Innovative program at Mass General Brigham supports chronic disease and preventive care

Female health professional talking to older man

At Mass General Brigham, an innovative tool called the Primary Care Quality Program uses data to better care for patients managing chronic diseases through their primary care offices. The program was developed to better support our system’s primary care providers by alerting them to patients who may need extra help managing their chronic disease check-ins as well as preventive care. 

"As a clinician, I care that we’re doing a good job taking care of our patients and making sure we’re taking action to keep their chronic conditions under control,” says Rebecca Cunningham, MD, Senior Medical Director of Primary Care for Mass General Brigham and a primary care physician at Brigham and Women’s Hospital. “Until we developed this program, our data collection was disjointed and not integrated into the workflow of clinical teams.” 

Over the past 6 years the program has leveraged Epic’s Electronic Medical Record (EMR) system to reach 1.1 million adult and pediatric primary care patients. Using Electronic Clinical Quality Measures (eCQMs), it recognizes gaps in care for chronic diseases like hypertension, diabetes, cardiovascular health, asthma, as well as preventive care, including cancer screenings and vaccines. 

Using Epic, population health coordinators can alert patients when they’re overdue for appointments, tests, or labs, and schedule them for what they need. The system can even generate mass communications— like scheduling mammography appointments for 10,000 patients at one time. This has been an especially important tool, as many patients delayed preventive care and screenings due to the COVID-19 pandemic. 

Additionally, there are plans to leverage this data to address more equitable care across race, ethnicity, language, and socioeconomic status as part of Mass General Brigham’s United Against Racism (UAR) initiatives.