Primary Care ABCS Registry Guide

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Submission Date: December 2012

Entry Type: Case Study

State/Territory Submitted on the Behalf of: Utah

States/Territories Involved: Utah

Domain Addressed:

Health Systems Strategies

Public Health Issue:

Many primary care practices (PCPs) in Utah have electronic health records (EHRs) but do not use data available to help them assess and improve the quality of care they are providing. Without a good understanding of how to use their EHRs most effectively to obtain reliable data, practices will not be able to use their EHR data to drive improvement.

Project Objectives:

By 06/2013, increase the number of primary care practices using an ABCS Registry in their EHR to identify and manage patients with heart disease, focusing on controlling high blood pressure, from 0 to 6 within the health care setting (Influencing the general population).

Program Action:

This project targets primary care practices (PCPs) participating in the Cardiac Learning Network and their patients

Partners inlude:

–  HealthInsight (Utah’s Quality Improvement Organization)

–  PCPs participating in the Cardiac Learning Network (approximately 60 practices)

HealthInsight is developing simple guidelines for electronic health records (EHRs) reporting and improvement efforts around the ABCS. They will focus on enhancing medical providers’ usage of their EHR; specifically, the identification and management of patients with heart disease. HealthInsight is uniquely positioned to facilitate this process due to their established relationships with medical providers as the Quality Improvement Organization (QIO) and Regional Extension Center (REC) for the State of Utah.

Activities will be twofold:

Phase I: Centers upon the development of standard guides to extract reports specific to the ABCS measures (e.g., Aspirin for Ischemic Vascular Disease, Blood Pressure Control, LDL Control, and Counseling for Smoking Cessation) from provider EHRs.

Phase II: Centers upon the piloting of these guides in six clinics. HealthInsight shall evaluate the effectiveness of these guides using pre/post measurement methodology. The guides will be incorporated into the JNC8 CME training, lead by Dr. Barry Stults. In addition, it could potentially be used in up to 60 clinics participating in the Cardiac Learning Sessions. HDSPP and HealthInsight will develop a plan for promotion and distribution.

Data/Other Information Collected:

– Pre/Post test evaluating effectiveness of guide

– Number of clinics that set up registries using the guide

– MillionHearts ABCS measures, including: IVD use of aspirin, HBP screening, controlling HBP, cholesterol screening, and tobacco use screening


The guide has been drafted and is being reviewed by Dr. Barry Stults and HealthInsight’s Medical Director. All 60 of the PCPs participating in the Cardiac Learning Network have expressed interest in participating, and 6 clinics have been selected to pilot the guide.

Challenges/Lessons Learned:

None so far

Next Steps:

Finalize the guide and pilot the guide in 6 clinics

Program Areas:

Epidemiology and Surveillance, Heart Disease and Stroke

State Contact Information:

Karen Coats
Utah Department of Health

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