Change in Postoperative Opioid Prescribing Patterns for Oculoplastic and Orbital Procedures Associated With State Opioid Legislation.

Importance: Understanding whether statewide legislation, such as the Michigan Opioid Laws, is associated with reduction in postoperative opioid prescriptions is informative in guiding future legislation. Objective: To identify changes in opioid prescribing patterns for oculoplastic and orbital procedures associated with the enactment of the Michigan Opioid Laws in 2017 and 2018. Design, Setting, and Participants: This cross-sectional study included 3781 patients who underwent any of 10 common oculoplastic and orbital procedures between June 1, 2016, and November 30, 2019, at a tertiary care institution. Exposures: From 2017 to 2018, Michigan enacted a series of laws to address the state's worsening opioid epidemic. Two major components of this legislation enacted on June 1, 2018, required prescribers to review a report of patients' opioid use history and obtain signed consent after educating patients on the use and disposal of opioids prior to prescribing. Main Outcomes and Measures: Demographic information, type of surgery, type and amount of opioid prescriptions, and morphine milligram equivalent (MME) were analyzed. MME was calculated as the product of dose, quantity, and opioid-specific conversion factor for each prescription. Linear interpolation spline regression was used to evaluate the association of prescription MME with time. Results: Of 3781 patients, 1614 (42.7%) were male. The mean (SD) age at the time of surgery was 63.3 (16.6) years. Of 2026 patients undergoing surgery before June 1, 2018, 1782 (88.0%) were prescribed postoperative opioids; of 1755 patients undergoing surgery after June 1, 2018, 878 (50.0%) were prescribed postoperative opioids (P < .001). There was no difference in age, sex, race/ethnicity, surgery type, or opioids prescribed between these 2 cohorts. Linear interpolation spline regression showed a decrease of 26.025 MMEs (equivalent to a 36.2% reduction of mean MME) between June 1, 2017, and September 30, 2018 (ß, -1.735; 95% CI, -0.088 to -0.024; P < .001), stabilizing at a persistently reduced rate of MME prescribed through the end of the study period (October 1, 2018, to November 30, 2019; ß, -0.005; 95% CI, -0.039 to 0.016; P = .42). Changes in MME in the 12 months before or 12 months after the period of legislation enactment were not identified. Conclusions and Relevance: In this cross-sectional study, reduction in opioid prescriptions for oculoplastic and orbital procedures was observed during the enactment period of the Michigan Opioid Laws and appeared to be sustained through the end of the study period. Similar statewide or national legislations aimed at increasing prescriber awareness and patient education on opioid use may help curtail the prescription opioid epidemic.

Electronic health record tools to assist with children's insurance coverage: a mixed methods study.

BACKGROUND: Children with health insurance have increased access to healthcare and receive higher quality care. However, despite recent initiatives expanding children's coverage, many remain uninsured. New technologies present opportunities for helping clinics provide enrollment support for patients. We developed and tested electronic health record (EHR)-based tools to help clinics provide children's insurance assistance. METHODS: We used mixed methods to understand tool adoption, and to assess impact of tool use on insurance coverage, healthcare utilization, and receipt of recommended care. We conducted intent-to-treat (ITT) analyses comparing pediatric patients in 4 intervention clinics (n = 15,024) to those at 4 matched control clinics (n = 12,227). We conducted effect-of-treatment-on-the-treated (ETOT) analyses comparing intervention clinic patients with tool use (n = 2240) to intervention clinic patients without tool use (n = 12,784). RESULTS: Tools were used for only 15% of eligible patients. Qualitative data indicated that tool adoption was limited by: (1) concurrent initiatives that duplicated the work associated with the tools, and (2) inability to obtain accurate insurance coverage data and end dates. The ITT analyses showed that intervention clinic patients had higher odds of gaining insurance coverage (adjusted odds ratio [aOR] = 1.32, 95% confidence interval [95%CI] 1.14-1.51) and lower odds of losing coverage (aOR = 0.77, 95%CI 0.68-0.88), compared to control clinic patients. Similarly, ETOT findings showed that intervention clinic patients with tool use had higher odds of gaining insurance (aOR = 1.83, 95%CI 1.64-2.04) and lower odds of losing coverage (aOR = 0.70, 95%CI 0.53-0.91), compared to patients without tool use. The ETOT analyses also showed higher rates of receipt of return visits, well-child visits, and several immunizations among patients for whom the tools were used. CONCLUSIONS: This pragmatic trial, the first to evaluate EHR-based insurance assistance tools, suggests that it is feasible to create and implement tools that help clinics provide insurance enrollment support to pediatric patients. While ITT findings were limited by low rates of tool use, ITT and ETOT findings suggest tool use was associated with better odds of gaining and keeping coverage. Further, ETOT findings suggest that use of such tools may positively impact healthcare utilization and quality of pediatric care. TRIAL REGISTRATION: ClinicalTrials.gov, NCT02298361 ; retrospectively registered on November 5, 2014.

Designing Health Information Technology Tools to Prevent Gaps in Public Health Insurance.

BACKGROUND: Changes in health insurance policies have increased coverage opportunities, but enrollees are required to annually reapply for benefits which, if not managed appropriately, can lead to insurance gaps. Electronic health records (EHRs) can automate processes for assisting patients with health insurance enrollment and re-enrollment. OBJECTIVE: We describe community health centers' (CHC) workflow, documentation, and tracking needs for assisting families with insurance application processes, and the health information technology (IT) tool components that were developed to meet those needs. METHOD: We conducted a qualitative study using semi-structured interviews and observation of clinic operations and insurance application assistance processes. Data were analyzed using a grounded theory approach. We diagramed workflows and shared information with a team of developers who built the EHR-based tools. RESULTS: Four steps to the insurance assistance workflow were common among CHCs: 1) Identifying patients for public health insurance application assistance; 2) Completing and submitting the public health insurance application when clinic staff met with patients to collect requisite information and helped them apply for benefits; 3) Tracking public health insurance approval to monitor for decisions; and 4) assisting with annual health insurance reapplication. We developed EHR-based tools to support clinical staff with each of these steps. CONCLUSION: CHCs are uniquely positioned to help patients and families with public health insurance applications. CHCs have invested in staff to assist patients with insurance applications and help prevent coverage gaps. To best assist patients and to foster efficiency, EHR based insurance tools need comprehensive, timely, and accurate health insurance information.

Assessment of the Abbreviated National Eye Institute Visual Function Questionnaire (NEI VFQ 9) in blepharoptosis and dermatochalasis.

PURPOSE: To evaluate the Abbreviated National Eye Institute Visual Function Questionnaire (NEI VFQ 9), which is shorter than those previously published, as a tool for assessing vision-related quality of life in patients with ptosis and dermatochalasis. METHODS: This is a cohort study of 46 patients who underwent blepharoptosis and/or upper eyelid blepharoplasty surgery by a single surgeon (CN) in 2013 in a public, academic, ambulatory care referral center. Patients included 29 who underwent blepharoplasty, 11 who underwent ptosis surgery, and 6 who underwent combined surgery. The NEI-VFQ 9 was administered pre- and postoperatively, and the composite scores were compared using Student's t-test. Survey duration was timed in a subset of patients. The hypothesis was that the NEI VFQ 9 could detect a statistically significant improvement in composite score after surgical intervention. RESULTS: The mean pre- and postoperative NEI VFQ 9 composite scores were 74.9 and 86.8, respectively, in the blepharoplasty-only group (P<0.0001), 72.07 and 86.41, respectively, in the ptosis-only group (P=0.004), and 75.8 and 87.2, respectively, in the combined group (P=0.022). There was no correlation between the gain in composite score and the change in upper eyelid margin to reflex distance. Twenty-five patients were timed filling out the survey, and the mean was 2.3 min. CONCLUSIONS: The NEI VFQ 9 consistently demonstrates a significant increase in visual function for blepharoptosis and dermatochalasis patients. Thus, it may be a useful tool for assessing vision-related quality of life in patients with ptosis and dermatochalasis.

Measuring Preventive Care Delivery: Comparing Rates Across Three Data Sources.

INTRODUCTION: Preventive care delivery is an important quality outcome, and electronic data reports are being used increasingly to track these services. It is highly informative when electronic data sources are compared to information manually extracted from medical charts to assess validity and completeness. METHODS: This cross-sectional study used a random sample of Medicaid-insured patients seen at 43 community health centers in 2011 to calculate standard measures of correspondence between manual chart review and two automated sources (electronic health records [EHRs] and Medicaid claims), comparing documentation of orders for and receipt of ten preventive services (n=150 patients/service). Data were analyzed in 2015. RESULTS: Using manual chart review as the gold standard, automated EHR extraction showed near-perfect to perfect agreement (κ=0.96-1.0) for services received within the primary care setting (e.g., BMI, blood pressure). Receipt of breast and colorectal cancer screenings, services commonly referred out, showed moderate (κ=0.42) to substantial (κ=0.62) agreement, respectively. Automated EHR extraction showed near-perfect agreement (κ=0.83-0.97) for documentation of ordered services. Medicaid claims showed near-perfect agreement (κ=0.87) for hyperlipidemia and diabetes screening, and substantial agreement (κ=0.67-0.80) for receipt of breast, cervical, and colorectal cancer screenings, and influenza vaccination. Claims showed moderate agreement (κ=0.59) for chlamydia screening receipt. Medicaid claims did not capture ordered or unbilled services. CONCLUSIONS: Findings suggest that automated EHR and claims data provide valid sources for measuring receipt of most preventive services; however, ordered and unbilled services were primarily captured via EHR data and completed referrals were more often documented in claims data.

Assessment of the Abbreviated National Eye Institute Visual Function Questionnaire (NEI VFQ 9) in blepharoptosis and dermatochalasis / Avaliação do Questionário Abreviado de Função Visual do National Eye Institute (NEI VFQ 9) em blefaroptose e dermatocálase

ABSTRACT Purpose: To evaluate the Abbreviated National Eye Institute Visual Function Questionnaire (NEI VFQ 9), which is shorter than those previously published, as a tool for assessing vision-related quality of life in patients with ptosis and dermatochalasis. Methods: This is a cohort study of 46 patients who underwent blepharoptosis and/or upper eyelid blepharoplasty surgery by a single surgeon (CN) in 2013 in a public, academic, ambulatory care referral center. Patients included 29 who underwent blepharoplasty, 11 who underwent ptosis surgery, and 6 who underwent combined surgery. The NEI-VFQ 9 was administered pre- and postoperatively, and the composite scores were compared using Student's t-test. Survey duration was timed in a subset of patients. The hypothesis was that the NEI VFQ 9 could detect a statistically significant improvement in composite score after surgical intervention. Results: The mean pre- and postoperative NEI VFQ 9 composite scores were 74.9 and 86.8, respectively, in the blepharoplasty-only group (P<0.0001), 72.07 and 86.41, respectively, in the ptosis-only group (P=0.004), and 75.8 and 87.2, respectively, in the combined group (P=0.022). There was no correlation between the gain in composite score and the change in upper eyelid margin to reflex distance. Twenty-five patients were timed filling out the survey, and the mean was 2.3 min. Conclusions: The NEI VFQ 9 consistently demonstrates a significant increase in visual function for blepharoptosis and dermatochalasis patients. Thus, it may be a useful tool for assessing vision-related quality of life in patients with ptosis and dermatochalasis.

RESUMO Objetivo: Avaliar o Questionário Abreviado de Função Visual do National Eye Institute (NEI VFQ 9) como uma ferramenta para avaliar a visão relacionada com a qualidade de vida (QoL) em pacientes com blefaroptose e dermatocálase. Método: Estudo de coorte de blefaroptose e dermatocálase pacientes tratados por um único cirurgião (CN) em 2013. O acompanhamento foi de 2-3 meses. Pacientes em um centro de referência acadêmico para a atenção pública ambulatorial com ptose funcional e/ou dermatocálase de pálpebra superior foram avaliados prospectivamente utilizando o NEI-VFQ 9. Quarenta e seis pacientes completaram o estudo: 29 pacientes se submeteram somente à blefaroplastia, 11 apenas à cirurgia de ptose, e 6 pacientes à cirurgia combinada. Foram excluídos pacientes com outra cirurgia simultânea da pálpebra. O teste foi repetido em uma visita pós-operatória. A duração teste foi cronometrada em um subgrupo de pacientes. Escores compostos pré e pós-operatórios foram comparados com o teste T de Student. O desfecho principal foi a pontuação composta. Os autores propõem que a NEI VFQ 9 seria capaz de detectar uma melhora estatisticamente significativa na pontuação composta após a intervenção cirúrgica. Resultados: No grupo de blefaroplastia apenas, o NEI VFQ 9 apresentou a média composta de 74,9 e 86,8 no pré e pós-operatório, respectivamente (p<0,0001). Para os pacientes submetidos apenas à cirurgia de ptose, a pontuação média composta foi 72,07 e 86,41, no pré e pós-operatório, respectivamente (p=0,004). No grupo de cirurgias combinadas combinação, a pontuação composta média pré-operatória foi de 75,8, e a pós-operatória foi de 87,2 (p=0,022). Não houve correlação entre o ganho de pontuação composta e a mudança no MRD1. Vinte e cinco pacientes foram cronometrados ao preencher o teste, a média foi de 2,3 minutos. Conclusões: O NEI VFQ 9 demonstra consistentemente um aumento na função visual para pacientes submetidos à cirurgia de blefaroptose e dermatocálase, sendo um instrumento de pesquisa mais curto do que daqueles publicados anteriormente.

Reporting on the Strategies Needed to Implement Proven Interventions: An Example From a "Real-World" Cross-Setting Implementation Study.

UNLABELLED: The objective of this study was to empirically demonstrate the use of a new framework for describing the strategies used to implement quality improvement interventions and provide an example that others may follow. Implementation strategies are the specific approaches, methods, structures, and resources used to introduce and encourage uptake of a given intervention's components. Such strategies have not been regularly reported in descriptions of interventions' effectiveness, or in assessments of how proven interventions are implemented in new settings. This lack of reporting may hinder efforts to successfully translate effective interventions into "real-world" practice. A recently published framework was designed to standardize reporting on implementation strategies in the implementation science literature. We applied this framework to describe the strategies used to implement a single intervention in its original commercial care setting, and when implemented in community health centers from September 2010 through May 2015. Per this framework, the target (clinic staff) and outcome (prescribing rates) remained the same across settings; the actor, action, temporality, and dose were adapted to fit local context. The framework proved helpful in articulating which of the implementation strategies were kept constant and which were tailored to fit diverse settings, and simplified our reporting of their effects. Researchers should consider consistently reporting this information, which could be crucial to the success or failure of implementing proven interventions effectively across diverse care settings. TRIAL REGISTRATION: clinicaltrials.gov Identifier: NCT02299791.

Testing health information technology tools to facilitate health insurance support: a protocol for an effectiveness-implementation hybrid randomized trial.

BACKGROUND: Patients with gaps in health insurance coverage often defer or forgo cancer prevention services. These delays in cancer detection and diagnoses lead to higher rates of morbidity and mortality and increased costs. Recent advances in health information technology (HIT) create new opportunities to enhance insurance support services that reduce coverage gaps through automated processes applied in healthcare settings. This study will assess the implementation of insurance support HIT tools and their effectiveness at improving patients' insurance coverage continuity and cancer screening rates. METHODS/DESIGN: This study uses a hybrid cluster-randomized design-a combined effectiveness and implementation trial-in community health centers (CHCs) in the USA. Eligible CHC clinic sites will be randomly assigned to one of two groups in the trial's implementation component: tools + basic training (Arm I) and tools + enhanced training + facilitation (Arm II). A propensity score-matched control group of clinics will be selected to assess the tools' effectiveness. Quantitative analyses of the tools' impact will use electronic health record and Medicaid data to assess effectiveness. Qualitative data will be collected to evaluate the implementation process, understand how the HIT tools are being used, and identify facilitators and barriers to their implementation and use. DISCUSSION: This study will test the effectiveness of HIT tools to enhance insurance support in CHCs and will compare strategies for facilitating their implementation in "real-world" practice settings. Findings will inform further development and, if indicated, more widespread implementation of insurance support HIT tools. TRIAL REGISTRATION: Clinical trial NTC02355262.

Innovative methods for parents and clinics to create tools for kids' care (IMPACCT Kids' Care) study protocol.

BACKGROUND: Despite expansions in public health insurance, many children remain uninsured or experience gaps in coverage. Community health centers (CHCs) provide primary care to many children at risk for uninsurance and are well-positioned to help families obtain and retain children's coverage. Recent advances in health information technology (HIT) capabilities provide the means to create tools that could enhance CHCs' insurance outreach efforts. OBJECTIVE: To present the study design, baseline patient characteristics, variables, and statistical methods for the Innovative Methods for Parents And Clinics to Create Tools for Kids' Care (IMPACCT Kids' Care) study. METHODS/DESIGN: In this mixed methods study, we will design, test and refine health insurance outreach HIT tools through a user-centered process. We will then implement the tools in four CHCs and evaluate their effectiveness and barriers and facilitators to their implementation. To measure effectiveness, we will quantitatively assess health insurance coverage continuity and utilization of healthcare services for pediatric patients in intervention CHCs compared to matched control sites using electronic health record (EHR) and Oregon Medicaid administrative data over 18months pre- and 18months post-implementation (n=34,867 children). We will also qualitatively assess the implementation process to understand how the tools fit into the clinics' workflows and the CHC staff experiences with the tools. CONCLUSIONS: This study creates, implements, and evaluates health insurance outreach HIT tools. The use of such tools will likely improve care delivery and health outcomes, reduce healthcare disparities for vulnerable populations, and enhance overall healthcare system performance. ClinicalTrials.gov Identifier: NCT02298361.

Community Health Center Use After Oregon's Randomized Medicaid Experiment.

PURPOSE: There is debate about whether community health centers (CHCs) will experience increased demand from patients gaining coverage through Affordable Care Act Medicaid expansions. To better understand the effect of new Medicaid coverage on CHC use over time, we studied Oregon's 2008 randomized Medicaid expansion (the "Oregon Experiment"). METHODS: We probabilistically matched demographic data from adults (aged 19-64 years) participating in the Oregon Experiment to electronic health record data from 108 Oregon CHCs within the OCHIN community health information network (originally the Oregon Community Health Information Network) (N = 34,849). We performed intent-to-treat analyses using zero-inflated Poisson regression models to compare 36-month (2008-2011) usage rates among those selected to apply for Medicaid vs not selected, and instrumental variable analyses to estimate the effect of gaining Medicaid coverage on use. Use outcomes included primary care visits, behavioral/mental health visits, laboratory tests, referrals, immunizations, and imaging. RESULTS: The intent-to-treat analyses revealed statistically significant differences in rates of behavioral/mental health visits, referrals, and imaging between patients randomly selected to apply for Medicaid vs those not selected. In instrumental variable analyses, gaining Medicaid coverage significantly increased the rate of primary care visits, laboratory tests, referrals, and imaging; rate ratios ranged from 1.27 (95% CI, 1.05-1.55) for laboratory tests to 1.58 (95% CI, 1.10-2.28) for referrals. CONCLUSIONS: Our results suggest that use of many different types of CHC services will increase as patients gain Medicaid through Affordable Care Act expansions. To maximize access to critical health services, it will be important to ensure that the health care system can support increasing demands by providing more resources to CHCs and other primary care settings.

Supporting health insurance expansion: do electronic health records have valid insurance verification and enrollment data?

OBJECTIVE: To validate electronic health record (EHR) insurance information for low-income pediatric patients at Oregon community health centers (CHCs), compared to reimbursement data and Medicaid coverage data. MATERIALS AND METHODS: Subjects Children visiting any of 96 CHCs (N = 69 189) from 2011 to 2012. Analysis The authors measured correspondence (whether or not the visit was covered by Medicaid) between EHR coverage data and (i) reimbursement data and (ii) coverage data from Medicaid. RESULTS: Compared to reimbursement data and Medicaid coverage data, EHR coverage data had high agreement (87% and 95%, respectively), sensitivity (0.97 and 0.96), positive predictive value (0.88 and 0.98), but lower kappa statistics (0.32 and 0.49), specificity (0.27 and 0.60), and negative predictive value (0.66 and 0.45). These varied among clinics. DISCUSSION/CONCLUSIONS: EHR coverage data for children had a high overall correspondence with Medicaid data and reimbursement data, suggesting that in some systems EHR data could be utilized to promote insurance stability in their patients. Future work should attempt to replicate these analyses in other settings.

Effect of expanding medicaid for parents on children's health insurance coverage: lessons from the Oregon experiment.

IMPORTANCE: In the United States, health insurance is not universal. Observational studies show an association between uninsured parents and children. This association persisted even after expansions in child-only public health insurance. Oregon's randomized Medicaid expansion for adults, known as the Oregon Experiment, created a rare opportunity to assess causality between parent and child coverage. OBJECTIVE: To estimate the effect on a child's health insurance coverage status when (1) a parent randomly gains access to health insurance and (2) a parent obtains coverage. DESIGN, SETTING, AND PARTICIPANTS: Oregon Experiment randomized natural experiment assessing the results of Oregon's 2008 Medicaid expansion. We used generalized estimating equation models to examine the longitudinal effect of a parent randomly selected to apply for Medicaid on their child's Medicaid or Children's Health Insurance Program (CHIP) coverage (intent-to-treat analyses). We used per-protocol analyses to understand the impact on children's coverage when a parent was randomly selected to apply for and obtained Medicaid. Participants included 14409 children aged 2 to 18 years whose parents participated in the Oregon Experiment. EXPOSURES: For intent-to-treat analyses, the date a parent was selected to apply for Medicaid was considered the date the child was exposed to the intervention. In per-protocol analyses, exposure was defined as whether a selected parent obtained Medicaid. MAIN OUTCOMES AND MEASURES: Children's Medicaid or CHIP coverage, assessed monthly and in 6-month intervals relative to their parent's selection date. RESULTS: In the immediate period after selection, children whose parents were selected to apply significantly increased from 3830 (61.4%) to 4152 (66.6%) compared with a nonsignificant change from 5049 (61.8%) to 5044 (61.7%) for children whose parents were not selected to apply. Children whose parents were randomly selected to apply for Medicaid had 18% higher odds of being covered in the first 6 months after parent's selection compared with children whose parents were not selected (adjusted odds ratio [AOR]=1.18; 95% CI, 1.10-1.27). The effect remained significant during months 7 to 12 (AOR=1.11; 95% CI, 1.03-1.19); months 13 to 18 showed a positive but not significant effect (AOR=1.07; 95% CI, 0.99-1.14). Children whose parents were selected and obtained coverage had more than double the odds of having coverage compared with children whose parents were not selected and did not gain coverage (AOR=2.37; 95% CI, 2.14-2.64). CONCLUSIONS AND RELEVANCE: Children's odds of having Medicaid or CHIP coverage increased when their parents were randomly selected to apply for Medicaid. Children whose parents were selected and subsequently obtained coverage benefited most. This study demonstrates a causal link between parents' access to Medicaid coverage and their children's coverage.

MyPreventiveCare: implementation and dissemination of an interactive preventive health record in three practice-based research networks serving disadvantaged patients--a randomized cluster trial.

BACKGROUND: Evidence-based preventive services for early detection of cancer and other health conditions offer profound health benefits, yet Americans receive only half of indicated services. Policy initiatives promote the adoption of information technologies to engage patients in care. We developed a theory-driven interactive preventive health record (IPHR) to engage patients in health promotion. The model defines five levels of functionality: (1) collecting patient information, (2) integrating with electronic health records (EHRs), (3) translating information into lay language, (4) providing individualized, guideline-based clinical recommendations, and (5) facilitating patient action. It is hypothesized that personal health records (PHRs) with these higher levels of functionality will inform and activate patients in ways that simpler PHRs cannot. However, realizing this vision requires both technological advances and effective implementation based upon clinician and practice engagement. METHODS/DESIGN: We are starting a two-phase, mixed-method trial to evaluate whether the IPHR is scalable across a large number of practices and how its uptake differs for minority and disadvantaged patients. In phase 1, 40 practices from three practice-based research networks will be randomized to add IPHR functionality to their PHR versus continue to use their existing PHR. Throughout the study, we will engage intervention practices to locally tailor IPHR content and learn how to integrate new functions into their practice workflow. In phase 2, the IPHR to all nonintervention practices to observe whether the IPHR can be implemented more broadly (Scalability). Phase 1 will feature an implementation assessment in intervention practices, based on the RE-AIM model, to measure Reach (creation of IPHR accounts by patients), Adoption (practice decision to use the IPHR), Implementation (consistency, fidelity, barriers, and facilitators of use), and Maintenance (sustained use). The incremental effect of the IPHR on receipt of cancer screening tests and shared decision-making compared to traditional PHRs will assess Effectiveness. In phase 2, we will assess similar outcomes as phase 1 except for effectiveness. DISCUSSION: This study will yield information about the effectiveness of new health information technologies designed to actively engage patients in their care as well as information about how to effectively implement and disseminate PHRs by engaging clinicians. TRIAL REGISTRATION: ClinicalTrials.gov: NCT02138448.

Using geographic information systems (GIS) to identify communities in need of health insurance outreach: An OCHIN practice-based research network (PBRN) report.

BACKGROUND: Our practice-based research network (PBRN) is conducting an outreach intervention to increase health insurance coverage for patients seen in the network. To assist with outreach site selection, we sought an understandable way to use electronic health record (EHR) data to locate uninsured patients. METHODS: Health insurance information was displayed within a web-based mapping platform to demonstrate the feasibility of using geographic information systems (GIS) to visualize EHR data. This study used EHR data from 52 clinics in the OCHIN PBRN. We included cross-sectional coverage data for patients aged 0 to 64 years with at least 1 visit to a study clinic during 2011 (n = 228,284). RESULTS: Our PBRN was successful in using GIS to identify intervention sites. Through use of the maps, we found geographic variation in insurance rates of patients seeking care in OCHIN PBRN clinics. Insurance rates also varied by age: The percentage of adults without insurance ranged from 13.2% to 86.8%; rates of children lacking insurance ranged from 1.1% to 71.7%. GIS also showed some areas of households with median incomes that had low insurance rates. DISCUSSION: EHR data can be imported into a web-based GIS mapping tool to visualize patient information. Using EHR data, we were able to observe smaller areas than could be seen using only publicly available data. Using this information, we identified appropriate OCHIN PBRN clinics for dissemination of an EHR-based insurance outreach intervention. GIS could also be used by clinics to visualize other patient-level characteristics to target clinic outreach efforts or interventions.

Using electronic health record data to evaluate preventive service utilization among uninsured safety net patients.

OBJECTIVE: This study compared the preventive service utilization of uninsured patients receiving care at Oregon community health centers (CHCs) in 2008 through 2011 with that of continuously insured patients at the same CHCs in the same period, using electronic health record (EHR) data. METHODS: We performed a retrospective cohort analysis, using logistic mixed effects regression modeling to calculate odds ratios and rates of preventive service utilization for patients without insurance, or with continuous insurance. RESULTS: CHCs provided many preventive services to uninsured patients. Uninsured patients were less likely than continuously insured patients to receive 5 of 11 preventive services, ranging from OR 0.52 (95% CI: 0.35-0.77) for mammogram orders to 0.75 (95% CI: 0.66-0.86) for lipid panels. This disparity persisted even in patients who visited the clinic regularly. CONCLUSION: Lack of insurance is a barrier to preventive service utilization, even in patients who can access care at a CHC. Policymakers in the United States should continue to address this significant prevention disparity.

The ADVANCE network: accelerating data value across a national community health center network.

The ADVANCE (Accelerating Data Value Across a National Community Health Center Network) clinical data research network (CDRN) is led by the OCHIN Community Health Information Network in partnership with Health Choice Network and Fenway Health. The ADVANCE CDRN will 'horizontally' integrate outpatient electronic health record data for over one million federally qualified health center patients, and 'vertically' integrate hospital, health plan, and community data for these patients, often under-represented in research studies. Patient investigators, community investigators, and academic investigators with diverse expertise will work together to meet project goals related to data integration, patient engagement and recruitment, and the development of streamlined regulatory policies. By enhancing the data and research infrastructure of participating organizations, the ADVANCE CDRN will serve as a 'community laboratory' for including disadvantaged and vulnerable patients in patient-centered outcomes research that is aligned with the priorities of patients, clinics, and communities in our network.

Use of qualitative methods and user-centered design to develop customized health information technology tools within federally qualified health centers to keep children insured.

Lack of health insurance negatively impacts children's health. Despite federal initiatives to expand children's coverage and accelerate state outreach efforts, millions of US children remain uninsured or experience frequent gaps in coverage. Most current efforts to enroll and retain eligible children in public insurance programs take place outside of the health care system. This study is a partnership between patients' families, medical informaticists, federally qualified health center (FQHC) staff, and researchers to build and test information technology tools to help FQHCs reach uninsured children and those at risk for losing coverage.

Estimating demand for care after a medicaid expansion: lessons from Oregon.

To estimate how the Affordable Care Act's Medicaid expansions will affect demand for services, we measured ambulatory care utilization among adult patients who gained insurance during Oregon's 2008 Medicaid expansion. Using electronic health record data from 67 community health centers, we assessed pre- and postcoverage utilization among patients who gained insurance, compared with patients continuously insured or uninsured. In comparisons of the pre- and postcoverage periods, mean annual encounters among persons who gained insurance increased 22% to 35%, but declined in the comparison groups. These findings suggest that providers should expect a significant increase in demand among patients who gain Medicaid coverage through the Affordable Care Act.

"Not a kidney or a lung:" research challenges in a network of safety net clinics.

BACKGROUND AND OBJECTIVES: To gain a better understanding of the facilitators and barriers to creating a practice-based research network (PBRN) of safety net clinics, we conducted a qualitative study within our network of safety net health centers. METHODS: Utilizing snowball sampling, we conducted interviews with 19 of our founding stakeholders and analyzed these interviews to draw out common themes. RESULTS: The results showed four barriers to research in our network: lack of research generated from clinician questions, lack of appropriate funding, lack of clinician time, and lack of infrastructure. We discuss these results and suggest that inadequate funding for practice-based research, particularly in the health care safety net, is a unifying theme of these four barriers. CONCLUSIONS: Our results suggest that the national funding strategy for research relevant to underserved populations and all of primary care must undergo a fundamental shift. We discuss the features of possible models to meet this need.