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U.S. Department of Health and Human Services
Health Resources and Services Administration
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April's Quality Improvement Grantee Spotlight

"The El Rio Community Health Center Uses Health IT to Address The Care of Chronic Conditions in Health Centers"


El Rio Community Health CenterEl Rio Community Health Center Service Site

This month, HRSA’s Quality Improvement (QI) Website highlights the work of El Rio Community Health Center. El Rio, a Bureau of Primary Health Care (BPHC) grantee, uses electronic medical record (EMR) - based clinical reporting tools to improve patient follow-up for preventive services. El Rio’s clinical reporting tool targets patients with chronic diseases for preventive services such as blood pressure checks, flu shots and HbA1c testing. Adhering to these preventative services is critical in helping El Rio patients manage their chronic conditions.

El Rio Community Health Center

Since 1970, El Rio Community Health Center (CHC) has been providing accessible and affordable healthcare to underserved populations in the greater Tucson area.  El Rio has become one of the largest non-profit, community health centers in the United States, serving over 1,000 people per day, with more than three quarters of its patients living at or below the federal poverty level. El Rio provides care to all populations serving a large proportion of Hispanic or Native American patients.

The Importance of Addressing Chronic Diseases

Chronic diseases—such as heart disease, cancer, and diabetes—are the leading causes of death and disability in the United States and account for 70% of all deaths1. Chronic diseases cause major limitations in daily living and can negatively affect quality of life and threaten the ability of older adults to remain independent. Among baby boomers, more than 37 million – or 6 out of 10 – are expected to be living with two or more chronic conditions by 2030. According to HHS Secretary Kathleen Sebelius,“Prevention activities can strengthen the nation’s healthcare infrastructure and reduce healthcare costs”2.

How El Rio Uses EHR Data to Improve Chronic Illness Care and Promote Prevention

El Rio has initiated a quality improvement project that utilizes an EMR reporting tool to identify patients due for follow up or preventive services. The goal of this project is to increase the number of patients with chronic illnesses such as diabetes, hypertension, and asthma who are receiving timely follow up care or routine screening.

Currently, sixteen sites are participating in this project. Medical informatics personnel work with providers and clinical management teams at each site to develop the criteria for patient identification such as diagnosis and lab results. The electronic medical record can then be programmed to generate reports for patients needing follow-up. Throughout the process, providers are asked for their input to help strengthen the process.

The generated reports identify patients who are due for follow up or preventive services, based on established guidelines for chronic disease management. These patients are then invited to schedule an appointment. Clinic staff track patients who do not respond to these outreach efforts and utilize Community Health Advisors for additional follow-up. To date, this population management quality improvement project has been used to support better care coordination for the following conditions:

  • Diabetes
  • Hypertension
  • Asthma
  • Breast cancer screenings
  • Cervical cancer screenings
  • Well Child Visits
  • Dental Cleanings
  • Colon Cancer Screenings (for the Fit at Fifty Program)

During a patient’s appointment, standards of care adopted by El Rio help to ensure that all health maintenance measures are addressed. For example, during a pediatric well child appointment, any immunizations that are due or overdue will be administered as appropriate.  In the case of women’s wellness visits, referrals are issued for mammograms, PAP testing and colonoscopies based on the woman’s age and standards of care.

Not only has El Rio achieved its primary goal of improved patient follow-up and preventive screenings, it has also been successful at improving patient health outcomes. As a result of its quality improvement efforts, the proportion of patients with controlled diabetes has increased significantly since the introduction of the population management reporting tools project. El Rio has also used the reporting tools to identify asthma patients who qualify for a grant program which provides home visits, free vacuums with HEPA filters, an air purifying system, and special bedding.

                        Quality Improvement in the EMR-based Reporting Tools Project

                     Figure 1: Quality Improvement in the EMR-Based Reporting Tools Project

The El Rio development team has established an electronic scorecard which clinical leadership utilizes to see how well providers are doing regarding specific initiatives such as EPSDT for pediatric patients and breast and cervical cancer screenings for women. The scorecard allows clinics to track progress on quality measures specific to organizational goals including patient experience, immunization status, and chronic disease management. The EMR-based reporting tools have also played an integral role in helping El Rio achieve NCQA recognition exit disclaimer as a Level 3 Patient-Centered Medical Home.

For more infomration, e-mail Mr. Robert Thompson, Chief Information Officer - El Rio Community Health Center.