Innovations in Primary Care
Automated EHR Alert Improved Hepatitis B Monitoring Rates at a Primary Care Clinic
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. 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.
Impact of Epic Care Gaps on Hepatitis B Care Retention
Corresponding author: Mark Berg, et al
University of Minnesota, St Paul, Minnesota
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The Annals of Family Medicine
26-May-2026