Creating a Wellness-Focused Information Technology System to Enhance Patient Outcomes in the HIV Patient-Centered Medical Home Project

Principal Investigator: Marcia Alcouloumre, MD
St. Mary Medical Center Foundation

Patient-Centered Medical Home Demonstration Project
Awarded: 2010

St. Mary Medical Center Comprehensive AIDS Resource and Education (CARE) Program and Clinics seek to improve clinical and administrative processes and patient outcomes and satisfaction through the integration of software systems on several different fronts. The overarching goal of the program will be to produce a model health and wellness-focused electronic record system that promotes and sustains patient health, satisfaction, and retention in care while enhancing service access for patients. The program will create a replicable set of nine technology-based approaches for enhancing the patient-centered medical home that can be applied by other agencies in California to reduce fragmentation while allowing these systems to better support patient health, wellness, and self-management outcomes.

The nine enhancements are: 1) Combining and integrating CARE dental clinic records with the NextGen EHR system in use in the CARE medical clinic, including incorporating x-ray imaging hardware and software that will allow electronic storage and retrieval of x-ray dental images; 2) Creating a web-based portal to give home health nurses mobile access to the CARE EHR system while working with homebound HIV patients in the field; 3) Piloting a new messaging portal through which local HIV testing sites can alert CARE when a new HIV-positive client has been identified and referred to the agency; 4) Creating a patient computer kiosk in the CARE clinic waiting room which allows client to access their health records and complete quality-related assessments while waiting for appointments; 5) Piloting a computer interface that allows the St. Mary Emergency Room to access patient information for CARE medical clinic clients when they enter the ER; 6) Deploying a password-accessible patient portal in NextGen that allows clients to access medical information from their own computers, or from computers based at the CARE medical clinic; 7) Incorporating CARE’s intake and case management programs into the NextGen system; 8) Creating an electronic interface with the LA County Casewatch system, the region's mandated Ryan White reporting platform which does not currently have an automated upload interface with any EHR in the region; and 9) Piloting a computerized pharmacy interface that enables CARE to ascertain when a critical client prescription has not been filled. Together, these enhancements are expected to improve patient health, increase patient and staff satisfaction, improve retention in care and treatment, and improve linkage to care. The first six enhancements will be implemented during the first program year and the remaining three enhancements will be carried out in program year two. All of the enhancements will be monitored, tracked, and refined in collaboration with the multi-site evaluator.