WA Portal Transformation Blog

The 4th Aim of Practice Transformation

Adriana Linares, MD
Adriana C. Linares, MD, DrPH
Blog Editor
Family Medicine with OB
PeaceHealth, Vancouver, WA

My name is Adriana Linares. I am a Colombian family physician who has worked in Washington state for the past five years. I moderate this blog as part of the transformation efforts of our team.


Please see below for an October addition from the Pierce County ACH Strategic Improvement Team. The post is about behavioral health providers' free access to OneHealthPort, Washington state’s Provider Data Service and Health Information Exchange (HIE) system.


We are going to write about the four aims, or pillars, of health care. We are a team of four people but would like to involve as many as possible. We would like feedback, comments, criticisms, and especially solutions to some of the topics we will discuss.

We decided to start with the fourth aim.

To be able to excel on our work, we as health care workers need to be satisfied.
I attended the American Academy of Family Physicians FMX (Experience) meeting in San Antonio, and came back motivated and ready to continue my efforts for excellence in health care. You know what helped me? The American Academy of Family Physicians presented a new portal: Physician Health First. It provides great resources, strategies and evaluations to enhance physician wellbeing. The Academy has heard its members and is working on trying to alleviate some of the problems associated with health care in the United States that burden the practice of medicine in our country.
I invite all of you to review the resources available on the WA Portal related to well being. We have included also resources related to staff wellness and providers in different areas of medicine.

Please let us know what you think. Send your comments -- what would you like for us to cover? How can we improve our blog?

Talk to you soon.

Clinical Data Repository (CDR) Application for Behavioral Health Providers

October 2018 -- Behavioral health providers contracted with Medicaid can now access OneHealthPort, Washington state’s Provider Data Service and Health Information Exchange (HIE) system, for a more comprehensive view of a client’s engagement in care.

As an HIE system, OneHealthPort houses the Clinical Data Repository (CDR) which allows users to view client/patient data for “the purposes of managing treatment, payment or business operations” (OneHealthPort, 2018). The CDR contains data for all Medicaid beneficiaries. The CDR allows for shared care planning as it contains claims, EHR data and utilization history for medical, dental and pharmacy lines of service.

Behavioral health providers can access the CDR at no cost to look up client utilization history and to view uploaded clinical summary documents. As an additional service, providers on the CDR may connect their EHR platforms so clinical information can be stored, accessed, and aggregated in one location. For example, a behavioral health provider can access the CDR to identify a client’s engagement in the healthcare delivery system to enhance coordination with other providers involved in client care.

Simply, the CDR is a population health tool to improve and coordinate whole-person care. Why not become a CDR user?

To learn more about the CDR and how it can benefit your practice contact Deb Hemler, Vice President of Development with OneHealthPort.

By:  Pierce County ACH's Strategic Improvement Team

OneHealthPort. (2018, October). Use of CDR. Retrieved from OneHealthPort: http://www.onehealthport.com/cdr/use-cdr


Collaborative Care Model for Behavioral Health Integration

Joseph Cerimele MD, MPH Co-Investigator and Curation Lead  cerimele@uw.edu
Joseph Cerimele MD, MPH
UW Medicine Department of Psychiatry

My clinical work includes working as a consulting psychiatrist in two ways in primary care clinics – one as a direct consultant using telehealth technology to see patients, and the other as an indirect consultant in a population based model of care called collaborative care. The Portal includes resources on both models of care. The Telepsychiatry Toolkit from the American Psychiatric Association provides background information on telepsychiatry, along with clinical training, reimbursement, and technical considerations. Telepsychiatry is one way to distribute specialist physician visits to areas with fewer specialists such as psychiatrists. Reimbursement for telehealth is expanding under MACRA, and 49 states cover telepsychiatry under Medicaid. Collaborative care is team based care involving the primary care clinician, a care manager, and a psychiatric consultant. Resources from the AIMS Center at the University of Washington are included in the Portal and are standard tools for clinics to use in deciding whether or how to implement collaborative care. One recent example is the Financial Modeling Workbook that can help organizations understand associated costs and revenues. Is your site working on new strategies for telehealth or on implementing a population based model of care such as collaborative care? Check out the Portal for resources.


Social determinants of health are central to health care

​   Ian Bennett, MD, PhD Professor, UW Department of Family Medicine Co-Director ibennett@uw.edu  ​
Ian Bennett, MD, PhD
UW Medicine, Departments of Family Medicine and Psychiatry & Behavioral Sciences

Early this week I had an encounter with a relatively new patient to me, which made me pause. She was desperately upset, saying she had been told by an ED physician that she “has lung cancer.” The physician had been evaluating her for possible pneumonia. I reviewed the discharge materials she had been given and found there was no mention of any sign of abnormalities in the range of imaging that was done. It turned out that this 50-year-old Washington native had dropped out of school early and was illiterate, which contributed to her misunderstanding the comments of the ED doc (probably related to them doing some smoking cessation counseling). Unsurprisingly, she and her family faced additional obstacles to health care involving lack of employment, housing, and insurance.

While sociologists, educators, and economists have pointed to the role of social factors in health and well being for decades it has only been in recent years there has been increasing awareness of the crucial role that social determinants of health (e.g., education and income), have on health throughout the lifecourse. As described in a recent article about screening for social determinants in primary care pediatrics, health care delivery sites can make a big difference in connecting patients to community services. These linkages improve the effectiveness of the health care delivery as well and lead to better health outcomes. The accountable communities of health (ACHs), throughout the state of Washington have made connection of community resources to the health care delivery systems a priority. WA Portal

Find out more about the opportunities to link community services to the work of care delivery sites by searching “social determinants” on the WA Portal resource library.