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URMC / Clinical & Translational Science Institute / Stories / December 2020 / Region Pioneers Use of Electronic Medical Records for Community Wellness and Health Equity

Region Pioneers Use of Electronic Medical Records for Community Wellness and Health Equity

Better known for its vineyards and imaging technologies, the Rochester-Finger Lakes region does not typically come to mind as a data industry titan. But when it comes to the cutting edge use of electronic medical records for improving community health, step aside Silicon Valley.

An unusual collaboration among three regional data teams has managed to navigate the labyrinth of political, legal and technical challenges that has largely kept digital medical records from becoming widely used for population health reporting. The proof of concept is the Community Health Indicators report, released this month by the Rochester RHIO, Common Ground Health and the University of Rochester Medical Center’s Center for Community Health & Prevention and Clinical & Translational Science Institute.

Now in its second year, the report provides a snapshot of county and regional rates for four key health measures: smoking, high blood pressure, diabetes and adult obesity. Instead of relying on sample surveys and other less comprehensive sources, these measures are pulled from more than a million patient observations securely stored by the Rochester RHIO, the region’s health information exchange. At no time is personally identifiable information made available to the research and data teams.

“The ability to use electronic medical records for improving public health is a game changer, with our region paving the way for others across the U.S.,” said Jill Eisenstein, RHIO president and chief executive officer. “We are fortunate to have community leaders who recognize the power of RHIO’s clinical data for driving health improvement and reducing inequities,” she said, noting that the Greater Rochester Chamber of Commerce provided the impetus and seed money for the initiative.

“The Community Health Indicators are like a patient portal for our region,” said Wade Norwood, Common Ground Health’s CEO, referring to the online platforms that give patients access to their lab results, diagnoses and other clinical information. This initiative aggregates that medical data and analyzes it by region, county, ZIP code, race, ethnicity and socio-economic status.

“The approach lets us to view the forest, not the trees,” said Norwood. “Instead of seeing that an individual patient has her diabetes under control, we see the average control rate for patients diagnosed with a condition. That community-level reporting helps public health officials, organizations, researchers and the public identify disparities and direct resources to neighborhoods and populations where they are needed most.”

As indicators are collected over time, the community can even more effectively track trends, develop responses, and measure progress.

To encourage wide use of the new data, the Community Health Indicators for 13 regional counties are available on, a free, interactive data platform developed by the Center for Community Health & Prevention and the Clinical & Translational Science Institute at the University of Rochester Medical Center. The website allows individuals to discover and analyze health outcomes and social determinants of health across the Finger Lakes region through customizable maps and reports.

Indicators for nine Finger Lakes counties are also included as part of Common Ground’s Regional Health Measures webpage.

“Our community has demonstrated a strong interest this kind in community-level health data,” said Kathleen Holt, senior scientist for the Center for Community Health & Prevention and the Clinical & Translational Science Institute. The Community Health Indicators have been the single most accessed item on over the past year, with 2785 views and 158 downloads of the detailed data set, she reported.

The newly released indicators are based on records from calendar year 2018. Highlights for the 13-county Finger Lakes region include:

  • Diabetes: 82% of patients with a diabetes diagnosis had their disease under control, indicated by an HbA1c level of less than <8.0%.
  • Smoking: 25% of patients say they smoke—worse than the latest national average of 14% reported by the Centers for Disease Control and Prevention (CDC).
  • Obesity: 46% of adult patients are obese (BMI ≥ 30)—worse than the national average of 40% reported by the CDC. ­­
  • High blood pressure: 65% of patients diagnosed with hypertension had their condition under control (≤140/90)—better than the national average of 54% reported by the CDC.

Co-authored by Rebecca Youmell, Susan Hagen and Judy Mendoza

Michael Hazard | 12/7/2020

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