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Streamlining Autism Diagnosis: How Electronic Health Record Tools Increased Early Identification and Referrals in a Primary Care Network

Streamlining Autism Diagnosis: How Electronic Health Record Tools Increased Early Identification and Referrals in a Primary Care Network 1024 575 Erin Gregory
Toddler playing with toys

In their recent publication, Boosting Autism Screening and Referrals with EHR-Integrated Tools at Well-Child Visits, Elizabeth W. Barnhardt, DO, MAEd, developmental-behavioral pediatrician at Nationwide Children’s Hospital and faculty member at The Ohio State University College of Medicine, and her team describe a quality improvement initiative designed to improve the early identification of autism spectrum disorder (ASD) across a large primary care network. By embedding screening tools and clinical decision support into the electronic health record (EHR), the project helped increase both screening completion and referral follow-through — without adding burden to already packed well-child visits.

Background and Rationale

Despite guidelines recommending autism-specific screening at 18- and 24-month visits, providers in the hospital’s 14-site primary care network reported inconsistent follow-through, limited time and uncertainty around next steps. Serving more than 100,000 patients — 81% on Medicaid, 48% identifying as Black or African American, and 35% requiring interpreters — this patient population is at elevated risk for delayed diagnosis.

“The biggest motivator was to address the number of health inequities that exist in the autism diagnostic process,” says Dr. Barnhardt. “This delay in diagnosis leads to delays in critical interventions that can improve developmental outcomes.”

A Digital Transformation

One of the first steps was digitizing the Modified Checklist for Autism in Toddlers, Revised with Follow-Up (M-CHAT-R/F). The tool was integrated into the EHR with automated scoring and branching logic, making it easier to complete both initial screening and follow-up interviews in real time. Education sessions, referral order sets and interpreter-supported workflows ensured equitable access and consistent screening across all language groups.

Measurable Impact

Between July 2019 and March 2024, the project led to:

  • Screening completion at 24-month visits increased from 79% to 94%.
  • Follow-up question completion for medium-risk scores reached 95%.
  • Referral rates after positive screening rose from 10% to 45%, with rates holding at 38% after 18 months.
  • 70% of referred children were sent to speech therapy, 73% to developmental-behavioral pediatrics (DBP), and 47% to early intervention (EI) services.

These improvements came without requiring longer visits or additional appointments — a key factor in provider and family buy-in.

Next Steps

The study authors note key limitations, including the inability to track external referrals made outside the institution and the fact that referral placement could not be directly linked to patient outcomes. Looking ahead, the team is working to bridge the gap between referral and evaluation to ensure that children not only get referred, but also receive timely services.

“Our next step is to evaluate whether patients are actually connecting to appropriate services based on referrals placed at the time of screening for autism and address any barriers which might exist,” says Dr. Barnhardt.

The team also plans to expand the initiative to include screening at 18-month visits, aligning with Bright Futures Guidelines and targeting even earlier identification. As implementation expands, continued research will be essential — not just to track referral rates, but to assess actual service connection, age of diagnosis and long-term developmental outcomes.

 

Reference:
Vundavalli S, Brown CM, Chaparro JD, Chandawarkar A, Bester S, Newmeyer A, Barnhardt EW. Boosting Autism Screening and Referrals with EHR-Integrated Tools at Well-Child Visits. J Dev Behav Pediatr. 2024 Nov-Dec 01;45(6):e578-e584.

Image credit: Adobe Stock

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