Petaluma Health Center mines health records to improve patient health

Before the first patient walks into the Petaluma Health Center every morning at 8:30, Dr. Danielle Oryn dons her “clinical informatics officer” hat and huddles with a medical assistant to discuss the patients coming in that day.

Of course they discuss the reason the patient is coming in, whether for a physical, flu symptoms and or some other illness. But they also consider health issues not readily observed, issues that until now would have been difficult to identify and manage.

The patient’s electronic health records have already been “mined” by specialized software that identifies patient needs such as immunizations, Pap smears, colon cancer screenings and any other preventative treatment.

“We’re looking to improve population health,” said Oryn, who is also a family doctor. “For example, we want to keep our patients with chronic medical problems like diabetes and hypertension to stay as healthy as possible and not have complications such as heart attack or stroke.”

Oryn, who is certified in clinical informatics, uses the health center’s electronic health records to conduct clinical data analysis to improve the center’s quality of care and ensure it operates more efficiently. The work, once the exclusive domain of public health officials and university researchers, allows the health center to better manage the well-being of its 35,000 patients.

It has invested about $3.2 million in the effort, which includes establishing a new call center, hiring nurse case managers and patient navigators, and building out its IT infrastructure. The efforts were recognized last week by the U.S. Department of Health and Human Services, which awarded the health center more than $254,000 in federal grants aimed at quality and efficiency.

The Petaluma Health Center was among 13 North Coast community clinics receiving more than $1 million in federal quality improvement funds. Many are members of the Redwood Community Health Coalition, a consortium of 17 community health clinics in Sonoma, Napa, Marin and Yolo counties.

According to HHS, the centers receiving the funds showed high levels of performance in one or more categories, including improving quality of care, increasing access to care, enhancing delivery of high value health care, addressing health disparities and success in achieving a patient-centered medical home providing primary care for dental, mental and medical needs.

“Americans deserve a health care system that’s affordable, accessible, of the highest quality, with ample choices, driven by world-leading innovations and responsive to the needs of the individual patient,” HHS Secretary Tom Price said in a press statement.

Petaluma Health Center has an annual budget of about $40 million, and receives 64 percent of its revenue from Medi-Cal reimbursements. Federal grants such as the ones announced last week comprise about 3 percent of its revenue.

Like many other health centers across the country, the Petaluma Health Center benefited from billions of dollars in federal funds under Obamacare aimed at beefing up the primary care network for Americans who became newly insured by the law’s expansion of Medicaid.

In Sonoma County, health centers serve about 250,000 residents, said Pedro Toledo, chief administrative officer of the Petaluma Health Center and former director of community and government relations at the Redwood Community Health Coalition.

Toledo said Petaluma Health Center is now a “data-driven” organization that looks at health care measures on a daily basis in “real time.” Oryn, he said, was hired to go through the data regularly and identify areas of improvement and ways to improve public health.

“We do that for everything, for colonoscopies, Pap smears for women, colorectal cancer, for diabetic patients ... those folks we bring them in regularly,” he said, adding that in the future many health centers in the North Coast will be mining their electronic health records. For now, he said, “we are one of the first.”

Ten years ago, health centers were using paper health records and could not use such extensive data-driven health strategies or conduct analysis of the population served by health center. Such analysis was usually conducted by the county public health department.

But Oryn and Toledo said recent IT investments have given the health center the tools it needs to improve the health of each of its clients and the community as a whole.

You can reach Staff Writer Martin Espinoza at 707-521-5213 or

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