Exposure and risk factors for COVID-19 and the impact of staying home on Michigan residents.

COVID-19 has had a substantial impact on clinical care and lifestyles globally. The State of Michigan reports over 80,000 positive COVID-19 tests between March 1, 2020 and July 29, 2020. We surveyed 8,041 Michigan Medicine biorepository participants in late June 2020. We found that 55% of COVID-19 cases reported no known exposure to family members or to someone outside the house diagnosed with COVID-19. A significantly higher rate of COVID-19 cases were employed as essential workers (45% vs 19%, p = 9x10-12). COVID-19 cases reporting a fever were more likely to require hospitalization (categorized as severe; OR = 4.4 [95% CI: 1.6-12.5, p = 0.005]) whereas respondents reporting rhinorrhea was less likely to require hospitalization (categorized as mild-to-moderate; OR = 0.16 [95% CI: 0.04-0.73, p = 0.018]). African-Americans reported higher rates of being diagnosed with COVID-19 (OR = 4.0 [95% CI: 2.2-7.2, p = 5x10-6]), as well as higher rates of exposure to family or someone outside the household diagnosed with COVID-19, an annual household income < $40,000, living in rental housing, and chronic diseases. During the Executive Order in Michigan, African Americans, women, and the lowest income group reported worsening health behaviors and higher overall concern for the potential detrimental effects of the pandemic. The higher risk of contracting COVID-19 observed among African Americans may be due to the increased rates of working as essential employees, lower socioeconomic status, and exposure to known positive cases. Continued efforts should focus on COVID-19 prevention and mitigation strategies, as well as address the inequality gaps that result in higher risks for both short-term and long-term health outcomes.

Exploring various polygenic risk scores for skin cancer in the phenomes of the Michigan genomics initiative and the UK Biobank with a visual catalog: PRSWeb.

Polygenic risk scores (PRS) are designed to serve as single summary measures that are easy to construct, condensing information from a large number of genetic variants associated with a disease. They have been used for stratification and prediction of disease risk. The primary focus of this paper is to demonstrate how we can combine PRS and electronic health records data to better understand the shared and unique genetic architecture and etiology of disease subtypes that may be both related and heterogeneous. PRS construction strategies often depend on the purpose of the study, the available data/summary estimates, and the underlying genetic architecture of a disease. We consider several choices for constructing a PRS using data obtained from various publicly-available sources including the UK Biobank and evaluate their abilities to predict not just the primary phenotype but also secondary phenotypes derived from electronic health records (EHR). This study was conducted using data from 30,702 unrelated, genotyped patients of recent European descent from the Michigan Genomics Initiative (MGI), a longitudinal biorepository effort within Michigan Medicine. We examine the three most common skin cancer subtypes in the USA: basal cell carcinoma, cutaneous squamous cell carcinoma, and melanoma. Using these PRS for various skin cancer subtypes, we conduct a phenome-wide association study (PheWAS) within the MGI data to evaluate PRS associations with secondary traits. PheWAS results are then replicated using population-based UK Biobank data and compared across various PRS construction methods. We develop an accompanying visual catalog called PRSweb that provides detailed PheWAS results and allows users to directly compare different PRS construction methods.

Design and implementation of a privacy preserving electronic health record linkage tool in Chicago.

OBJECTIVE: To design and implement a tool that creates a secure, privacy preserving linkage of electronic health record (EHR) data across multiple sites in a large metropolitan area in the United States (Chicago, IL), for use in clinical research. METHODS: The authors developed and distributed a software application that performs standardized data cleaning, preprocessing, and hashing of patient identifiers to remove all protected health information. The application creates seeded hash code combinations of patient identifiers using a Health Insurance Portability and Accountability Act compliant SHA-512 algorithm that minimizes re-identification risk. The authors subsequently linked individual records using a central honest broker with an algorithm that assigns weights to hash combinations in order to generate high specificity matches. RESULTS: The software application successfully linked and de-duplicated 7 million records across 6 institutions, resulting in a cohort of 5 million unique records. Using a manually reconciled set of 11 292 patients as a gold standard, the software achieved a sensitivity of 96% and a specificity of 100%, with a majority of the missed matches accounted for by patients with both a missing social security number and last name change. Using 3 disease examples, it is demonstrated that the software can reduce duplication of patient records across sites by as much as 28%. CONCLUSIONS: Software that standardizes the assignment of a unique seeded hash identifier merged through an agreed upon third-party honest broker can enable large-scale secure linkage of EHR data for epidemiologic and public health research. The software algorithm can improve future epidemiologic research by providing more comprehensive data given that patients may make use of multiple healthcare systems.

Colorectal cancer screening at community health centers: A survey of clinicians' attitudes, practices, and perceived barriers.

OBJECTIVE: Colorectal cancer (CRC) screening rates remain lower among some racial/ethnic groups and individuals with low income or educational attainment who are often cared for within community health centers (CHCs). We surveyed clinicians in a network of CHCs to understand their attitudes, practice patterns, and perceived barriers to CRC screening. METHODS: A clinician survey was conducted in 2013 within the Community Health Applied Research Network (CHARN). RESULTS: 180 clinicians completed the survey (47.9% response rate). Participants had an average of 11.5 (SD: 9.8) years in practice, 62% were female, and 57% were physicians. The majority of respondents somewhat agreed (30.2%) or strongly agreed (57.5%) that colonoscopy was the best screening test. However, only 15.8% of respondents strongly agreed and 32.2% somewhat agreed that colonoscopy was readily available for their patients. Fecal immunochemical testing (FIT), a type of fecal occult blood test (FOBT), was viewed less favorably; 24.6% rated FIT as very effective. CONCLUSIONS: Although there are no data showing that screening colonoscopy is superior to FIT, CHC clinicians believe colonoscopy is the best CRC screening test for their patients, despite the high prevalence of financial barriers to colonoscopy. These attitudes could be due to lack of knowledge about the evidence supporting long-term benefits of fecal occult blood testing (FOBT), lack of awareness about the improved test characteristics of FIT compared to older guaiac-based FOBT, or the absence of systems to ensure adherence to regular FOBT screening. Interventions to improve CRC screening at CHCs must address clinicians' negative attitudes towards FIT.

CAPriCORN: Chicago Area Patient-Centered Outcomes Research Network.

The Chicago Area Patient-Centered Outcomes Research Network (CAPriCORN) represents an unprecedented collaboration across diverse healthcare institutions including private, county, and state hospitals and health systems, a consortium of Federally Qualified Health Centers, and two Department of Veterans Affairs hospitals. CAPriCORN builds on the strengths of our institutions to develop a cross-cutting infrastructure for sustainable and patient-centered comparative effectiveness research in Chicago. Unique aspects include collaboration with the University HealthSystem Consortium to aggregate data across sites, a centralized communication center to integrate patient recruitment with the data infrastructure, and a centralized institutional review board to ensure a strong and efficient human subject protection program. With coordination by the Chicago Community Trust and the Illinois Medical District Commission, CAPriCORN will model how healthcare institutions can overcome barriers of data integration, marketplace competition, and care fragmentation to develop, test, and implement strategies to improve care for diverse populations and reduce health disparities.

Medication safety after implementation of a commercial electronic health record system in five safety-net practices: a mixed methods approach.

PURPOSE: This study, conducted in five safety-net practices, including two nurse-managed health centers (NMHCs) and three federally qualified health centers (FQHCs), examined the impact of implementing a commercial electronic health records (EHRs) system on medication safety. DATA SOURCE: A mixed methods approach with two sources of data were used: (a) a query of prescription records captured by the EHR retrieving co-prescribed medications with identified drug-drug interaction (DDI) risks, and (b) semistructured interviews with clinicians and leadership about the usability and benefits of EHR-embedded clinical decision support in the form of DDI alerts. CONCLUSIONS: We found an exceptionally low rate of DDI pairs in all five practices. Only 130 "true" DDI pairs were confirmed representing 149,087 visits and 62 providers. Among the 130, the largest categories were related to antihypertensive medications, which are in fact often prescribed together. There were no significant differences between physicians and nurse practitioners on the rate of DDI pairs nor between NMHCs and FQHCs. IMPLICATIONS FOR PRACTICE: Implementation of an EHR in these five safety-net settings had a positive impact on medication safety. The issue of missing end dates is noteworthy in terms of DDIs and unnecessary alerts that could lead to alert fatigue.

Program to improve colorectal cancer screening in a low-income, racially diverse population: a randomized controlled trial.

PURPOSE More effective strategies are needed to improve rates of colorectal cancer screening, particularly among the poor, racial and ethnic minorities, and individuals with limited English proficiency. We examined whether the direct mailing of fecal occult blood testing (FOBT) kits to patients overdue for such screening is an effective way to improve screening in this population. METHODS All adults aged 50 to 80 years who did not have documentation of being up to date with colorectal cancer screening as of December 31, 2009, and who had had at least 2 visits to the community health center in the prior 18 months were randomized to the outreach intervention or usual care. Patients in the outreach group were mailed a colorectal cancer fact sheet and FOBT kit. Patients in the usual care group could be referred for screening during usual clinician visits. The primary outcome was completion of colorectal cancer screening (by FOBT, sigmoidoscopy, or colonoscopy) 4 months after initiation of the outreach protocol. Outcome measures were compared using the Fisher exact test. RESULTS Analyses were based on 104 patients assigned to the outreach intervention and 98 patients assigned to usual care. In all, 30% of patients in the outreach group completed colorectal cancer screening during the study period, compared with 5% of patients in the usual care group (P <.001). Nearly all of the screenings were by FOBT. The groups did not differ significantly with respect to the percentage of patients making a clinician visit or the percentage for whom a clinician placed an order for a screening test. CONCLUSIONS The mailing of FOBT kits directly to patients was efficacious for promoting colorectal cancer screening among a population with high levels of poverty, limited English proficiency, and racial and ethnic diversity. Non-visit-based outreach to patients may be an important strategy to address suboptimal rates of colorectal cancer screening among populations most at risk for not being screened.

Developing an electronic clinical decision support system to promote guideline adherence for healthy weight management and cardiovascular risk reduction in children: a progress update.

Overweight and obesity are common challenges facing pediatric clinicians. Electronic health records (EHRs) can impact clinician behavior through the presentation of relevant, patient-specific information during clinical encounters, potentially improving clinician recognition and management of overweight/obesity in children. Little research has been published evaluating the impact of EHR-facilitated decision support on the treatment of obesity in children. The main objectives of our community clinician-led project are: 1) to build customized, evidence-based decision support into an EHR; 2) To evaluate the impact of decision support on the identification and treatment of overweight and obese children; and 3) to improve behavior around screening for obesity-related comorbidities. Through a clinician-led consensus process, we customized end user templates in the commercially-available EHR at an urban community health center with a known high prevalence of childhood overweight and obesity. Evidence based decision support was build into the screens to prompt clinicians to identify and address overweight and obesity, as well as for related comorbidities. Pre/post measures will be used to evaluate the impact of these tactics on clinician behavior. The customized EHR templates took longer than anticipated to develop, but are now being used by pediatric clinicians at the health center. Feedback to date suggests that clinicians find the evidence based decision support useful at the point of care, especially around ordering recommended screening tests. Clinicians must be active participants in the design of decision support in order for it to impact their behavior. Off-the-shelf EHR products do not automatically come with comprehensive functionality to support evidence-based interventions around clinician behavior. Modifications are needed to achieve the full promise of health information technology as it relates to delivering high quality, patient-centered, for underserved populations.

Using electronic health records to measure physician performance for acute conditions in primary care: empirical evaluation of the community-acquired pneumonia clinical quality measure set.

BACKGROUND: Electronic health records (EHRs) have the potential to facilitate performance measurement for acute conditions. OBJECTIVE: To evaluate the reliability and feasibility-of-use of a performance measure set for community-acquired pneumonia in an ambulatory EHR. DESIGN: Retrospective, cross-sectional electronic chart review. SETTING: Primary Care Clinics. PATIENTS: Adults with an administrative claims diagnosis of pneumonia during a 14-month period. MEASUREMENTS: Two reviewers independently examined data in the EHR to determine if (1) the encounter was a visit for acute pneumonia; (2) there was documentation for each of 12 performance measures; and (3) such information was in coded form. RESULTS: Of 688 encounters with a claim diagnosis of pneumonia, 210 (31%) were identified by either reviewer as a primary care acute pneumonia visit. The 2 reviewers agreed that 198 encounters to 71 different clinicians were visits for acute pneumonia [kappa, 0.96; 95% confidence interval (CI), 0.93-0.98]. Measure performance ranged from 10% for providing location of care rationale to 91% for documenting blood pressure, averaging 52% across all 12 measures. Inter-rater reliability ranged from 0.66 (95% CI, 0.47-0.84) for providing a location of care rationale to 0.97 (95% CI, 0.91-1.0) for vital sign assessment. The proportion of data that was in coded form ranged from 0% for mental status, hydration status, chest x-ray performance, and location of care to 100% for medications and immunizations. CONCLUSIONS: Although EHRs offer potential advantages for performance measurement for acute conditions, accurate identification of pneumonia visits was challenging, performance generally appeared poor, and much of the data were not in coded form.

Developing ambulatory care physician performance measures.

Major US corporations and consumer groups are demanding more accountability for their health care expenditures. In response, the federal government, specialty boards, and state medical boards are evaluating ways to implement objective measures of quality. Many dermatologists already choose to participate in quality measurement and improvement activities. More will need to, as recertification and relicensure requirements change. Dermatologists need measures that are specialty-specific, as measures developed for primary care physicians are generally not appropriate for a dermatologic practice.