JMIR Publications

ABSTRACT

Background:

Health systems increasingly screen patients for social and whole-person needs, yet electronic health record (EHR) data often remain passive if there is no workflow that converts identified need into structured action during routine care. In safety-net and federally qualified health center (FQHC) settings, this gap is especially consequential because clinicians must respond to multidomain need within time-constrained encounters while also meeting documentation, coding, and referral requirements.

Objective:

This study evaluated an Epic-based digital workflow that links a Whole PERSON Health Score (WPHS) assessment to a Best Practice Advisory (BPA), SmartSet, and accountability dashboard in a safety-net FQHC network, with the aim of moving from whole-person screening to actionable, auditable response in routine care.

Methods:

We conducted an observational implementation evaluation of the WPHS BPA–SmartSet workflow at Riverside University Health System using the RE-AIM framework. The analytic dataset linked WPHS assessments with BPA alerts from January 2023 through February 2026. We examined screening reach, conversion of at-risk assessments into BPA-linked workflow opportunities (Implementation), downstream action after alerts (Effectiveness), variation across clinics (Adoption), and monthly trends over time (Maintenance).

Results:

During the study period, 150,363 WPHS assessments were completed among 103,018 unique patients; 96.3% of assessments identified at least one at-risk domain, with a mean of 3.44 at-risk domains per assessment. Among 144,743 eligible at-risk assessments, 81,045 were linked to a BPA (linkage rate 56.0%). Across 95,255 BPA alerts, clinicians opened the SmartSet in 81.2% of alerts and documented at least one downstream action in 80.8%; CPT-related activity occurred in 76.8% of alerts, Z-code documentation in 31.1%, and referrals in 23.6%. Workflow performance improved over time, with BPA linkage among at-risk assessments increasing from 16.3% to 71.8% and downstream action from 7.3% to 66.4% between January 2023 and February 2026. Performance was strongest in high-volume primary care and community health clinics.

Conclusions:

In this safety-net FQHC setting, whole-person need was common and frequently multidomain, and an Epic BPA–SmartSet workflow supported high levels of clinician engagement and documented action once alerts appeared in the EHR. The principal implementation bottleneck was the upstream conversion of eligible at-risk assessments into provider-facing alerts, not clinician response after alert presentation. For digital health leaders seeking to operationalize whole-person care, the findings suggest that EHR-based decision support should prioritize reliable triggering, bundled documentation and referral tasks, and dashboard-based accountability rather than screening alone.