Posted: May 13, 2015

Working toward the Triple Aim in an Academic Practice: Population Health in a Family Medicine Residency Clinic


OHSU Family Medicine at South Waterfront is a university affiliated teaching practice with 46,000 visits per year and a current patient panel of 18,000 patients. The clinic integrates 24 faculty members, and 11 residents onto our four clinical teams. In 2008 Health Maintenance reminders became available in our Epic EHR at OHSU. This allowed us to begin to experiment at an individual clinician level the impact these reminders would have on proactive population health in our practice. In October 2009, after piloting this for a year, best practices surrounding the use of these reminders and their impact on patient health outcomes were shared with the clinic team. In September 2011 as a result of these best practices, a new position in the clinic, "Health Maintenance Coordinator" was established. This new role included two full-time medical assistants whose jobs were to place health maintenance reminders on all patients using evidence based criterion for things such as cancer screenings, diabetic testing and immunizations. Training was also provided to medical assistants to review overdue health maintenance topics and pend orders while rooming the patients. The clinic wide health maintenance processes were started in April 2012. The family medicine department created a population based patient registry for these interventions. The coordinators receive these reports which indicate the specific patients that are overdue for these screenings and/or interventions. The Health Maintenance Coordinators then proactively outreach to the patients using the patients preferred form of communication to close these gaps in care. To help the clinic better understand the role of these new health maintenance coordinators and the impact they were having on the health of our patient population a visual quality improvement board was created and placed in a common area; this is continuously updated and maintained by The Health Maintenance Coordinators.


Population Health, Family Medicine, Public Health Sciences, Medical Assistants, Health Maintenance Reminders, Health Maintenance Coordinator


Daisuke Yamashita, MD, Oregon Health & Science University School of Medicine

Emily Barclay, MS, Oregon Health & Science University School of Medicine