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Advances in technology are leading to improvements in so many aspects of our daily lives – and health care is no exception. With the advent of health care reform, providers and other stakeholders are working to improve health care outcomes while reducing health care costs through a variety of technological and data-based tools, such as Electronic Health Records (EHR).

I’m pleased to announce that here in Massachusetts we are leading the way in the next step in the use of electronic data exchange to build stronger bi-directional communication between health care providers and the community-based organizations which offer support and services to patients with a variety of health conditions and diagnoses.

It’s an innovative pilot project called e-Referral, funded through a State Innovation Model Testing award through the Centers for Medicaid and Medicare Services (CMS). Here’s how it works. Let’s say a patient has just been diagnosed with diabetes by her doctor. We know that one important next step following that diagnosis can be to counsel the patient to lose weight or to make a change in her diet. Using the new e-Referral data exchange system, the doctor can automatically communicate with a community-based organization (CBO) which provides diabetes education and chronic disease self-management classes. But that’s not all – that CBO can automatically communicate back to the doctor that the patient was contacted, education provided, classes were taken, and even weight was lost. During subsequent office visits with the patient, the doctor can measure how that particular diabetes intervention may have contributed to an improved outcome for that patient’s diabetes diagnosis. And that data can be used to measure the overall impact that such interventions can have on chronic diseases and conditions.

The e-Referral system would work the same for a variety of other health conditions. A doctor who recommends that his patient quit smoking could automatically connect that patient with smoking cessation services in the community; or a patient with asthma could be connected to organizations that assess the home for asthma triggers, and so on. In each of these cases, the e-Referral system would allow bi-directional communication between health care providers and the community-based organizations which can offer support and services to improve patient outcomes. This is an extraordinary step forward in building closer links between the traditional health care delivery system and the larger communities where patients live, work, and play.

Over the course of the next three years, the Department will develop a statewide roll-out plan and directly assist more than 20 health care provider sites to embed e-Referral into their electronic health record software.  In time, we are confident that these efforts will demonstrate that the e-Referral system and clinical to community-based interventions that it facilitates will improve health outcomes.  As a nurse, I couldn’t be more excited and proud of the work happening at the Department to support clinicians, patients, and community organizations in this effort.

Written By:


Commissioner of the Department of Public Health

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