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Identifying and Addressing Inequities Intensified by COVID-19

Clinicians use Epic to proactively reach out to higher-risk patients

The initial waves of COVID-19 infections revealed stark disparities in outcomes for different populations across the country. In Michigan, for example, African-Americans make up just 14% of the population, but account for over 40% of deaths from COVID-19 statewide after infections spiked in the southeastern part of the state. Factors that disproportionately affect some groups—including barriers to accessing care, chronic health conditions, and socioeconomic circumstances—have made these patients more vulnerable to serious COVID-19 complications.

Clinicians at Spectrum Health in Michigan worked to change that trend by partnering with community organizations to bring targeted preventive care to their most at-risk patients before cases peaked in their area.

“We’ve been given the gift of time,” said Dr. Ken Fawcett, VP of Spectrum Health Healthier Communities. “We’re using that time to try to prevent the tragedy that unfolded in southeastern Michigan from happening here.”

Spectrum’s clinicians identify patients for proactive outreach using a risk score based on data in their Epic charts, including age, race, pre-existing health conditions such as hypertension, and social determinants of health, such as food insecurity. Then, they contact high-risk patients to set up a virtual visit in MyChart.

“The idea is to do a tune-up for those pre-existing conditions now, so they’re better managed when the chance of infection rises,” Dr. Fawcett said.

Spectrum is also addressing the pandemic’s economic impact by helping patients access housing, food, and financial resources. Care managers and social workers who already performed this outreach are now joined by outpatient clinicians who are helping to reach more patients. Community organizations helped Spectrum design the training and workflow for these additional clinicians.

To help health systems identify and address inequities, Epic developed a new dashboard that compares an organization’s overall patient population with COVID-19 infection and severity rates to show which racial and ethnic groups are disproportionately affected. From the dashboard, users can dig into questions such as whether a specific ZIP Code has been hit harder by the virus.

To learn more about Spectrum’s work, the health equity dashboard, and other Epic resources, Epic community members can tune into a webinar. Community members can also find out more about setting up the dashboard in the Managing Coronavirus Disease 2019 (COVID-19) With Epic white paper , which is updated regularly with new build and workflows.