A Novel Method for Estimating Transgender Status Using Electronic Medical Records

PURPOSE:

We describe a novel algorithm for identifying transgender people and determining their male-to-female (MTF) or female-to-male (FTM) identity in electronic medical records of an integrated health system.

METHODS:

A computer program scanned Kaiser Permanente Georgia electronic medical records from January 2006 through December 2014 for relevant diagnostic codes, and presence of specific keywords (e.g., "transgender" or "transsexual") in clinical notes. Eligibility was verified by review of de-identified text strings containing targeted keywords, and if needed, by an additional in-depth review of records. Once transgender status was confirmed, FTM or MTF identity was assessed using a second program and another round of text string reviews.

RESULTS:

Of 813,737 members, 271 were identified as possibly transgender: 137 through keywords only, 25 through diagnostic codes only, and 109 through both codes and keywords. Of these individuals, 185 (68%, 95% confidence interval [CI]: 62%-74%) were confirmed as definitely transgender. The proportions (95% CIs) of definite transgender status among persons identified via keywords, diagnostic codes, and both were 45% (37%-54%), 56% (35%-75%), and 100% (96%-100%). Of the 185 definitely transgender people, 99 (54%, 95% CI: 46%-61%) were MTF, 84 (45%, 95% CI: 38%-53%) were FTM. For two persons, gender identity remained unknown. Prevalence of transgender people (per 100,000 members) was 4.4 (95% CI: 2.6-7.4) in 2006 and 38.7 (95% CI: 32.4-46.2) in 2014.

CONCLUSIONS:

The proposed method of identifying candidates for transgender health studies is low cost and relatively efficient. It can be applied in other similar health care systems.

Purchase full article at:   http://goo.gl/2issyt

By:  Roblin D1, Barzilay J2, Tolsma D2, Robinson B2, Schild L2, Cromwell L2, Braun H3, Nash R3, Gerth J4, Hunkeler E5, Quinn VP6, Tangpricha V7, Goodman M8.

• 1School of Public Health, Georgia State University, Atlanta; Center for Clinical and Outcomes Research, Kaiser Permanente Georgia, Atlanta.
• 2Center for Clinical and Outcomes Research, Kaiser Permanente Georgia, Atlanta.
• 3Rollins School of Public Health, Emory University, Atlanta, GA.
• 4Emory College of Arts and Sciences, Atlanta, GA.
• 5Division of Research, Kaiser Permanente, Oakland, CA.
• 6Kaiser Permanente Southern California, Pasadena.
• 7Emory University, School of Medicine, Atlanta, GA; The Atlanta VA Medical Center, Atlanta, GA.
• 8Rollins School of Public Health, Emory University, Atlanta, GA. Electronic address: mgoodm2@emory.edu. 

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Qualitative Analysis of Programmatic Initiatives to Text Patients with Mobile Devices in Resource-Limited Health Systems

Background

Text messaging is an affordable, ubiquitous, and expanding mobile communication technology. However, safety net health systems in the United States that provide more care to uninsured and low-income patients may face additional financial and infrastructural challenges in utilizing this technology. Formative evaluations of texting implementation experiences are limited. We interviewed safety net health systems piloting texting initiatives to study facilitators and barriers to real-world implementation.

Methods

We conducted telephone interviews with various stakeholders who volunteered from each of the eight California-based safety net systems that received external funding to pilot a texting-based program of their choosing to serve a primary care need. We developed a semi-structured interview guide based partly on the Consolidated Framework for Implementation Research (CFIR), which encompasses several domains: the intervention, individuals involved, contextual factors, and implementation process. We inductively and deductively (using CFIR) coded transcripts, and categorized themes into facilitators and barriers.

Results

We performed eight interviews (one interview per pilot site). Five sites had no prior texting experience. Sites applied texting for programs related to medication adherence and monitoring, appointment reminders, care coordination, and health education and promotion. No site texted patient-identifying health information, and most sites manually obtained informed consent from each participating patient. Facilitators of implementation included perceived enthusiasm from patients, staff and management belief that texting is patient-centered, and the early identification of potential barriers through peer collaboration among grantees. Navigating government regulations that protect patient privacy and guide the handling of protected health information emerged as a crucial barrier. A related technical challenge in five sites was the labor-intensive tracking and documenting of texting communications due to an inability to integrate texting platforms with electronic health records.

Conclusions

Despite enthusiasm for the texting programs from the involved individuals and organizations, inadequate data management capabilities and unclear privacy and security regulations for mobile health technology slowed the initial implementation and limited the clinical use of texting in the safety net and scope of pilots. Future implementation work and research should investigate how different texting platform and intervention designs affect efficacy, as well as explore issues that may affect sustainability and the scalability.

Full article at:   http://goo.gl/SAsnqs

By:  Sachin K. Garg, Courtney R. Lyles, Sara Ackerman, Margaret A. Handley, Dean Schillinger, Gato Gourley, Veenu Aulakh, and Urmimala Sarkar

Division of General Internal Medicine and Center for Vulnerable Populations at San Francisco General Hospital, University of California, San Francisco (UCSF), San Francisco, USA

Department of Social and Behavior Sciences, UCSF, San Francisco, USA

Center for Care Innovations, Oakland, USA

Department of Epidemiology and Biostatistics, UCSF, San Francisco, USA

Sachin K. Garg, Phone: (415) 353-7900, Email: ude.fscu@grag.nihcas.

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Barriers and Facilitators to Online Portal Use among Patients and Caregivers in a Safety Net Health Care System

Background

Patient portals have the potential to support self-management for chronic diseases and improve health outcomes. With the rapid rise in adoption of patient portals spurred by meaningful use incentives among safety net health systems (a health system or hospital providing a significant level of care to low-income, uninsured, and vulnerable populations), it is important to understand the readiness and willingness of patients and caregivers in safety net settings to access their personal health records online.

Objective

To explore patient and caregiver perspectives on online patient portal use before its implementation at San Francisco General Hospital, a safety net hospital.

Methods

We conducted 16 in-depth interviews with chronic disease patients and caregivers who expressed interest in using the Internet to manage their health. Discussions focused on health care experiences, technology use, and interest in using an online portal to manage health tasks. We used open coding to categorize all the barriers and facilitators to portal use, followed by a second round of coding that compared the categories to previously published findings. In secondary analyses, we also examined specific barriers among 2 subgroups: those with limited health literacy and caregivers.

Results

We interviewed 11 patients and 5 caregivers. Patients were predominantly male (82%, 9/11) and African American (45%, 5/11). All patients had been diagnosed with diabetes and the majority had limited health literacy (73%, 8/11). The majority of caregivers were female (80%, 4/5), African American (60%, 3/5), caregivers of individuals with diabetes (60%, 3/5), and had adequate health literacy (60%, 3/5). A total of 88% (14/16) of participants reported interest in using the portal after viewing a prototype. Major perceived barriers included security concerns, lack of technical skills/interest, and preference for in-person communication. Facilitators to portal use included convenience, health monitoring, and improvements in patient-provider communication. Participants with limited health literacy discussed more fundamental barriers to portal use, including challenges with reading and typing, personal experience with online security breaches/viruses, and distrust of potential security measures. Caregivers expressed high interest in portal use to support their roles in interpreting health information, advocating for quality care, and managing health behaviors and medical care.

Conclusions

Despite concerns about security, difficulty understanding medical information, and satisfaction with current communication processes, respondents generally expressed enthusiasm about portal use. Our findings suggest a strong need for training and support to assist vulnerable patients with portal registration and use, particularly those with limited health literacy. Efforts to encourage portal use among vulnerable patients should directly address health literacy and security/privacy issues and support access for caregivers.

Full article at:   http://goo.gl/60yyps

By:  Lina Tieu, MPH, ¹ Urmimala Sarkar, MD, MPH,¹ Dean Schillinger, MD,¹ James D Ralston, MD, MPH,² Neda Ratanawongsa, MD, MHS,¹ Rena Pasick, DrPH,³ and Courtney R Lyles, PhD¹

¹Division of General Internal Medicine, University of California, San Francisco, San Francisco, CA, United States

²Group Health Research Institute, Seattle, WA, United States

³Helen Diller Family Comprehensive Cancer Center, University of California, San Francisco, San Francisco, CA, United States

Lina Tieu, Division of General Internal Medicine, University of California, San Francisco, DGIM at SFGH, Box 1364, 1001 Potrero Ave, Bldg 10, Ward 13, San Francisco, CA, 94143, United States, Phone: 1 415 206 7878, Fax: 1 415 206 7880, Email: ude.fscu@ueiT.aniL.

J Med Internet Res. 2015 Dec; 17(12): e275.

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Unintended Adverse Consequences of Electronic Health Record Introduction to a Mature Universal HIV Screening Program

Early HIV detection and treatment decreases morbidity and mortality and reduces high-risk behaviors. Many Emergency Departments (EDs) have HIV screening programs as recommended by the Centers for Disease Control and Prevention. Recent federal legislation includes incentives for electronic health record (EHR) adoption. Our objective was to analyze the impact of conversion to EHR on a mature ED-based HIV screening program. 

A retrospective pre- and post-EHR implementation cohort study was conducted in a large urban, academic ED. Medical records were reviewed for HIV screening rates from August 2008 through October 2013. On 1 November 2010, a comprehensive EHR system was implemented throughout the hospital. Before EHR implementation, labs were requested by providers by paper orders with HIV-1/2 automatically pre-selected on every form. This universal ordering protocol was not duplicated in the new EHR; rather it required a provider to manually enter the order. Using a chi-squared test, we compared HIV testing in the 6 months before and after EHR implementation; 55,054 patients presented before, and 50,576 after EHR implementation. Age, sex, race, acuity of presenting condition, and HIV seropositivity rates were similar pre- and post-EHR, and there were no major patient or provider changes during this period. 

Average HIV testing rate was 37.7% of all ED patients pre-, and 22.3% post-EHR, a 41% decline, leading to 167 missed new diagnoses after EHR. The rate of HIV screening in the ED decreased after EHR implementation, and could have been improved with more thoughtful inclusion of existing human processes in its design.

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By:  Laura N. Medford-Davis^a*, Katharine Yang^b, Siavash Pasalar^c, M. Tyson Pillow^bc, Nancy P. Miertschin^c, William F. Peacock^bc,Thomas P. Giordano^cde & Shkelzen Hoxhaj^bc

^a Department of Emergency Medicine, University of Pennsylvania, Philadelphia, PA, USA

^b Department of Medicine, Section of Emergency Medicine, Baylor College of Medicine, Houston, TX, USA

^c Harris Health System, Houston, TX, USA

^d Department of Medicine, Sections of Infectious Diseases and Health Services Research, Baylor College of Medicine, Houston, TX, USA

^e Center for Innovations in Quality, Effectiveness and Safety, Michael E. DeBakey VA Medical Center, Houston, TX, USA

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A Description of Midlife Women Experiencing Intimate Partner Violence Using Electronic Medical Record Information

BACKGROUND:

Intimate partner violence (IPV) is an important health problem affecting women of all ages, but is often not addressed during healthcare visits.

PURPOSE:

To use electronic records of diagnoses and telephone advice calls to describe the clinical patterns of midlife women experiencing IPV.

MATERIALS AND METHODS:

Using case-control methodology, women with an ICD9 diagnosis of IPV were chosen from those enrolled in 2005-2006 in Kaiser Permanente Northern California (KPNC) and matched on visit date, age, and facility with women without such a diagnosis. The study population was divided into subsets: ages 45-53 years (318 cases, 1588 controls); ages 54-64 years (200 cases, 1000 controls). Diagnoses and symptoms reported by phone that were significantly related to the cases compared with the controls were identified using multivariate logistic regression.

RESULTS:

Among women aged 45-53 years, diagnoses of anxiety and of psychiatric problems and calls for head injury, mental health problems, and sexually transmitted diseases were associated with IPV. Among women aged 54-64 years, diagnoses of anxiety and other psychiatric problems, injuries (other than head and neck), urinary tract infection (UTI), headache, and calls for mental health problems were associated with IPV. Among all women aged 45-64 years, history of prior IPV was strongly associated with subsequent diagnosis of IPV.

CONCLUSIONS:

Information available in the electronic health record of women who have been identified as experiencing IPV can be used to identify patterns of symptoms and diagnosis among midlife women. These patterns can potentially be used to improve identification of IPV in this age group. In addition to screening of all women for IPV, the presence of psychiatric problems, injuries, headache, and UTI and prior experience of IPV should prompt additional focused clinical inquiry about IPV in midlife women.

Full article at:   http://goo.gl/8DoQRT

By:   Eaton A1, Temkin TL2, Fireman BH1, McCaw BR3, Kotz KJ3, Amaral D2, Bhargava R2.

• 11 Division of Research, Kaiser Permanente Northern California , Oakland, California.
• 22 Appointment and Advice Call Center, Kaiser Permanente Northern California , Oakland, California.
• 33 Family Violence Prevention Program, Kaiser Permanente Northern California , Oakland, California. 

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Using the Electronic Medical Record to Refer Women Taking Category D or X Medications for Teratogen and Contraceptive Counseling

Read at: http://ht.ly/Q6ysL HT @UCSDHealth 

The primary care physicians who prescribe the potential teratogens should ensure patients know about highly effective contraceptives. However, a study by Eisenberg identified that time constraint is a major barrier to adequate contraceptive counseling. Internists in the Eisenberg study believed that an electronic medical records (EMR) alert would be worthwhile. In addition, two-thirds of the internists agreed that “a referral or telephone consultation service for assistance in providing appropriate contraception for women on potential teratogens would be useful” (Eisenberg et al., 2010).

The EMR provides an opportunity to identify women taking potentially teratogenic medications and offer teratogen and contraceptive counseling. These women specifically may benefit from more counseling about longacting reversible contraception. The purpose of this study was to explore the feasibility and patient satisfaction with an EMR alert, and a referral system for teratogen and contraceptive counseling.