Challenges involved in establishing a web-based clinical decision support tool in community health centers.

Implementation lessons: Establishing a shared 'hub-and-spoke,' web-based clinical decision support system (CDSS) in an EHR shared by >600 community health centers incurred a myriad of challenges, which are summarized here to guide others seeking to use similar CDSS. Legal and compliance challenges involved ensuring secure data exchanges, determining which entity maintains data records, and deciding which data are sent to the CDSS. Technical challenges involved using lab data from multiple sources and improving the CDSS' cache routine performance in its new setting. Clinical implementation challenges involved identifying optimal strategies for generating data on CDSS use rates, modifying the CDSS functionality for obtaining clinician/staff feedback, and customizing the risk thresholds that trigger the CDSS for the new setting.

Priorities Wizard: Multisite Web-Based Primary Care Clinical Decision Support Improved Chronic Care Outcomes with High Use Rates and High Clinician Satisfaction Rates.

INTRODUCTION: Priorities Wizard is an electronic health record-linked, web-based clinical decision support (CDS) system designed and implemented at multiple Health Care Systems Research Network (HCSRN) sites to support high quality outpatient chronic disease and preventive care. The CDS system (a) identifies patients who could substantially benefit from evidence-based actions; (b) presents prioritized evidence-based treatment options to both patient and clinician at the point of care; and (c) facilitates efficient ordering of recommended medications, referrals or procedures. METHODS: The CDS system extracts relevant data from electronic health records (EHRs), processes the data using Web-based clinical decision support algorithms, and displays the CDS output seamlessly on the EHR screen for use by the clinician and patient. Through a series of National Institutes of Health-funded projects led by HealthPartners Institute and the HealthPartners Center for Chronic Care Innovation and HCSRN partners, Priorities Wizard has been evaluated in cluster-randomized trials and expanded to include over 20 clinical domains. RESULTS: Cluster-randomized trials show that this CDS system significantly improved glucose and blood pressure control in diabetes patients, reduced 10-year cardiovascular (CV) risk in high-CV risk adults without diabetes, improved management of smoking in dental patients, and improved high blood pressure identification and management in adolescents. CDS output was used at 71-77 percent of targeted visits, 85-98 percent of clinicians were satisfied with the CDS system, and 94 percent reported they would recommend it to colleagues. CONCLUSIONS: Recently developed EHR-linked, Web-based CDS systems have significantly improved chronic disease care outcomes and have high use rates and primary care clinician satisfaction.

Gaps in Well-Child Care Attendance Among Primary Care Clinics Serving Low-Income Families.

BACKGROUND AND OBJECTIVES: It is unclear which specific well-child visits (WCVs) are most frequently missed and whether age-specific patterns of attendance differ by race or insurance type. METHODS: We conducted a retrospective cohort study of children 0 to 6 years old between 2011 and 2016 within 2 health networks spanning 20 states. WCVs were identified by using International Classification of Diseases, Ninth and 10th Revisions and Current Procedural Terminology codes. We calculated adherence to the 13 American Academy of Pediatrics-recommended WCVs from birth to age 6 years. To address data completeness, we made 2 adherence calculations after a child's last recorded WCV: 1 in which we assumed all subsequent WCVs were attended outside the network and 1 in which we assumed none were. RESULTS: We included 152 418 children in our analysis. Most children were either publicly insured (77%) or uninsured (14%). The 2-, 4-, and 6-month visits were the most frequently attended (63% [assuming no outside care after the last recorded WCV] to 90% [assuming outside care]), whereas the 15- and 18-months visits (41%-75%) and 4-year visit (19%-49%) were the least frequently attended. Patients who were publicly insured and uninsured (versus privately insured) had higher odds of missing WCVs. Hispanic and Asian American (versus non-Hispanic white) patients had higher odds of attending WCVs. DISCUSSION: The 15- and 18-month WCVs as well as the 4-year WCV are the least frequently attended WCVs. The former represent opportunities to identify developmental delays, and the latter represents an opportunity to assess school readiness.

A case of severe MAGIC syndrome treated successfully with the tumor necrosis factor-alpha inhibitor infliximab.

We report a patient with an overlap of relapsing polychondritis and Behcet disease whose cartilaginous inflammation and genital lesions were refractory to corticosteroids and immunosuppressants, but fully remitted with the tumor necrosis factor-alpha inhibitor, infliximab. We believe this case represents the first report of a response to a tumor necrosis factor inhibitor in a patient with mouth and genital ulcerations with inflamed cartilage syndrome.

Repertoire diversification in mice with an IgH-locus-targeted transgene for the rearranged VH domain of a physiologically selected anti-ssDNA antibody.

To test the fate of developing B cells with autoreactive receptor components, we studied mice homozygous for a knock-in transgene coding the VH domain of an IgM ssDNA-binding antibody. The transgene has unmutated C57 BL/6 V gene segments. Homozygous knock-in mice developed normal numbers of spleen and bone marrow B cells and normal serum Ig concentrations, and had the same low level of serum anti-ssDNA antibody as non-transgenic mice. Mature B cells expressed the transgene, and it underwent mutation and class switching. In young knock-in animals, nearly all IgM and some IgG cDNA clones from bone marrow and spleen contained the transgene V(H)D(H)J(H), with few or no mutations. In many IgM clones from older animals, however, and many IgG clones from both young and old mice, VH domains were revised by productive replacement with a new V(H)D(H) segment. VL segments were diverse. Immunized homozygous knock-in mice produced serum antibodies to polysaccharide, nucleic acid and protein antigens. Monoclonal IgM and IgG antibodies to nucleic acids used either transgenic or revised VH domains; but all of 20 IgG monoclonal antibodies to thyroglobulin used revised VH domain genes. Thus, B cells expressing an autoreactive (ssDNA-binding) VH domain did progress through development and were precursors for cells producing IgM and IgG, but underwent extensive VH gene revision in diversification of antibody responses.