246055 Designing a system to support and measure the impact of cardiovascular disease intervention across Colorado

Monday, October 31, 2011

Amy Bubar, MPH , CPC Community Health, Aurora, CO
Mori J. Krantz, MD, FACC , CPC Community Health, Aurora, CO
Raymond Estacio, MD, FACP , CPC Community Health, Aurora, CO
Stephanie Coronel, MPH, CHES , CPC Community Health, Aurora, CO

Colorado Heart Healthy Solutions (CHHS) is a comprehensive program designed to improve cardiovascular health across the state. Focusing on the underserved population, CHHS utilizes Community Health Workers (CHWs) to screen individuals for various heart disease indicators, and provide case management to those deemed at-risk. At-risk clients are those who have a heart disease indicator not at goal per national guidelines.


The Outreach, Screening and Referral (OSCAR) system was designed to provide a user-friendly application that CHWs can use to provide evidence-based health recommendations, track client interaction and community resource data, and allow staff to monitor the overall program performance.


In early 2009 an external software vendor was contracted to design a system according to specifications that supported the objectives of CHHS. The system was launched later that year and includes a tablet interface for each remote CHW, a web-based application for program administration, and a SQL server where data from disparate communities are synchronized in real time and stored in a central repository. Results:

Eighteen CHWs of varying computer abilities now use OSCAR to support clients across 26 Colorado counties. Because CHWs enter client data into OSCAR during the interaction, the system generates customized, evidence-based health recommendations, guides the CHW through motivational interviewing to set health improvement goals, and compares data with prior interactions. Most importantly, OSCAR measures temporal changes in health indicators at the client level, within communities and across Colorado. Among the first 2,600 at-risk individuals to be retested (mean time=11±7 months), CHHS has seen a mean decrease in LDL-cholesterol: 16.9±39.9 mg/dL (p=<0.001); and systolic blood pressure: 4.3±16.4 mm Hg (p=<0.001).


OSCAR is a novel demonstration of a comprehensive health information technology used to manage a large-scale public health program and monitor individual health outcomes, outside the health-care delivery system.

Learning Areas:
Administer health education strategies, interventions and programs
Chronic disease management and prevention
Communication and informatics
Conduct evaluation related to programs, research, and other areas of practice
Implementation of health education strategies, interventions and programs
Public health or related education

Learning Objectives:
1. Describe the benefits of a centralized data collection system 2. Differentiate how an interactive data collection system can educate and promote health by engaging clients in real-time assessments of client progress 3. List the positive program outcomes data provided by the system

Keywords: Information Technology, Community Health Promoters

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: I am qualified to present because I oversee the outreach, screening, and referral system for a cardiovascular outreach program.
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.