Leveraging Electronic Health Records to Collect and Integrate Outcomes-Based Data in Care

As part of a Ryan White HIV/AIDS Program (RWHAP) Special Projects of National Significance (SPNS) initiative Improving Health Outcomes through the Coordination of Supportive Employment and Housing Services, Gay Men’s Health Crisis (GMHC) updated its data management process to better document housing and employment service outcomes. Enhancements to the electronic health record (EHR) contributed to positive housing, employment, and viral suppression outcomes for clients.

New York, NY

Implementation Guide
Emerging Intervention
Emerging Intervention
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Data utilization approach
Icon for HIV Care Continuum
Viral suppression
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All clients
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RWHAP Part F - Dental; RWHAP Part - F SPNS
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Community-based organization/non-clinical setting
Need Addressed

The collection, management, analysis, and distribution of data to measure client progress on various HIV outcomes and adjust service plans can be extremely resource-intensive without streamlined data entry and management processes.

“Previously, this [housing and employment] type of outcome data was not being tracked. It would get thrown into a progress note or something in a place where it was really hard for us to see what the outcome was because it meant we would have to dig through every progress note and that for 10,000 clients is not feasible.”

Core Elements
Comprehensive care coordination program

GMHC received SPNS funding for Project HEALTH, a comprehensive care coordination program that aims to mitigate structural, clinical, and individual factors that prevent engagement in care, participation in the workforce, housing stability, and viral suppression.

Inclusion of housing and employment indicators in EHR

Along with standard HIV outcomes, GMHC used SPNS funding to make changes in the EHR to collect additional housing and employment indicators.

Monitor EHR data entry for fidelity to procedures and accurate data

GMHC Analytics and Evaluation staff monitored the data entered in the EHR to ensure data entry procedures were being followed and the data were accurate.

Use of new data to monitor client progress and inform client’s service plan

Program staff were able to monitor client progress over time and make any necessary changes to the client’s service plan with these new measures.

Use of aggregate data across the program for reporting and quality improvement

All clinical and programmatic output and outcome level data were entered in a single location which allows the evaluation team to quickly identify quality improvement projects and report on program progress.

“We as an agency had been moving to sort of collecting more outcomes, as well as outputs as a shift. And the [RWHAP] SPNS funding gave us the funding to make the electronic health record updates that we needed to make. Making electronic health record updates to your system is very costly. And so we wanted to be able to capture it in a way that was going to be good for everyone, not just the specific program.”


Enhancements to GMHC’s EHR were evaluated in 2020 as part of the SPNS project, Project HEALTH.  

Category Information
Evaluation data

Clients’ demographic, service, housing, employment, and medical data.


Percentage of clients engaged in care, on medication, and virally suppressed; the number of clients permanently housed; and percentage of clients who had a positive change in employment status.

  • 72% of clients had a positive housing outcome.
  • About half of the clients had a positive employment outcome.
  • 98.5% of clients with a reported viral load in the final months of the program were virally suppressed.

Source: Communication with the Best Practices Compilation team. 2020–2021.

Planning & Implementation

Selection of EHR modifications to make. Staff across GMHC discussed the initiative to ensure updates or modifications to the EHR were useful to multiple programs throughout the agency and fell within the scope of the proposed budget.

Review of data points to track. GMHC determined the programmatic outcomes that would need to be tracked within the EHR. They reviewed the data points with the data team to ensure a common understanding and provide them with feedback on additional data points that would be beneficial to track.

Pilot test of EHR modifications. Once the data collection plan was finalized, the GMHC Analytics and Evaluation team developed a mockup of the EHR modifications for program staff and managers to test and provide feedback. Once finalized, the mockup was sent to the EHR company for development. The EHR company developed the modifications and then pushed them to the test site. This allowed the Analytics and Evaluation team, as well as program staff, to test the modifications. Once the modifications were finalized, it was pushed to the production EHR environment.

Staff training. Finally, the program staff was then trained on data entry procedures.

Data team levels of effort. The EHR Manager dedicates approximately 20 hours a week to meetings with program teams and the EHR representative, mock-up development, testing, and training. The Monitoring and Evaluation Specialist dedicates approximately seven hours a week to meetings with program teams and monitoring data entry. Case Managers and Program Staff dedicate approximately three hours a week to meetings with the Analytics and Evaluation team about the data points, reviewing modifications, and training. Program Managers dedicate approximately five hours a week to meetings with the Analytics and Evaluation team, mock-up review, testing, and training.

  • Staff turnover can jeopardize the continued entry of high-quality programmatic data in the EHR. Therefore, the EHR manager reviews the quality of the data, trains incoming staff, and provides refreshers to existing staff on an ongoing basis as this initiative has continued beyond the RWHAP SPNS funding. All agency staff have been trained to use these enhancements to track client’s housing and employment outcomes data.
  • Housing and workforce development programs use the information collected to track changes to housing and employment status, length of housing stability, and length of employment. This has enabled them to better monitor and coordinate supportive services for their clients.
  • The collection of this data has enabled GMHC to more easily use housing and employment outcome indicators to quickly identify quality improvement projects, report on program progress, and understand how housing and employment outcomes impact the HIV care continuum.

Photo Source: HRSA Ryan White HIV/AIDS Program Photo Library

Lessons Learned
  • GHMC engaged staff from all levels of the organization to build a data-driven culture. When all staff from top to bottom understand the importance of collecting programmatic data, staff are more likely to engage in the process.
  • Specific data entry examples within an internal EHR manual supported the entry of standardized data. Furthermore, a data entry "cheat sheet" that consists of a step-by-step guide and definitions was a useful tool for program staff.
  • Monitoring of data entry should begin early in the implementation to ensure more timely data entry by the program team and allow for quicker identification of additional training needs.

“Before we start a major grant, everybody, all of the grant team, the evaluation team, the program team, sits down and talks about what we're going to need to actually do this. So that when we are building this budget, I know [how much money] I'm going to need [for sustainability]… [and] I can capture the data I need to prove that [the SPNS project is] working.”

Gay Men’s Health Crisis (GHMC)
Shivang Shah, MPH
Director of Analytics & Evaluation

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