diabetes control, among many others.