Clinical Informatics

Expanding the use of data and technology

NACHC’s Clinical Informatics team empowers health center staff to improve patient care by using Electronic Health Records (EHR), HIT tools and data more effectively, educating care teams in informatics principles and techniques, and enabling providers to manage populations and close care gaps.

What we do​

  • Build and support data infrastructure (the systems needed to collect, use, and share data) so staff can improve governance and meet patient needs.​
  • Drive data-informed care by offering training to better understand and use data and technology.
  • Integrate data systems by standardizing definitions for data and reporting (creating harmony).
  • Advocate for industry-wide solutions through partnerships with health centers, Primary Care Associations (PCAs), Health Center Controlled Networks (HCCNs), national organizations and federal agencies. ​
  • Use human-centered design by integrating patients and care teams into quality improvement efforts.
  • Engage and reduce stress for staff from health centers, PCAs and HCCNs by building enduring technical/data capacity that improves workflow and effectiveness.
  • Aggregate and standardize data to share results, findings, and provide feedback across the public health continuum.

Evidence-Based Design

  • Improvement Methodologies for Informatics
  • Human Centered Design: an approach to designing information systems that starts with the health center patient and staff; and ends with new solutions that are tailored to suit their needs. Several key questions are asked throughout the process.

Data-infrastructure Support for Health Centers

While infrastructure is the foundation or framework that supports an organization or community, data-infrastructure is the physical and virtual resources that support the flow, storage, processing and analysis of data. This includes the infrastructure needed to support your health center’s electronic medical records. Some resources:

Health Information Technology (HIT) projects

  • COVID Multi-State​ Data Initiative
    • The COVID-19 Multi-State Data Initiative created a public health cloud data warehouse for monitoring and understanding the pandemic as it unfolded in health centers around the country. In 2022, the project involves more than 25 states. The data warehouse contains more than a million patient-level deidentified records on patients who received COVID-related services or diagnoses at health centers. These data show patterns reflecting the spread and impact of COVID-19 on health center patients and operations.
  • HEP C Care Cascade​ 
    • Hepatitis C is now a largely curable disease; however, most Hepatitis C patients do not know they are infected. The Hep C Care Cascade worked with two large national networks to support care teams moving patients through Hepatitis C screening to diagnosis to treatment to test proving cure by creating dashboards to identify patients’ Hep C care gaps and helping teams to close them based on the CDC guidelines.
  • HIV Clinical Decision Support​
    • Advancements in the detection and treatment of HIV (human immunodeficiency virus) have changed it from a fatal condition into a manageable chronic disease. Today it is primarily transmitted by people who are undiagnosed and thus, do not know they have it. NACHC worked with CDC to build an electronic health records (EHR) compatible clinical decision support software tool to support and even automate the appropriate testing of patients without an HIV diagnosis who are at low and elevated risk according to CDC guidelines. The free tool is available to any organization interested in supporting HIV screening and testing.
  • Identifying Essential Workers​
    • The COVID-19 pandemic demonstrated how critically a person’s work and workplace can impact their health—before the availability of the COVID-19 vaccine, essential workers were at a much higher risk of infection and death. However, healthcare organizations could not effectively target these populations with their care because of the lack of support in EHRs for occupational health data. This project works with 3 large HCCNs to implement basic occupational health data into health records to drive risk evaluation and mitigation strategies for the pandemic and beyond.
  • Maternal Quality and Post-Partum Care
    • NACHC engaged two large and one regional HCCNs to address the care continuum of quality post-partum services. Typical EHR functionality and clinical workflows do not adequately support the effective, longitudinal management of maternal quality from the prenatal period through delivery and the post-partum period.  NACHC is now partnering with three networks and the California Maternal Quality Care Collaborative (CMQCC) to extend the target areas from contraception, gestational diabetes and post-partum visits to the broad spectrum of evidence-based actions during and immediately after pregnancy. By creating a cohesive workflow and HIT decision support care module, we can enable the coordinated delivery of prenatal and post-partum visits around important domains including contraception. gestational diabetes follow-up, hypertensive disorders of pregnancy, substance abuse treatment and prevention and post-partum depression and anxiety screening. This work will result in comprehensive sets of quality measures, workflows, and informatics best practices with well-specified data dictionaries to support the entire continuum of maternal quality care.
  • Pediatric Weight Management
    • NACHC and the CDC collaborated with a HCCN across Denver, CO to link pediatric data from healthcare organizations. The goal was to understand how patient outcomes around obesity link to community-based interventions around physical activity and nutrition. Now, we are further advancing our knowledge and coordination of care for pediatric patients at risk for obesity and their families as we extend the work to include household linkages.

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