New workflow tweaks are narrowing gaps in cardio‑kidney‑metabolic screening more effectively than education campaigns alone, a recent population‑health roundtable highlighted.
Hands‑On Changes Boost Urine Testing
At Boston Medical Center, primary‑care clinics switched to a “clinic collect” model, handing patients a urine collection cup during rooming instead of sending them to a separate lab. The shift, described by Katelyn O’Brien, PharmD of BMC, led to a measurable rise in urine albumin‑to‑creatinine ratio (uACR) completion rates.
Similarly, the Beth Israel Lahey Health system is training medical assistants—not physicians—to trigger uACR orders for patients with hypertension or type‑2 diabetes, according to Sylvia Rosas, MD of the Joslin Diabetes Center. Rosas compared the uACR shortfall to colonoscopy preparation, noting that while more than 80% of colonoscopy patients follow prep instructions, fewer than half of eligible patients complete uACR testing.
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At Yale School of Medicine, Ralph Riello, PharmD reported embedding automated nudges into a decision‑support trial. The system flags patients missing only a uACR result and automatically generates an order when an on‑site lab is available. He also creates zip‑code heat maps to pinpoint underserved areas, guiding outreach and community‑screening efforts.
Streamlining Specialist Input
BMC’s e‑consult platform lets primary‑care clinicians or pharmacists route questions to specialists without a formal referral, reducing patient confusion about which specialist to contact for medication changes, said Emily Persson, PharmD. The model also supports a growing ambulatory pharmacy team of more than 60 clinical pharmacists embedded across specialties, expanding pharmacists’ role in titrating guideline‑directed therapies and handling prior authorizations.
Ralph Riello, PharmD, highlighted the importance of not maximizing a single drug class before adding the next.
In the middle of the discussion, it became clear that these workflow fixes resemble past efforts to improve diabetes monitoring, where simple point‑of‑care testing boosted HbA1c screening rates. The current emphasis on uACR mirrors that pattern, suggesting that embedding tests into routine visits can overcome longstanding underuse without large‑scale awareness campaigns.
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Screening improved quickly.
Faculty outlined concrete actions for the next year. O’Brien plans to broaden pharmacists’ collaborative practice agreements to include uACR ordering. Varsha Tanguturi, MD, medical director of CKM Compass at Mass General Brigham Population Health, said her team will work to cross patients over between disease silos, adding therapies that address multiple conditions simultaneously. The group agreed that modest operational changes—like handing a specimen cup at checkout or automating order prompts—can close screening gaps that education alone has failed to bridge.
According to the report, the new processes lifted uACR completion from roughly 45% to over 70% within six months, a change that translates into thousands more patients receiving early intervention.
