Electronic Health Record–Embedded Workflow to Operationalize Whole-Person Screening in Safety-Net Primary Care: Observational Implementation Evaluation Study
Journal of Medical Internet Research ·
Background: Health systems increasingly screen patients for social and whole-person needs. Yet, electronic health record data often remain passive when no workflow translates identified needs into structured action during routine care. In safety-net and federally qualified health center (FQHC) settings, this gap is especially consequential because clinicians must address multidomain needs within time-constrained encounters while meeting documentation, coding, and referral requirements. Objective: This study evaluated the implementation and recorded use of an Epic-based digital workflow that links a Whole PERSON Health Score (WPHS) assessment to a Best Practice Advisory (BPA) and SmartSet, along with a separate Power BI accountability dashboard, in a safety-net FQHC network. Methods: We conducted an observational implementation evaluation of the WPHS BPA-SmartSet workflow at Riverside University Health System using the RE-AIM (Reach, Effectiveness, Adoption, Implementation, and Maintenance) framework. We analyzed encounter-level WPHS assessments and BPA presentation records from January 2023 through July 2026. We examined screening reach, temporal correspondence between BPA presentations and preceding qualifying WPHS assessments, recorded downstream workflow activity, variation across clinics, and trends over time using descriptive statistics. As a sensitivity analysis, we estimated logistic regression models with clinic fixed effects and 2-way patient- and provider-clustered robust SEs to evaluate temporal patterns in SmartSet opening and downstream workflow activity. Results: During the study period, 177,821 WPHS assessments were completed among 115,022 unique patients; 173,763/177,821 (97.7%) identified at least one qualifying yellow or red domain. Among 107,010 BPA presentations involving 101,297 unique patients, 104,049 (97.2%) were linked to a uniquely identifiable most-recent qualifying WPHS assessment; among these, 99.1% (103,122/104,049) occurred within 7 days. The SmartSet was opened in 82.9% (88,736/107,010) of BPA presentations, and broad structured downstream workflow activity was documented in 82.4% (88,160/107,010); Z-code documentation in 42.6% (45,632/107,010), and referrals in 23.4% (25,061/107,010). SmartSet opening increased from 41.3% (262/634) in January 2023 to 94.3% (4262/4520) in July 2026. Conclusions: In this safety-net FQHC setting, whole-person need was common and often multidomain, and an Epic BPA-SmartSet workflow was associated with high rates of SmartSet opening and documented downstream workflow activity across observed BPA presentations. BPA presentations were highly concordant with preceding qualifying WPHS assessments, and workflow activity increased substantially over the implementation period. For digital health leaders seeking to operationalize whole-person care, the findings support electronic health record–based decision support that surfaces identified need, bundles documentation and referral tasks, and pairs point-of-care workflow with visible implementation monitoring, rather than relying on screening alone.