Evaluating Implementation of an EHR-enabled Alzheimer’s Disease Care Pathway in Primary Care to Enhance Assessment and Detection Practices
Kimberly Huntington-Alfano1, Amita Pai2, Holly Jain3, Sarah Gallant3, Cecilia McAlear3, Caitlin Rivet4, Sarah Moore4, Kylie Prehn1, Brent Forester4
1Midwestern University, 2Corewell Health William Beaumont University Hospital, 3Brain Health Leaders Network, 4Tufts University School of Medicine
Objective:
This initiative seeks to evaluate the implementation of an electronic health record (EHR) enabled Alzheimer’s disease (AD) care pathway and AD assessment and detection practice outcomes.
Background:
The 2025 Alzheimer’s Association Special Report indicated that nearly 80% of Americans want to know if they had AD before experiencing symptoms or prior to symptoms interfering with daily activities. While a brief cognitive assessment (CA) is a required component of the Medicare Annual Wellness Visit (AWV), PCP CA practices remain suboptimal, with 58% of surveyed PCPs citing time constraints as a barrier. To streamline workflows and measure AD assessment practices, Midwestern University, Corewell Health, and Tufts Medicine implemented EHR-enabled AD care pathways in primary care settings.
Design/Methods:
In October 2025, all sites began implementing EHR-integrated cognitive screening tests (MoCA, Mini-Cog, MMSE, or the SLUMS) with auto-score features, for patients presenting with cognitive concerns or during AWVs. Tools to enhance further cognitive evaluation include an OPA (“our practice advisory”) and a cognitive impairment SmartSet. Primary endpoints include number of eligible patients that receive a CA, number with an abnormal CA score, and number receiving further workup, including labs, imaging, and referrals.
Results:
Baseline data pre-implementation across three sites over 6 months indicates that 18% of eligible patients received a CA; of those, 18.6% received an abnormal screening score, and 13% had lab testing completed within the last 6 months to rule out reversible causes of cognitive impairment. Ultimately, 0.25% of eligible patients during the baseline period received a new AD diagnosis code (G30.0, G30.1, G30.8, G30.9).
Conclusions:
Baseline data highlights gaps in use of CA for eligible patients in primary care, and reinforces the need for continued education and standardized, EHR-integrated workflows. Future analyses will evaluate active study period data and changes relative to baseline.
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