Mind the Gap: Improving Care Delivery and Patient Outcomes

Background/Purpose: Health care delivery requires an illustration of high quality and low cost. Addressing care gaps historically relied on physicians with highly variable processes and inconsistent results. In our organization, solutions were implemented on a one-off basis, effectively impacting at most three metrics per year. There was a need for a standard system to track and improve care delivery. The first step of the process was to identify an accurate source of truth in the electronic health record (EHR) that would capture cancer screening (i.e. breast, cervical, colon), disease screening (i.e. diabetes, abdominal aortic aneurysm, Hep C, HIV, chlamydia), and vaccinations. Our quality program strongly endorsed the use of Health Maintenance (HM) module in the electronic health system (i.e. EPIC) as the single source of truth for preventive care. At the beginning of 2017, the HM module was greatly underutilized by the physicians and staff. The goal of the project was to have physicians and staff use the HM module to close quality care gaps. The campaign was called “Mind the Gap” and it consisted of two phases. Phase I of the project was to have the care team learn to use the HM module and Phase II was to increase and optimize the use of the HM module.

Implementation/Methods: The HM module is a preventive care tracking tool in the EHR. Using the module, clinicians can track immunizations and routine screening tests or manage patients with chronic diseases. When a patient becomes due for preventive care, the system can notify the clinician and the support staff. Such notification can appear in the patient header, snapshot screen and other reports, multiple provider schedules, and the HM activity. The Informatics and Technology team constantly update the HM module to align with guidelines from the Centers for Disease Control and Prevention (CDC) and other health agencies.

Results: The Mind the Gap program was designed to leverage the HM module to improve care delivery. The HM module was used as a standard system to track preventive care items that may be due. The EHR provided an e-learning tip sheet and the quality team created a data entry process to train physicians and staff to use the new system. Clinic staff was leveraged to support providers in documenting previous immunizations and screenings. Data feedback helped shape conversations around best practice interventions and ways to improve performance. The process is refined based on what is working in the clinics through continuous quality improvement efforts.

Evaluation/Outcomes/Conclusion: When it comes to achieving optimal health, research shows that following preventive care guidelines for vaccinations, disease screenings, and cancer screenings are the best way to get there. In the past year, the primary care clinics have closed nearly 270,000 health maintenance and preventive care gaps. Creating a culture of continuous improvement had taken time and great effort from the leadership, staff, and providers. Our team has utilized data analytics and care team engagement to improve care delivery and patient outcomes.