In Alameda County, California, health center providers can now offer more holistic care for Barbara*, a pregnant woman who is experiencing homelessness, while expecting her first child. Using OCHIN Epic EHR for the first time, clinicians across various clinics have been able to coordinate labs and ultrasounds for Barbara without duplication and share the results via the electronic health records (EHR) system.

“Now we can accommodate our patient wherever she is staying at the time,” said Kim Cardoso, CNM, NP, who provides care to Barbara as a nurse practitioner at LifeLong Medical Care, “and she can follow her own care via her cell phone. It is a beautiful solution for a complex patient in an unusual time.”

LifeLong is one of eight distinct health centers comprising the Community Health Center Network (CHCN), which collectively serves more than 270,000 patients throughout the East Bay of San Francisco. Even before the pandemic, this large and diverse network of providers realized there was an opportunity to improve its delivery of high-quality patient care with the aid of EHR technology to seamlessly connect clinicians, specialty providers, and hospital staff throughout the region.

Once COVID-19 arrived, OCHIN Epic EHR proved even more essential—helping CHCN providers meet the growing and changing demands for health care with new capabilities, like video-enabled virtual visits, multi-lingual translation support, and integrated medical, dental, and behavioral health services. To date, more than 2 million patient records have been securely exchanged among more than 500 providers on the new system—electronically connecting CHCN’s care teams with two major hospital systems.

“We’re already seeing the positive impact and transformative potential of the OCHIN Epic EHR, as it’s deployed across our network,” said Ralph Silber, CEO of CHCN, in a press release.

Strengthening Provider Connections

Access to a current patient medical record through EHR ensures that providers have an accurate view of their patient’s health, so they can offer the best care possible as patients continue to move between clinics and/or local hospitals during the pandemic and beyond. It also enables primary care providers (PCPs) to connect their patients to specialists and follow up with these colleagues as needed to ensure coordinated, holistic care delivery.

“OCHIN Epic provides PCPs with vastly larger clinical picture, which is important in transitions of care,” said Dr. John Okemah, MD, the former chief medical officer at Native American Health Center. “In the past, this information would take days or weeks to receive. Our patients benefit from knowing their PCP is in communication with other team members and we can more fully explain what they previously may not have fully understood about their health.”

In another example, pediatric care teams at Axis Community Health routinely discuss the importance of oral health during each well-child checkup and use OCHIN Epic Wisdom to track these encounters and follow up with dental appointments.

“As a dental provider, it is important for me to educate my patients on the connection between their overall health and oral health,” said the clinic’s dental director, Patrice Lane, DDS. “Being able to streamline internal consults and referrals has given me the opportunity to provide more accessible care for our patients and maximize their time with us.”

Streamlined Pandemic Response

Back at LifeLong Medical Care, custom smart phrases within OCHIN Epic EHR help ensure patients are screened for COVID consistently, while the integrated MyChart patient online portal enables easier follow up and remote care. For example, patients and providers can exchange photos, screenshots, educational materials, and other updates virtually. The patient tracking feature allows providers to sort and create customized patient lists for tailored communications, which has been particularly valuable in conducting outreach to higher-risk obstetrics (OB) patients at home during COVID.

“One of our first projects during the pandemic was to find our patients most at risk for preeclampsia so that we could get them blood pressure monitors for use at home,” Cardoso said. “We used My Reports to find patients who had been prescribed baby aspirin (used as prevention starting in the second trimester) and/or who had diagnostic histories that make them higher risk.” According to Cardoso, the demographic data in OCHIN Epic also helped her to identify Black women for outreach—a particularly important group to monitor and support proactively, since long-standing racial disparities in health care have made preeclampsia deaths three times more common among African American women than white women in the U.S.

“Many of our providers have said to me, they can’t imagine taking care of their patients during the pandemic without being on Epic,” Silber said. “And we are quickly figuring out ways to use Epic to address the health inequities that have plagued our communities for so many years.”

A New Model of Community Care, Delivered Virtually

The CHCN deployment of OCHIN Epic EHR was made possible through an innovative partnership between OCHIN, Kaiser Permanente, and Sutter Health, which leveraged community benefit funds from the local hospital system to finance the new EHR deployment. The result is a collaborative effort that has transformed in-patient and out-patient care coordination by facilitating the timely and secure flow of patient data between hospital and clinical care teams.

“Since the implementation of Epic at Alameda Health System, I have been able to access clinical notes from multiple disciplines in real time,” said Alina Gularte, an inpatient care transitions nurse with CHCN. “This provides a better overall clinical picture of what the patient’s needs are, and the ability to start discharge planning with the hospital case manager from day one of admission.”

OCHIN Epic EHR is now available at all eight of CHCN’s community health centers, following a large, virtual roll out for La Clínica de la Raza in April.

“We were really pleased to be able to complete this deployment for CHCN, despite the pandemic, by offering full support for a virtual go-live at La Clínica,” said OCHIN CEO Abby Sears. “Now more than ever, we need to ensure frontline providers and public health authorities are able to exchange real-time health information and can respond quickly to the needs of their communities.”

Read more from CHCN here: https://chcnetwork.org/ochin-epic/

*Patient’s name has been changed to protect anonymity.