In the bustling urban landscape of St. Paul, Minnesota, an innovative transformation unfolded within a safety-net primary care clinic that sought to address a persistent challenge in hepatitis B management. Chronic hepatitis B, a viral infection impacting the liver, necessitates vigilant monitoring through regular blood tests to avert severe complications such as liver failure and hepatocellular carcinoma. However, routine surveillance often faltered in primary care settings, largely due to fragmented workflows and the absence of systematic reminders during patient visits. This scenario mirrored a nationwide struggle to provide consistent care for chronic hepatitis B patients, many of whom slipped through the cracks after initial specialist referrals.
The clinic’s breakthrough came in the form of an automated electronic health record (EHR) alert integrated within the widely used Epic system. Recognizing that many patients with chronic hepatitis B returned to primary care for unrelated health issues and that liver specialists’ follow-up was inconsistent, the health system introduced a new alert mechanism. Introduced in May 2024, this alert flagged any patient who was overdue for a critical lab test—the hepatitis B DNA test, a marker essential for assessing viral load and guiding therapeutic decisions. By systematically surfacing this care gap during routine visits, the alert embedded proactive monitoring directly into the clinic’s existing workflows.
Prior to the alert’s implementation, efforts to recall patients using traditional outreach methods such as phone calls, letters, and appointment scheduling largely faltered. These approaches were not only labor-intensive but also frequently ineffective, given patients’ complex social determinants of health and competing priorities. The automated alert circumvented these limitations by capitalizing on in-person visits, prompting clinic staff—nurses, medical assistants, and physicians alike—to address hepatitis B monitoring opportunistically. This seamless integration epitomized a shift toward leveraging digital health tools to enhance preventive care delivery at the point of contact.
Evaluating the impact of this innovation over the subsequent 14 months revealed compelling improvements. Among 104 patients with chronic hepatitis B managed within the clinic, those not requiring concurrent liver cancer screening exhibited a remarkable increase in timely hepatitis B DNA test completion—from 34 percent prior to the alert to 51 percent afterward. This significant uptick underscored the power of systematic electronic prompts in overcoming previously entrenched barriers. Across the entire patient cohort, the overall monitoring rate climbed to 27 percent, surpassing national benchmarks that typically hovered between 11 and 21 percent, thus establishing the clinic as a leader in hepatitis B care retention.
This advance holds broader implications in the realm of chronic disease management and primary care innovation. Hepatitis B’s often silent progression underscores the critical need for sustained surveillance. Yet, monitoring has historically been compromised by disjointed care transitions and competing clinical priorities during brief office visits. By proactively embedding EHR alerts that capitalize on every interaction with patients, the health system has showcased a scalable strategy to combat care gaps that transcend hepatitis B, offering a template for managing other chronic infections and conditions.
Technically, the alert leverages Epic’s sophisticated care gap module, which continuously analyzes patient records against evidence-based guidelines to identify overdue preventive services and tests. Once triggered, the alert prompts clinical staff within the standard workflow, accompanied by actionable recommendations to order the necessary hepatitis B DNA assay. This minimizes disruption while maximizing clinical uptake, as providers receive real-time feedback nudging them toward guideline-concordant care. Such integration represents the maturation of health information technology from passive data repositories to dynamic clinical decision support engines that actively shape care in real-world practice.
The success of the intervention was underpinned by multidisciplinary collaboration that aligned clinical leadership, informatics specialists, and frontline care teams. By engaging staff to iteratively design and refine alert parameters and workflows, the implementation fostered ownership and responsiveness. Training sessions clarified the clinical significance of hepatitis B DNA testing, and feedback loops captured user experiences, driving continuous quality improvement. These organizational behaviors augmented the technological innovation, illustrating that digital solutions flourish when coupled with human-centered design and culture change.
Moreover, this case study illuminates the critical importance of addressing social determinants influencing patient engagement. Although electronic alerts cannot directly mitigate barriers such as transportation, language proficiency, or socioeconomic instability, consolidating needed testing during opportunistic visits reduces reliance on separate outreach efforts that may fail due to these challenges. By streamlining care delivery within existing encounters, the alert mechanism embodies a pragmatic approach tailored to the realities confronting vulnerable urban populations served by safety-net providers.
Looking ahead, the success observed here raises exciting possibilities for expanding automated EHR prompts to other elements of hepatitis B care, such as hepatitis B surface antigen testing, hepatic imaging surveillance, or vaccination. Additionally, replicating this model across diverse healthcare settings and integrating predictive analytics to personalize alert thresholds could catalyze individualized care pathways that anticipate and preempt disease progression. The implications for chronic disease management are profound, as health systems increasingly harness digital infrastructure to elevate care quality and equity.
This study, led by Mark Berg and colleagues at the University of Minnesota, illustrates how modern informatics can bridge longstanding gaps in primary care delivery. By embedding automated alerts within familiar clinical routines, the health system not only improved hepatitis B monitoring rates but also advanced a paradigm wherein technology augments clinician capacity rather than adding burden. This symbiotic relationship between human expertise and technological sophistication is likely to define the future trajectory of primary care practice.
In summary, the deployment of an automated hepatitis B DNA test alert within the Epic EHR at an urban safety-net clinic yielded measurable improvements in monitoring adherence among patients with chronic hepatitis B. The intervention transcended conventional outreach methods by harnessing routine clinical encounters, empowering care teams to close care gaps in a timely, efficient manner. The observable increase from 34 to 51 percent in timely testing within the high-risk subgroup vividly demonstrates the clinical efficacy of embedding automated decision support tools to ensure adherence to recommended surveillance protocols.
This innovation not only enhances patient outcomes by enabling earlier detection of viral activity and timely intervention but also heralds a scalable blueprint for addressing chronic disease management challenges endemic across primary care settings. As health systems confront rising chronic disease burdens and strive for more equitable care, leveraging EHR-based automation emerges as a potent strategy for transforming preventive health services and safeguarding populations at risk.
The continuous evolution of EHR functionalities from static record-keeping systems to proactive clinical governance platforms represents a pivotal advancement in healthcare delivery. In this context, the success of the hepatitis B monitoring alert underscores the imperative for health informatics to remain closely integrated with clinical workflows, fostering seamless real-time interventions that resonate with providers and patients alike. This alignment is poised to drive further innovations that recalibrate the balance between technology and human care in mutually reinforcing ways.
Such achievements, born from iterative design, real-world clinical insight, and patient-centered goals, exemplify the potential unlocked when digital health tools are conscientiously deployed to address entrenched care disparities. The promising results at the St. Paul clinic illuminate the path toward a future where chronic infections like hepatitis B are managed proactively and persistently, leveraging both human and technological resources to achieve optimal health outcomes.
Subject of Research: Chronic hepatitis B monitoring and care retention using automated electronic health record alerts in a primary care setting.
Article Title: Automated EHR Alert Improved Hepatitis B Monitoring Rates at a Primary Care Clinic
News Publication Date: 26-May-2026
Web References: https://www.annfammed.org/content/24/3/273.pdf
Keywords: Hepatitis B, chronic liver infection, electronic health record, EHR alert, hepatitis B DNA test, primary care, care gaps, disease monitoring, health informatics, preventive care, safety-net clinic, clinical decision support
