At an urban safety-net primary care clinic in St. Paul, Minnesota, monitoring of patients with chronic hepatitis B, a liver infection requiring regular blood tests to prevent serious complications, mirrored national challenges. Many patients diagnosed with chronic hepatitis B were referred to gastroenterology but later returned only to primary care for unrelated needs.

Histopathology_of_massive_hepatic_necrosis_in_hepatitis_B (1)

Source: Ran Xue, Yueke Zhu, Hui Liu & Qinghua Meng

Histopathology of massive hepatic necrosis in hepatitis B: liver cell dropout, residual hepatocytes and intact portal tract pattern could be seen in this field (HE; original magnification, x100).

Without systematic prompting, hepatitis B monitoring rarely surfaced during these visits, and efforts to re-engage patients through phone calls, letters, and scheduling attempts proved labor-intensive and often ineffective.

In May 2024, the health system and clinic noted the appearance of a new “care gap” alert in their Epic electronic health record (EHR) system that flagged patients with hepatitis B who were overdue for one blood test, the hepatitis B DNA test.

As part of the existing workflow to address care gaps at every visit, the alert prompted clinic staff to discuss the test during whatever appointment the patient was already attending.

Among 104 patients with chronic hepatitis B, the share getting timely monitoring in the subgroup not requiring liver cancer screening rose from 34% to 51% in the 14 months after the alert was activated. Overall monitoring across all 104 patients had reached 27%, above the 11% to 21% range reported in national evaluations. 

The study is published in The Annals of Family Medicine.

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