Changes in disparities following the implementation of a health information technology-supported quality improvement initiative.

BACKGROUND: Health information technology (HIT)-supported quality improvement initiatives have been shown to increase ambulatory care quality for several chronic conditions and preventive services, but it is not known whether these types of initiatives reduce disparities. OBJECTIVES: To examine the effects of a multifaceted, HIT-supported quality improvement initiative on disparities in ambulatory care. DESIGN: Time series models were used to assess changes in racial disparities in performance between white and black patients for 17 measures of chronic disease and preventive care from February 2008 through February 2010, the first 2 years after implementation of a HIT-supported, provider-directed quality improvement initiative. PATIENTS: Black and white adults receiving care in an academic general internal medicine practice in Chicago. INTERVENTIONS: The quality improvement initiative used provider-directed point-of-care clinical decision support tools and quality feedback to target improvement in process of care and intermediate outcome measures for coronary heart disease, heart failure, hypertension, and diabetes as well as receipt of several preventive services. MAIN MEASURES: Modeled rate of change in performance, stratified by race and modeled rate of change in disparities for 17 ambulatory care quality measures KEY RESULTS: Quality of care improved for 14 of 17 measures among white patients and 10 of 17 measures among black patients. Quality improved for both white and black patients for five of eight process of care measures, four of five preventive services, but none of the four intermediate outcome measures. Of the seven measures with racial disparities at baseline, disparities declined for two, remained stable for four, and increased for one measure after implementation of the quality improvement initiative. CONCLUSIONS: Generalized and provider-directed quality improvement initiatives can decrease racial disparities for some chronic disease and preventive care measures, but achieving equity in areas with persistent disparities will require more targeted, patient-directed, and systems-oriented strategies.

Pulsating bead-based assay.

In recent years, there has been a growing interest in using porous microbeads such as agarose beads as solid supports to bind target molecules from complex fluid samples. Porous beads have large surface area to volume ratios and high receptor concentrations, and they facilitate relatively high sensitivity detection and multiplexing. Unfortunately, to take full advantage of the porous beads' attributes, long incubation times are needed due to the relatively slow mass transfer of target molecules from the exterior solution into the beads' interior. To accelerate the mass transfer process, we propose a novel assay in which functionalized porous beads are periodically compressed and expanded. Preliminary experiments were carried out to compare the performance of the pulsating beads with that of conventional, nonpulsating beads. These experiments indicate that the pulsating beads significantly accelerate binding rates with minimal increase in nonspecific binding. Thus, pulsing has the potential of significantly reducing assay time.

Changes in performance after implementation of a multifaceted electronic-health-record-based quality improvement system.

BACKGROUND: Electronic health record (EHR) systems have the potential to revolutionize quality improvement (QI) methods by enhancing quality measurement and integrating multiple proven QI strategies. OBJECTIVES: To implement and evaluate a multifaceted QI intervention using EHR tools to improve quality measurement (including capture of contraindications and patient refusals), make point-of-care reminders more accurate, and provide more valid and responsive clinician feedback (including lists of patients not receiving essential medications) for 16 chronic disease and preventive service measures. DESIGN: Time series analysis at a large internal medicine practice using a commercial EHR. SUBJECTS: All adult patients eligible for each measure (range approximately 100-7500). MEASURES: The proportion of eligible patients who satisfied each measure after removing those with exceptions from the denominator. RESULTS: During the year before the intervention, performance improved significantly for 8 measures. During the year after the intervention, performance improved significantly for 14 measures. For 9 measures, the primary outcome improved more rapidly during the intervention year than during the previous year (P < 0.001 for 8 measures, P = 0.02 for 1). Four other measures improved at rates that were not significantly different from the previous year. Improvements resulted from increases in patients receiving the service, documentation of exceptions, or a combination of both. For 5 drug-prescribing measures, more than half of physicians achieved 100% performance. CONCLUSIONS: Implementation of a multifaceted QI intervention using EHR tools to improve quality measurement and the accuracy and timeliness of clinician feedback improved performance and/or accelerated the rate of improvement for multiple measures simultaneously.

Disparities in enrollment and use of an electronic patient portal.

BACKGROUND: With emphasis on the meaningful use of electronic health records, patient portals are likely to become increasingly important. Little is known about patient enrollment in, and use of, patient portals after explicit invitation from providers. OBJECTIVES: To examine enrollment in, and use of, an electronic patient portal by race/ethnicity, gender and age. DESIGN: Observational, cross sectional study. PARTICIPANTS: Patients with attending physicians seen at one urban, academic primary care practice between May 2008 and October 2009 who received electronic orders inviting their participation in an electronic patient portal. MAIN MEASURES: (a) Enrollment in the patient portal, (b) Solicitation of provider advice among enrollees, (c) Requests for medication refills among enrollees. KEY RESULTS: Overall, 69% of 7,088 patients enrolled in the patient portal. All minority patients were significantly less likely to enroll than whites: 55% blacks, 64% Latinos and 66% Asians compared with 74% whites (chi-square p < 0.05 for all pairwise comparisons). These disparities persisted in adjusted analyses, although differences for Asians were no longer significant. In addition, the oldest patients were less likely to enroll than the youngest (adjusted OR 0.79, 95% CI 0.65-0.97). Although there were no racial/ethnic disparities in use of the patient portal among enrollees, we found differences by age and gender. The youngest patients were significantly less likely to solicit provider advice or request medication refills than any other age group in unadjusted and adjusted analyses. Similarly, male patients were less likely to solicit provider advice than women in all analyses. CONCLUSION: Large racial/ethnic disparities were seen in enrollment in our patient portal. Among enrollees, use of the portal was similar by race/ethnicity, but not by age or gender. Future efforts to expand use of the patient portal need to address potential mechanisms for these disparities to ensure this technology is accessible to diverse patient populations.

Frequency of inappropriate medical exceptions to quality measures.

BACKGROUND: Quality improvement programs that allow physicians to document medical reasons for deviating from guidelines preserve clinicians' judgment while enabling them to strive for high performance. However, physician misconceptions or gaming potentially limit programs. OBJECTIVE: To implement computerized decision support with mechanisms to document medical exceptions to quality measures and to perform peer review of exceptions and provide feedback when appropriate. DESIGN: Observational study. SETTING: Large internal medicine practice. PARTICIPANTS: Patients eligible for 1 or more quality measures. MEASUREMENTS: A peer-review panel judged medical exceptions to 16 chronic disease and prevention quality measures as appropriate, inappropriate, or of uncertain appropriateness. Medical records were reviewed after feedback was given to determine whether care changed. RESULTS: Physicians recorded 650 standardized medical exceptions during 7 months. The reporting tool was used without any medical reason 36 times (5.5%). Of the remaining 614 exceptions, 93.6% were medically appropriate, 3.1% were inappropriate, and 3.3% were of uncertain appropriateness. Frequencies of inappropriate exceptions were 7 (6.9%) for coronary heart disease, 0 (0%) for heart failure, 10 (10.8%) for diabetes, and 2 (0.6%) for preventive services. After physicians received direct feedback about inappropriate exceptions, 8 of 19 (42%) changed management. The peer-review process took less than 5 minutes per case, but for each change in clinical care, 65 reviews were required. LIMITATION: The findings could differ at other sites or if financial incentives were in place. CONCLUSION: Physician-recorded medical exceptions were correct most of the time. Peer review of medical exceptions can identify myths and misconceptions, but the process needs to be more efficient to be sustainable. PRIMARY FUNDING SOURCE: Agency for Healthcare Research and Quality.

Improving hypertension quality measurement using electronic health records.

BACKGROUND: Simple hypertension outcome measures may not indicate which patients receive poor care. This could be problematic as incentives increase. OBJECTIVE: Compare measured quality using simple outcome measures to more sophisticated measures utilizing data available within an electronic health record. DESIGN: Cross-sectional study. SUBJECTS: A total of 5905 hypertensive adults with 3 or more clinic visits between July 1, 2005 and December 31, 2006 at an internal medicine clinic. MEASURES: We measured simple control as the proportion of diagnosed hypertension patients with their last blood pressure below goal (<140/90 mm Hg or <130/80 if diabetic). We compared this to sequentially more complex measures. RESULTS: Among nondiabetic patients, baseline measurement of control was 58.1% [95% confidence interval (CI), 56.5-59.6]. Counting patients as having adequate care whose last or mean blood pressure was at or below goal raised performance to 75.4%. Accounting for patients prescribed aggressive treatment raised it to 82.5%. Accounting for low diastolic blood pressure raised it to 83.6%. Including patients with undiagnosed hypertension lowered it to 80.5%. For diabetes patients, baseline measurement of control was 29.9% (95% CI, 27.6-32.3) and changed to 46.4%, 72.8%, 76.7%, and 73.6%, respectively. CONCLUSIONS: It is possible to use electronic health record data to devise hypertension measures that may better reflect who has actionable uncontrolled blood pressure, do not penalize clinicians treating resistant hypertension patients, reduce the encouragement of potentially unsafe practices, and identify patients possibly receiving poor care with no hypertension diagnosis. This could improve the detection of true quality problems and remove incentives to over treat or stop caring for patients with resistant hypertension.

Association between prior experiences of discrimination and patients' attitudes towards health care providers collecting information about race and ethnicity.

BACKGROUND: Previously, we reported a high level of comfort among Californians for collecting race/ethnicity information by health care providers (HCPs). However, minorities were less comfortable providing race/ethnicity information and were more worried than non-Hispanic whites about the potential misuse of this information. OBJECTIVE: To determine if perceived experiences of discrimination (both in general and in medical care) were associated with comfort providing race/ethnicity information, and conversely, to worry about providing the information. DESIGN AND PARTICIPANTS: Telephone survey of 480 Californians, including 101 whites, 98 Asians, 173 Hispanics, 82 blacks, and 26 multiracial individuals. MEASUREMENTS: Comfort level giving HCPs information about race/ethnicity (measured on a 1-10 scale, with text anchors of "very uncomfortable" at 1 and "very comfortable" at 10), worry that the information could be used to discriminate against patients, and worry that the information could be used to find undocumented immigrants. Worry was measured using a four-point Likert scale- not worried at all, a little worried, somewhat worried, and very worried. Respondents were also asked about perceived discrimination in general and perceived discrimination in medical care. RESULTS: Compared to whites, Hispanics (Beta-coefficient (BC) = -1.16, SE = 0.51) and Mandarin/Cantonese-speaking Asians (BC = -1.40, SE = 0.65) reported significantly less comfort giving HCPs information about their race/ethnicity, while blacks (BC = 0.70, SE = 0.16), Hispanics (BC = 0.91, SE = 0.18), and multiracial individuals (BC = 0.63, SE = 0.24) were significantly more worried that race/ethnicity information could be used to discriminate against them. Adjusting for perceived experiences of discrimination in general and in medical care partially explained the higher discomfort and worry among minorities. CONCLUSIONS: Perceived experiences of discrimination are associated with greater discomfort and worry about providing race/ethnicity data. Health care institutions should consider how they can address the public's concerns about possible misuses of data.

Finger-actuated, self-contained immunoassay cassettes.

The building blocks for an inexpensive, disposable, luminescence-based microfluidic immunoassay cassette are described, and their integration in a point-of-care diagnostic system is demonstrated. Fluid motion in the cassette is driven by depressing finger-actuated pouches. All reagents needed for the immunoassay can be stored in the cassette in liquid form. Prior to use, the cassette consists of two separate parts. A top storage component contains pouches, sealed storage chambers, a metering chamber, and needle seats. The bottom processing component contains connection needles, a mixing chamber, and a detection chamber with immobilized proteins. Subsequent to sample introduction, the storage and processing components are mated. The needles form hydraulic connections between the two parts and, in some cases, close valves. The pouches are then actuated sequentially to induce flow of various reagents and facilitate process operations. The cassette is compatible with different detection modalities. Both a cassette with immunochromatographic-based detection and a cassette with microbead-based detection were constructed and evaluated. The immunochromatographic cassette was used to detect antibodies to HIV in saliva samples. The bead-based cassette was used to detect the proinflammatory chemokine IL-8. The experimental data demonstrates good repeatability and reasonable sensitivity.

Patients with worse mental health report more physical limitations after adjustment for physical performance.

OBJECTIVE: To determine whether mental health scores are associated with self-reported physical limitations after adjustment for physical performance. Patient-reported physical limitations are widely used to assess health status or the impact of disease. However, patients' mental health may influence their reports of their physical limitations. METHODS: Mental health and physical limitations were measured using the SF-36v2 mental health and physical functioning subscales in a cross-sectional study of 1024 participants. Physical performance was measured using tests of strength, endurance, dexterity, and flexibility. Multivariable linear regression was performed to examine the relationship between self-reported mental health and physical limitations adjusting for age, gender, race/ethnicity, education, body mass index, and measured physical performance. RESULTS: The score distributions for mental health and physical functioning were similar to that of the United States population in this age range. In unadjusted analyses, every 10-point decline in mental health scores was associated with a 4.8-point decline in physical functioning scores (95% Confidence Interval (CI) = -4.2 to -5.3; p < .001). After adjusting for covariables including measured physical performance, every 10-point decline in mental health scores was associated with a 3.0-point decline in physical functioning scores (95% CI = -2.5 to -3.6; p < .001). CONCLUSIONS: People with poor mental health scores seem to report more physical limitations than would be expected based on physical performance. When comparing self-reported physical limitations between groups, it is important to consider differences in mental health.

Health literacy, cognitive abilities, and mortality among elderly persons.

BACKGROUND: Low health literacy and low cognitive abilities both predict mortality, but no study has jointly examined these relationships. METHODS: We conducted a prospective cohort study of 3,260 community-dwelling adults age 65 and older. Participants were interviewed in 1997 and administered the Short Test of Functional Health Literacy in Adults and the Mini Mental Status Examination. Mortality was determined using the National Death Index through 2003. MEASUREMENTS AND MAIN RESULTS: In multivariate models with only literacy (not cognition), the adjusted hazard ratio was 1.50 (95% confidence of interval [CI] 1.24-1.81) for inadequate versus adequate literacy. In multivariate models without literacy, delayed recall of 3 items and the ability to serial subtract numbers were associated with higher mortality (e.g., adjusted hazard ratios [AHR] 1.74 [95% CI 1.30-2.34] for recall of zero versus 3 items, and 1.32 [95% CI 1.09-1.60] for 0-2 vs 5 correct subtractions). In multivariate analysis with both literacy and cognition, the AHRs for the cognition items were similar, but the AHR for inadequate literacy decreased to 1.27 (95% CI 1.03 - 1.57). CONCLUSIONS: Both health literacy and cognitive abilities independently predict mortality. Interventions to improve patient knowledge and self-management skills should consider both the reading level and cognitive demands of the materials.

Health literacy and mortality among elderly persons.

BACKGROUND: Individuals with low levels of health literacy have less health knowledge, worse self-management of chronic disease, lower use of preventive services, and worse health in cross-sectional studies. We sought to determine whether low health literacy levels independently predict overall and cause-specific mortality. METHODS: We designed a prospective cohort study of 3260 Medicare managed-care enrollees in 4 US metropolitan areas who were interviewed in 1997 to determine their demographic characteristics, chronic conditions, self-reported physical and mental health, and health behaviors. Participants also completed the shortened version of the Test of Functional Health Literacy in Adults. Main outcome measures included all-cause and cause-specific (cardiovascular, cancer, and other) mortality using data from the National Death Index through 2003. RESULTS: The crude mortality rates for participants with adequate (n = 2094), marginal (n = 366), and inadequate (n = 800) health literacy were 18.9%, 28.7%, and 39.4%, respectively (P < .001). After adjusting for demographics, socioeconomic status, and baseline health, the hazard ratios for all-cause mortality were 1.52 (95% confidence interval, 1.26-1.83) and 1.13 (95% confidence interval, 0.90-1.41) for participants with inadequate and marginal health literacy, respectively, compared with participants with adequate health literacy. In contrast, years of school completed was only weakly associated with mortality in bivariate analyses and was not significant in multivariate models. Participants with inadequate health literacy had higher risk-adjusted rates of cardiovascular death but not of death due to cancer. CONCLUSIONS: Inadequate health literacy, as measured by reading fluency, independently predicts all-cause mortality and cardiovascular death among community-dwelling elderly persons. Reading fluency is a more powerful variable than education for examining the association between socioeconomic status and health.

Automated review of electronic health records to assess quality of care for outpatients with heart failure.

BACKGROUND: Electronic health records (EHRs) may be used to assess quality of care. OBJECTIVE: To evaluate the accuracy of automated review of EHR data to measure quality of care for outpatients with heart failure. DESIGN: Observational study of quality of care for heart failure comparing automated review of EHR data with automated review followed by manual review of electronic notes for patients with apparent quality deficits (hybrid review). SETTING: An academic general internal medicine clinic with several years' experience using a commercial EHR. PATIENTS: 517 adults with a qualifying International Classification of Diseases, Ninth Revision, diagnosis of heart failure in their EHR data and 2 or more clinic visits over the past 18 months. MEASUREMENTS: Left ventricular ejection fraction (LVEF), prescription of a beta-blocker and an angiotensin-converting enzyme (ACE) inhibitor or angiotensin-receptor blocker (ARB) for patients with left ventricular systolic dysfunction (LVEF <0.40) and prescription of warfarin for patients with comorbid atrial fibrillation. RESULTS: Performance based on automated review of EHR data was similar to that based on hybrid review for assessing LVEF measurement (94.6% vs. 97.3%), prescription of beta-blockers (90.9% vs. 92.8%), and prescription of ACE inhibitors or ARBs (93.9% vs. 98.7%). However, performance based on automated review was lower than that based on hybrid review for prescription of warfarin for atrial fibrillation (70.4% vs. 93.6%), primarily because automated review did not detect documentation of accepted reasons for not prescribing warfarin. LIMITATIONS: The findings may not be applicable to other practices and other EHRs. The authors used EHR data to identify eligible patients, so the study may have excluded some patients with heart failure. Patient charts were manually reviewed only if a provider appeared to fail a quality measure on automated review and did not determine the sensitivity and specificity of automated review according to standard definitions. CONCLUSIONS: Automated review of EHR data to measure the quality of care of outpatients with heart failure missed many exclusion criteria for medications documented only in providers' notes. As a result, it sometimes underestimated performance on medication-based quality measures.

Lab-on-a-chip technologies for oral-based cancer screening and diagnostics: capabilities, issues, and prospects.

The design of a microfluidic lab-on-a-chip system for point-of-care cancer screening and diagnosis of oral squamous cell carcinoma (OSCC) is presented. The chip is based on determining a approximately 30-gene transcription profile in cancer cells isolated from oral fluid samples. Microfluidic cell sorting using magnetic beads functionalized with an antibody against cancer-specific cell-surface antigens (e.g., epithelial cell adhesion molecule [EpCAM]) is described. A comprehensive cancer diagnostics chip will integrate microfluidic components for cell lysis, nucleic acid extraction, and amplification and detection of a panel of mRNA isolated from a subpopulation of cancer cells contained in a clinical specimen.

Assessing the validity of national quality measures for coronary artery disease using an electronic health record.

BACKGROUND: Nationally endorsed, clinical performance measures are available that allow for quality reporting using electronic health records (EHRs). To our knowledge, how well they reflect actual quality of care has not been studied. We sought to evaluate the validity of performance measures for coronary artery disease (CAD) using an ambulatory EHR. METHODS: We performed a retrospective electronic medical chart review comparing automated measurement with a 2-step process of automated measurement supplemented by review of free-text notes for apparent quality failures for all patients with CAD from a large internal medicine practice using a commercial EHR. The 7 performance measures included the following: antiplatelet drug, lipid-lowering drug, beta-blocker following myocardial infarction, blood pressure measurement, lipid measurement, low-density lipoprotein cholesterol control, and angiotensin-converting enzyme inhibitor or angiotensin receptor blocker for patients with diabetes mellitus or left ventricular systolic dysfunction. RESULTS: Performance varied from 81.6% for lipid measurement to 97.6% for blood pressure measurement based on automated measurement. A review of free-text notes for cases failing an automated measure revealed that misclassification was common and that 15% to 81% of apparent quality failures either satisfied the performance measure or met valid exclusion criteria. After including free-text data, the adherence rate ranged from 87.5% for lipid measurement and low-density lipoprotein cholesterol control to 99.2% for blood pressure measurement. CONCLUSIONS: Profiling the quality of outpatient CAD care using data from an EHR has significant limitations. Changes in how data are routinely recorded in an EHR are needed to improve the accuracy of this type of quality measurement. Validity testing in different settings is required.

Literacy and misunderstanding prescription drug labels.

BACKGROUND: Health literacy has increasingly been viewed as a patient safety issue and may contribute to medication errors. OBJECTIVE: To examine patients' abilities to understand and demonstrate instructions found on container labels of common prescription medications. DESIGN: Cross-sectional study using in-person, structured interviews. SETTING: 3 primary care clinics serving mostly indigent populations in Shreveport, Louisiana; Jackson, Michigan; and Chicago, Illinois. PATIENTS: 395 English-speaking adults waiting to see their providers. MEASUREMENT: Correct understanding of instructions on 5 container labels; demonstration of 1 label's dosage instructions. RESULTS: Correct understanding of the 5 labels ranged from 67.1% to 91.1%. Patients reading at or below the sixth-grade level (low literacy) were less able to understand all 5 label instructions. Although 70.7% of patients with low literacy correctly stated the instructions, "Take two tablets by mouth twice daily," only 34.7% could demonstrate the number of pills to be taken daily. After potential confounding variables were controlled for, low (adjusted relative risk, 2.32 [95% CI, 1.26 to 4.28]) and marginal (adjusted relative risk, 1.94 [CI, 1.14 to 3.27]) literacy were significantly associated with misunderstanding. Taking a greater number of prescription medications was also statistically significantly associated with misunderstanding (adjusted relative risk, 2.98 [CI, 1.40 to 6.34] for > or =5 medications). LIMITATIONS: The study sample was at high risk for poor health literacy and outcomes. Most participants were women, and all spoke English. The authors did not examine the association between misunderstanding and medication error or evaluate patients' actual prescription drug-taking behaviors. CONCLUSIONS: Lower literacy and a greater number of prescription medications were independently associated with misunderstanding the instructions on prescription medication labels.

Changes in health for the uninsured after reaching age-eligibility for Medicare.

BACKGROUND: Uninsured adults in late middle age are more likely to have a health decline than individuals with private insurance. OBJECTIVE: To determine how health and the risk of future adverse health outcomes changes after the uninsured gain Medicare. DESIGN: Prospective cohort study. PARTICIPANTS: Participants (N=3,419) in the Health and Retirement Study who transitioned from private insurance or being uninsured to having Medicare coverage at the 1996, 1998, 2000, or 2002 interview. MEASUREMENTS: We analyzed risk-adjusted changes in self-reported overall health and physical functioning during the transition period to Medicare (t(-2) to t(0)) and the following 2 years (t(0) to t(2)). RESULTS: Between the interview before age 65 (t(-2)) and the first interview after reaching age 65 (t(0)), previously uninsured individuals were more likely than those who had private insurance to have a major decline in overall health (adjusted relative risk [ARR] 1.46; 95% confidence interval [CI] 1.03 to 2.04) and to develop a new physical difficulty affecting mobility (ARR 1.24; 95% CI 0.96 to 1.56) or agility (ARR 1.33; 95% CI 1.12 to 1.54). Rates of improvement were similar between the 2 groups. During the next 2 years (t(0) to t(2)), adjusted rates of declines in overall health and physical functioning were similar for individuals who were uninsured and those who had private insurance before gaining Medicare. CONCLUSIONS: Gaining Medicare does not lead to immediate health benefits for individuals who were uninsured before age 65. However, after 2 or more years of continuous coverage, the uninsured no longer have a higher risk of adverse health outcomes.

Patients' attitudes toward health care providers collecting information about their race and ethnicity.

BACKGROUND: Experts recommend that health care providers (HCPs) collect patients' race/ethnicity, but HCPs worry that this may alienate patients. OBJECTIVE: To determine patients' attitudes toward HCPs collecting race/ethnicity data. DESIGN: Cross-sectional survey. PARTICIPANTS: General Internal Medicine patients (n=220). MEASUREMENTS: Perceived importance of having HCPs collect race/ethnicity data, their concerns about this, comfort level providing this information, and reactions to 4 statements explaining the rationale for collecting this. RESULTS: Approximately 80% somewhat or strongly agreed that HCPs should collect information on patients' race/ethnicity. However, 28% had significant discomfort (score 5 or less on 10-point scale) reporting their own race/ethnicity to a clerk, and 58% were somewhat or very concerned that this information could be used to discriminate against patients. Compared with whites, blacks, and Hispanics felt less strongly that HCPs should collect race/ethnicity data from patients (P=.04 for both pairwise comparisons), and blacks were less comfortable reporting their own race/ethnicity than whites (P=.03). Telling patients that this information would be used for monitoring quality of care improved comfort more than telling patients that the data collected (a) was mandated by others, (b) would be used to guide staff hiring and training, and (c) would be used to ensure the patient got the best care possible. CONCLUSIONS: Most patients think HCPs should collect information about race/ethnicity, but many feel uncomfortable giving this information, especially among minorities. Health care providers can increase patients' comfort levels by telling them this will be used to monitor quality of care.

Electronic health record identification of prediabetes and an assessment of unmet counselling needs.

RATIONALE, AIMS AND OBJECTIVES: Large clinical trials demonstrate that lifestyle modification can prevent or delay the onset of diabetes in those with prediabetes. However, recent National Health and Nutrition Survey data suggest that prediabetes often goes unrecognized, and the majority of prediabetic individuals do not report having received lifestyle advice from physicians. We explored whether electronic health record (EHR) query of glucose measurements can identify prediabetic patients, and we estimated rates of prediabetic lifestyle counselling in a large, urban, primary care practice. METHODS: Electronic search identified patients with plasma glucose levels of 100 to 199 mg dL(-1) between 1 June 2007 and 1 June 2009, excluding those with diabetes or diabetic medications/supplies. From these 5366 patients, 100 randomly selected patients underwent classification into provisional categories based on available EHR data: likely prediabetes, likely diabetes, glucose abnormality in the setting of acute illness, or normal glucose metabolism. In those likely to have prediabetes, we assessed lifestyle modification counselling. RESULTS: Fifty-eight per cent (95% CI 48% to 68%) of patients sampled were likely to have prediabetes. Fourteen per cent of those sampled were likely to have diabetes. Thirty-one per cent of prediabetics (95% CI 22% to 42%) had documented lifestyle counselling. Counselled patients had a significantly higher baseline mean body mass index compared to those not counselled (34.1 versus 29.9, P = 0.037). CONCLUSIONS: EHR query using glucose measurements can identify prediabetic patients and those requiring further glucose metabolism evaluation, including those with undiagnosed diabetes. Future research should investigate EHR-based, population-level interventions to facilitate prediabetes recognition and counselling.

A membrane-based, high-efficiency, microfluidic debubbler.

In many lab-on-chip applications, it is necessary to remove bubbles from the flow stream. Existing bubble removal strategies have various drawbacks such as low degassing efficiency, long degassing time, large dead volumes, sensitivity to surfactants, and the need for an external vacuum or pressure source. We report on a novel, simple, robust, passive, nozzle-type, membrane-based debubbler that can be readily incorporated into microfluidic devices for rapid degassing. The debubbler is particularly suitable to operate with microfluidic systems made with plastic. The debubbler consists of a hydrophobic, porous membrane that resembles a normally closed valve, which is forced open by the working fluid's pressure. To illustrate the operation of the debubbler, we describe its use in the context of a chip containing a bead array for immunoassays. Our debubbler was able to completely filter gas bubbles out of a segmented flow at rates up to 60 µl s(-1) mm(-2) of membrane area.

The marginal value of pre-visit paper reminders when added to a multifaceted electronic health record based quality improvement system.

OBJECTIVE: We have reported that implementation of an electronic health record (EHR) based quality improvement system that included point-of-care electronic reminders accelerated improvement in performance for multiple measures of chronic disease care and preventive care during a 1-year period. This study examined whether providing pre-visit paper quality reminders could further improve performance, especially for physicians whose performance had not improved much during the first year. DESIGN: Time-series analysis at a large internal medicine practice using a commercial EHR. All patients eligible for each measure were included (range approximately 100-7500). MEASUREMENTS: The proportion of eligible patients in the practice who satisfied each of 15 quality measures after removing those with exceptions from the denominator. To analyze changes in performance for individual physicians, two composite measures were used: prescribing seven essential medications and completion of five preventive services. RESULTS: During the year after implementing pre-encounter reminders, performance continued to improve for eight measures, remained stable for four, and declined for three. Physicians with the worst performance at the start of the pre-encounter reminders showed little absolute improvement over the next year, and most remained below the median performance for physicians in the practice. CONCLUSIONS: Paper pre-encounter reminders did not appear to improve performance beyond electronic point-of-care reminders in the EHR alone. Lagging performance is likely not due to providers' EHR workflow alone, and trying to step backwards and use paper reminders in addition to point-of-care reminders in the EHR may not be an effective strategy for engaging slow adopters.