Practice Management Toolbox

Implementation of a population-based cirrhosis identification and management system


We identified 2,065 patients who met the case definition of cirrhosis (diagnosed and potentially undiagnosed) and were not in regular liver care. Based on initial review, 1,507 patients had an indication to be seen in the liver clinic. Among the remaining 558, the most common reasons for not requiring liver clinic follow-up were: being seen in other facilities (138 in other VHA and 51 in outside hospitals), followed in other specialty clinics (e.g., liver transplant or infectious disease, n = 93), or absence of cirrhosis based on initial review (n = 165) (see Figure 1 for other reasons).

Figure 1. Initial results of P-CIMS implementation. Identification of patients with cirrhosis and their linkage to specialty care. EMR, electronic medical record; HCC, hepatocellular carcinoma.

We used two different strategies to reach out to the patients. Of the 1,507 patients, 597 were previously seen in the liver clinics but were lost to follow-up. These patients were contacted directly by the liver clinic staff. The other 910 patients with cirrhosis (of 1,507) had never been seen in the ambulatory liver clinics (n = 559) or were seen more than 2 years before the implementation of cirrhosis tracker (n = 351). These patients were reached through their PCPs. We used standard electronic medical record templates to request PCP’s assistance in reviewing patients' records and submitting a liver consultation after they discussed the need for liver evaluation with the patient.


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