Implementation of an Interoperable Data Coordination Platform to Strengthen HIV Primary Care, Care Coordination, and Electronic Health Record Integration - Migrant Health Center, Western Region, Inc. (MHC) is a Community-Based 330(g)(e)(h), nonprofit, 501(c)(3) federally qualified health center providing integrated health services through sixteen clinical sites in northwestern, western, and southwestern Puerto Rico. Since 1995, MHC has provided Ryan White Part C Early Intervention Services for people living with HIV (PWH). MHC is applying under the Electronic Health Record and Data Coordination (EHR&DC) activity category to strengthen its HIV care infrastructure through implementation of ClinicLynk, an interoperable platform that integrates data across the organization’s existing electronic health record and related clinical information systems. The project will improve care coordination, data integration, pharmacological safety, chronic disease monitoring, and data-informed clinical decision-making while reducing manual data review and strengthening patient navigation for low-income PWH. During calendar year 2025, MHC served 311 active Ryan White patients, enrolled 10 new people with HIV into care and successfully re-engaged 21 individuals who had previously fallen out of care, tracked 1,839 referrals, and documented 728 missed appointments, a 16% no-show rate, highlighting the need for enhanced interoperability and proactive care coordination. These patients generated 740 HIV medical visits, 886 viral load tests, 901 CD4 tests, 655 behavioral health visits, 1,970 non-medical case management encounters, and 3,256 medical case management and adherence counseling encounters. MHC currently uses eClinicalWorks (eCW), Relevant, CAREWare, TriYoung, laboratory portals, and insurance portals to support HIV care and related services. Although essential, these systems do not provide one unified, timely view of patient needs across the HIV care continuum, requiring staff to manually review multiple platforms to monitor appointments, labs, referrals, adherence needs, chronic disease indicators, and care coordination activities. ClinicLynk will support integrated dashboards, care gap identification, risk stratification, and timely interventions to improve retention in care and overall health outcomes. The platform will help identify patients at risk for HIV care gaps, delayed laboratory monitoring, medication adherence concerns, uncontrolled chronic conditions, hospitalization, and loss to follow-up. Rather than replacing MHC’s existing EHR, ClinicLynk will enhance the organization’s data infrastructure by integrating relevant data sources and supporting timely, patient-centered interventions. MHC requests $150,000 for the one-year project period (September 1, 2026–August 31, 2027) and requests funding preference with supporting documentation included in Attachment 2. The project will benefit low-income, uninsured, underinsured, and medically underserved PWH across western Puerto Rico by strengthening organizational capacity to deliver coordinated, high-quality HIV primary care through enhanced data infrastructure, improved workflow efficiency, and sustainable technology-supported care management. By the end of the project period, MHC expects to strengthen HIV care infrastructure, improve data coordination, enhance patient navigation, and increase organizational capacity to deliver high-quality HIV primary care for low-income people living with HIV.
