Indianapolis-based Patient Centered Medical Home Leverages EHR & Workflows to Smoking Cessation Counseling Rates by 30% Over 4 Years

Source: HIMSS

Through 150 licensed providers, HealthNet annually provides affordable health care to more than 59,286 individuals in Indianapolis’ inner-city neighborhoods, 65% of whom are Medicaid recipients.  HealthNet has a network of eight primary care health centers, one OB/GYN care center, one pediatric and adolescent care center, one maternal fetal medicine center, five dental clinics, seven school-based clinics, a homeless program with eight shelter clinics, and additional support services.  

The organization has also been accredited by the Joint Commission as an Ambulatory Practice since 1980, and is the only FQHC in Indiana with this distinction.  HealthNet achieved Patient Centered Medical Home (PCMH) designation from the Joint Commission in October 2012 and has successfully attested 98% of its eligible providers for Medicaid Meaningful Use.

Local Problem Identified
The Healthcare Effectiveness Data and Information Set (HEDIS) is a list of measures used by more than 90% of U.S. health plans to measure performance on key clinical quality indicators. Not only are these measures important indicators of performance internally, but they also serve as an excellent external benchmarking tool. 

HealthNet’s performance on multiple HEDIS measures were stagnant and below average prior to EMR implementation in 2009. HealthNet did not have a standardized process for identifying patients in need of well child care and the information provided by the health plans was not usually actionable at the individual health center and practitioner level. In many cases, the health plans provided the data after the HEDIS measurement deadlines had passed, and the data provided was often 18 months old. In addition, HealthNet also needed to demonstrate improvements on several Uniform Data Set (UDS) measures, which is a required standardized report all FQHC’s and Federal 330 Public Health Fund recipients must submit annually to the Bureau of Primary Health Care (BPHC).

Solution Enacted
HealthNet utilized the customization available within the EMR to develop templates for documenting required data in structured fields and used pre-programmed assessment codes which were needed to capture the data from claims. Templates were developed for: adult tobacco assessment and counseling, adult weight screening and follow up and weight assessment and counseling for children and adolescents, as well as all three well child measures.  

Custom reports were built to provide staff with lists of patients who were in need of such services prior to measurement deadlines. In addition, compliance reports were generated monthly to allow leadership and the EMR and Quality Teams to gauge the level of improvement for each measure.  Managers at each clinic designated staff to work this report monthly. In some cases medical assistants are reaching out to patients to scheduled needed appointments, and in other cases the job is assigned to front office staff. In addition, providers have started adding Well Child Check codes to the patients’ problem lists to show when this code has been used in the past.

Due to their EHR implementation and associated workflow changes, HealthNet outcomes significantly improved in the measures chosen for intervention, including a 30% improvement in smoking cessation counseling for adults between 2011 to 2014, moving from 77% in 2011 to 100% in 2014. 

Facility State/Region: IN
Facility Country: United States
Award: 2015 Davies Community Health Award
Award link:
Sub Classifications: Patient Engagement & Population Management-Prevention: Improvements in smoking cessation
Facility Type: Large Primary Care Practice (Ten+ physicians)
Citation: HIMSS. (2015). HealthNet of Indianapolis – Davies Community Health Award.  Accessed July 23, 2017.