Innovation & Transformation in Primary Care


OHSU's Department of Family Medicine studies how innovation and transformation in primary care works, and how it affects clinical workflow, workforce, and patients' health outcomes. We experiment with new tools and functions in the electronic health record; implementation of care teams; integration of physical, mental and behavioral health; and expansion of new types of services to be more patient-centered. We also pioneer the use of health data to inform innovation and transformation efforts through the use of dashboards and reporting.

Innovative Methods for Parents and Clinics to Create Tools for Kids' Care (IMPACCT)

Principal Investigators: Deb Cohen, PhD;Jen DeVoe, MD, DPhil
This project engages stakeholder groups (including families, policy makers, and CHCs) in an iterative process to develop patient-centered IT tools that facilitate Community Health Centers' ability to conduct public health insurance outreach to families of their pediatric patients. The tools will be adapted from IT strategies proven to help patients and clinics manage chronic diseases.

Turning EHRs into Assets for Mental Health and Uniting Practice (TEAM-UP)

Principal Investigator: Deb Cohen, PhD
This study thoroughly examines an innovative and novel technological solution in the Epic EHR that can be used as a model for documenting, sharing, and monitoring patients' mental and physical health needs and that holds promise for defragmenting current information systems and supporting integrated clinical practice.

Clinical Information Needs of CHCs for HIT (CLINCH-IT)

Principal Investigator: Deb Cohen, PhD
This study focuses on identifying the clinically relevant information that clinicians and clinical teams commonly need when caring for complex patient populations, and examine how clinical teams use health IT to address the social and economic circumstances that are often central to their complex patients' health and healthcare (known as social determinants of health). The information needs are identified to ensure effective care coordination for complex patients through extensive ethnographic assessment and interviews, and employ state-of-the-art user-centered design methods to rapidly develop and test health IT tools that address these needs.

Community-based HIT Tools for Cancer Screening and Health Insurance Promotion (CATCH-UP)

Principal Investigator: Jen DeVoe, MD, DPhil
This project will conduct a clinic-level cluster randomized trial in 12 CHCs (~47,000 patients aged 18-64) to test the effectiveness of Community-based HIT Tools for Cancer Screening and Health Insurance romotion ("CATCH-UP" tools) at improving rates of (1) cancer screening and prevention services, and (2) health insurance coverage. The CATCH-UP tools are designed to identify and reach uninsured CHC patients who are eligible for enrollment in public insurance coverage, and to encourage re-enrollment of publicly-insured patients before coverage gaps occur.

The DATA Initiative

Principal Investigator: Scott Fields, MD
The goal of this project is to develop the infrastructure to create and utilize a system of quality analytics (the tools used to drive decisions and actions), design the educational programs necessary to prepare physicians to manage and analyze information and processes of continuous quality improvement, and build a partnership between clinicians and researchers to study the effectiveness of data-based interventions and delivery system improvements on quality care.

OHSU Richmond Community Health Center Cluster

Principal Investigator: Ern Teuber, PhD
For more than 15 years it has served the generally underserved population of southeast Portland, an area with two designated Medically Underserved Areas. It is also a training site for 12 family medicine physician residents. As a Federally Qualified Health Center, the clinic has received supplemental funding for projects in the following areas:
Maternity/Perinatal: Grow and strengthen capability for labor and deliveries. Improve services for prenatal care, newborn home visits, prenatal and parenting education, and coordination of care. Grow the opportunities for residents to participate in supervised deliveries.
Clinical Pharmacy: Involvement in medication therapy management, working directly with patients and primary care providers about effective management of disease through medications, medication reconciliation, and home visits to assess the total pharmacological picture.
Behavioral Health Integration (BHI): Establish appropriate leadership for implementation of behavioral health integration practice change strategies, identify and implement the most appropriate health risk assessment data collection tools, divide our patient population into groups with similar needs and probabilities for improvement, define the most appropriate pathways for addressing the health risks of each segmented patient group, develop and test appropriate "pathways" for each population segment, promote patient-centered development and implementation of self-care plans, and create the infrastructure to track and evaluate the process.

SBIRT Oregon Training Initiative

Principal Investigator: John Muench, MD
This project develops a teaching faculty that delivers training curriculum with high fidelity that increases learners' knowledge, attitudes, and behavior towards delivering SBIRT to patients as part of routine care. It will more fully actualize the integration of behavioral health providers into primary care settings in Oregon by meeting the training needs of both medical clinicians and behavioral health specialists, producing a critical mass of medical professionals who can perform, implement, and sustain evidence-based SBIRT practices into the future. The goal is to deliver training curricula to at least 150 medical residents at OHSU, 405 social work students at Portland State University (PSU), and 125 counseling students at Oregon State University (OSU)-Cascades.