Question: Describe the EHR vision in the case study.

Davies Ambulatory Award Community Health Organization (CHO) Name of Applicant Organization: Community Health Centers, Inc. Organizations Address: 110 S. Woodland St. Winter Garden, Florida 34787 Submitters Name: Kim Barkman Submitters Title: Director of Clinical Informatics Submitters Email: k.barkman@chcfl.org Core or Menu Item: Core Case Study Clinical Outcomes/Patient Centered Medical Home Executive Summary: Community Health Centers Inc.s (CHC) mission is to provide quality and compassionate, primary and preventive medical, dental, and pharmaceutical services to Central Floridas economically and culturally diverse communities. CHC is a patient-oriented organization providing special assistance to the medically underserved, uninsured, and at risk populations of Central Florida. Established in 1972, Community Health Centers has built 11 medical and dental centers throughout several counties, serving 53,610 patients annually. In looking to the future for how to best provide and improve the quality, safety and efficiency of care within the organization, CHC turned their focus to the Patient Centered Medical Home (PCMH) model. The CHC Quality team then embarked on a journey to implement PCMH programs to support patient care planning, patient care coordination, chronic disease management and patient engagement. To achieve the outlined goals of becoming a PCMH, the team worked to establish processes for how to most optimally utilize the Electronic Health Record (EHR) to meet the patient centered standards for the delivery of primary care.

1 Background Knowledge CHC provides comprehensive services including medical and dental care, health education and promotion, health assessments and screening, pharmaceuticals, laboratory, and X-ray services. These services are provided by a combined total of 62 physicians, dentists, ARNPs, and hygienists that include providers who are board certified in Family Practice, Pediatrics, Obstetrics/Gynecology, Internal Medicine and Optometry. CHC has approximately 400 employees, with most based at the centers providing patient care, as well as administrative support teams. All provider disciplines and staff members utilize a single integrated EHR. The use of a single EHR at CHC allows for patient clinical care information to be collected, stored, managed, and shared across care teams and among providers. The requirements for achieving medical home recognition in accordance to the National Committee for Quality Assurance required that CHC meet the standards of: 1. Ensuring patient access to care during office hours and after. 2. Identification and management of patient populations through the utilization of data for disease management. 3. Documentation of patient care coordination. 4. Patient engagement. 5. Tracking and follow up documentation for labs and referrals. 6. Quality improvement reporting. Embedded in each of the 6 requirements for medical home recognition are elements that provide the baseline for how to best manage the patients needs. The following elements for patient centered medical home recognition are where CHC focused their attention related to the use of the EHR: Access to care during office hours and after hours. Patient access to electronic health information. Provide patients with an electronic copy of their after care summary. Documentation of planned care through pre visit planning. Identification of patients with important diagnoses and conditions in practice. Exchange clinical information among providers. Identification of patients with care gaps and care needs to send reminders for preventive and follow-up care to patients. E prescribing of medication. Computerized physician order entry of medication and labs. Tracking, flagging and follow up for labs, referrals and diagnostic imaging. Maintaining up to date and active list of patient diagnoses. Medication and drug allergy interactions. Clinical data reporting. Electronic chart documentation. Managing care coordination during care transitions.