June 23, 2026
Community-based clinics increasingly screen patients for contextual factors such as food insecurity, housing instability and transportation challenges because these factors affect how well patients can manage chronic conditions like diabetes and hypertension. As community clinics collect more of this information, a key question has emerged: Can electronic health record tools help care teams use data on patient-reported, nonclinical drivers of health outcomes to make meaningful adjustments to patient care?
New research from OCHIN suggests the answer is yes — at least in part.
“The trial showed that EHR tools can help clinic staff remember to ask patients about contextual factors that might make it harder to follow care plans,” said Rachel Gold, PhD, one of the study’s lead investigators. “Asking patients about these factors can lead to improved chronic disease management, though staff may not always document care adjustments that were made.”
Study examines EHR decision support in practice
The Contextualized Care in Community Health Centers’ Electronic Health Records (COHERE) study, conducted from 2021 to 2025, was a pragmatic clinical trial that developed and evaluated EHR-based tools to target care for patients with uncontrolled blood pressure or diabetes in six OCHIN network clinics, with 20 additional sites serving as controls.
Researchers co-designed the tools in partnership with community clinic staff. An advisory board of clinicians and staff from OCHIN clinics iteratively developed the tools, providing input on content and how they appeared in the EHR. The tools were then piloted for one year in three OCHIN clinics and extensively revised based on user feedback.
The revised tools were designed to increase screening for contextual factors influencing health outcomes, improve documentation using Z-codes, identify barriers to medication adherence and support documentation of care plan adjustments made in response to those factors, such as medication selection and follow-up scheduling.
Overview of the COHERE study EHR tools
| Tool | Tool Overview | |
|---|---|---|
| Alert to screening patients for nonclinical drivers of health outcomes | Reminds staff to screen patients for nonclinical drivers of health outcomes if the last screening was conducted more than 12 months ago or never conducted. | |
| Alert to document nonclinical drivers of health outcomes in the problem list | Reminds staff to add or remove Z-codes related to nonclinical drivers of health outcomes to the problem list or visit diagnosis based on recent screening results. | |
| Medication adherence barriers alert (OPA) | For patients with uncontrolled diabetes/hypertension when adherence to prescribed medications is not documented at the visit. Included fields for documenting whether the patient was taking the medication, not taking it (with a reason), or taking it differently (with a reason). | |
| In-line alert: Medication is not available as a generic† | When a newly prescribed outpatient medication is not available as a generic, among patients with diabetes/hypertension and reported contextual factors influencing health outcomes. | |
| In-line alert: Reminder to discuss titrating insulin based on food availability† | When a new outpatient insulin order is placed, and the patient is experiencing food insecurity, among patients with diabetes/hypertension and reported contextual factors influencing health outcomes. | |
| In-line alert: Prompt for conversation about barriers to taking medication† | For a new prescription for diabetes and/or hypertension medication, among patients with diabetes/hypertension and reported contextual factors influencing health outcomes. | |
| In-line alert: Prompt to consider patient preference for 30- vs. 90-day medication† | When a new medication has no end date or an end date >30 days in the future, and dispense days are not entered, among patients with diabetes and/or hypertension and reported contextual factors influencing health outcomes (does not display for existing medications). | |
| In-line alert: Note to pharmacy regarding lowering medication costs† | For any prescription among patients with diabetes and/or hypertension and reported contextual factors influencing health outcomes. | |
| Documentation checklist† | A checklist of adjustments made by the care team to guide clinical discussions and documentation; list of options based on patient-specific factors (e.g., HbA1c ≥9%, blood pressure >140/90, missed appointments and contextual factors influencing health outcomes). | |
| †In-line medication alerts and the documentation checklist were intended to prompt conversations between patient and provider. | ||
Study findings were published in Annals of Family Medicine in March 2026. They highlight both the potential benefits of EHR tools in helping community clinics address contextual factors influencing health outcomes and the challenges of designing tools that meet clinical needs.
What the study found
Community clinics using the tools had higher rates of screening for contextual factors that influence health outcomes, as well as documenting them using Z-codes. This suggests EHR tools may support identifying and documenting these factors as part of routine care, potentially improving outcomes and supporting appropriate billing for patients with more complex needs.
One nurse family practitioner at a study clinic highlighted the tools’ efficiency.
“I personally feel it’s a lot better just because then I don’t have to reinvent the wheel,” they said, adding that spending extra time looking for a code that seems to fit can slow them down. The tool captures what’s occurring and makes the process much easier, they said.
Among patients with uncontrolled hypertension at the start of the study, blood pressure control improved more at clinics using the tools than at those that did not. However, there was no difference in hemoglobin A1c control among patients with uncontrolled diabetes, suggesting that more extensive interventions may be needed to address contextual factors affecting diabetes control.
However, clinic teams rarely used the tools designed to suggest or document care plan adjustments, even though the tools were developed by other health center staff. Some staff said the tools added little value because tailoring care to patients’ needs is already standard practice.
Overall, the findings highlight both the promise and the limitations of EHR‑based tools. While the tools supported screening and documentation, they did not appear to add value for documenting care plan adjustments — likely because such adjustments are already routine.
What this means for community-based clinics
Based on the findings, health centers may consider these approaches:
- Activate screening and documentation tools.
- Tools that remind staff to screen for contextual factors influencing health outcomes and document them using Z codes can strengthen documentation, improve efficiency and ease staff burden. More complete documentation is a key step toward using these data to improve patient health. It may also help ensure billing reflects patients’ complex needs and that clinics meet evolving incentives and requirements in an era of value-based pay.
- Use screening tools to support patient blood pressure control.
- Blood pressure management improved more in clinics using the tools, suggesting the tools’ potential ability to improve both patient outcomes and future costs of care. While the study did not establish a direct link to care plan adjustments, increased screening may lead to better understanding of patient needs and more responsive care. Improving HbA1c may require additional interventions.
- Incorporate nonclinical drivers of health outcomes data into clinical workflows.
- Clinic staff reported that greater visibility of data on patients’ contextual factors influencing health outcomes supported clinician autonomy and patient-centered decision-making, even when not formally documented.
Learn more
The EHR tools tested in the COHERE study are available to OCHIN network clinics. OCHIN members can contact their clinical support analyst to learn more about the COHERE tools in OCHIN Epic.
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This work was supported by the National Institute of Minority Health and Disparities of the National Institutes of Health (grant number: R01MD014886). The funding source had no role in the design and conduct of the study; collection, management, analysis, and interpretation of the data; preparation, review, or approval of the manuscript; and decision to submit the manuscript for publication.
