Center for Health Systems Research Investigators and Projects

Improving Early Detection and Treatment of Depression

Project Lead: Kristen Azar, RN, MSN/MPH, CHSR Principal Investigator, East Campus

The Challenge: Depression threatens the well-being of patients and their families, and is a significant cause of disability in the U.S. It is the most common mental health condition, but screening rates remain extremely low.

CHSR Approach: Leverage Sutter Health electronic health record (EHR) data to improve screening practices and ensure vulnerable patients receive timely care. CHSR researchers are using EHR data to better understand the real-world care practices of primary care providers around detection of depression during primary care visits, follow-up care, and treatment. The team will compare screened versus non-screened patients, and identify follow-up care in patients with depression. This study will be completed by December 2019.

The Impact: Results of this work will help improve the detection and treatment of depression in primary care. Early identification of depression may increase the effectiveness of treatment and reduce long-term effects on patient wellbeing and healthcare costs.

Project Team: Kristen Azar, RN, MSN/MPH, Shruti Vaidya, MS, Ivelina Popova, Jinnan Li, PhD, MPH, Andrew Hudnut, MD, Alice Pressman, PhD, MS.

Funding Sources: Takeda, Lundbeck

Publications:

• Measuring Health Equity for Ambulatory Care Sensitive Conditions in a Large Integrated Healthcare System: the development of an index. Pressman A, Lockhart S, Petersen J, Robinson S, Moreno M, Azar KMJ. Health Equity 2019; 3.1. DOIL 10.1089/heq.2018.0092
• Current Science on Consumer Use of Mobile Health for Cardiovascular Disease Prevention: A Scientific Statement From the American Heart Association. Burke LE, Ma J, Azar KM, et al. Circulation 2015;132:1157-213.
• Virtual small groups for weight management: an innovative delivery mechanism for evidence-based lifestyle interventions among obese men. Azar KM, Aurora M, Wang EJ, Muzaffar A, Pressman A, Palaniappan LP. Transl Behav Med 2015;5:37-44.

Joy of Work: Improving Physician Wellbeing

Project Lead: Ellis Dillon, PhD, Principal Investigator, West Campus

The Challenge: Over 50% of U.S. physicians report symptoms of burnout including depersonalization and/or emotional exhaustion.

CHSR Approach: Evaluate and understand factors comprising physician burnout, and support strategies to foster physician wellbeing across Sutter Health. Our team surveyed physicians from six Sutter-affiliated medical groups and explored changes over time. In 2018, 1,035 physicians (65%) completed the survey, and 842 commented on workplace changes that would significantly improve wellbeing.

We merged wellbeing survey responses from individual physicians with administrative data and data from electronic health records. We used statistical analyses to identify the factors significantly associated with burnout: having adequate support staff, finding work meaningful, feeling highly valued, and number of Epic in-basket messages received weekly.

Physicians’ written comments indicated they desired improved staff support, in-basket message support, decreased workload/improved work-life balance, progress note/documentation support, and improved leadership.e Impact: We are collaborating with Robert Nordgren, MD, Chief Executive Officer, Palo Alto Foundation Medical Group (PAFMG), and Suzanne Pertsch, MD, Director, PAFMG Office of Physician Wellness, to disseminate the findings and support efforts to enhance wellbeing.

The Impact: We are collaborating with Robert Nordgren, MD, Chief Executive Officer, Palo Alto Foundation Medical Group (PAFMG), and Suzanne Pertsch, MD, Director, PAFMG Office of Physician Wellness, to disseminate the findings and support efforts to enhance wellbeing.

Ongoing studies will compare physician and staff burnout, and assess the relationship between staffing levels and physician and staff wellbeing.

Project Team: Ellis Dillon, PhD, Amy Meehan, MPH, Yan Yang, PhD, Veronique Martin, Jinnan Li, PhD, MPH, Martina Li, MPH, Nina Szwerinski, and Dominick Frosch, PhD.

Funding Sources: Sutter Health and Palo Alto Foundation Medical Group

Publications:

• Provider Perspectives on Advance Care Planning Documentation in the Electronic Health Record: The Experience of Primary Care Providers and Specialists Using Advance Health Care Directives and Physician Orders for Life Sustaining Treatment. Dillon, E., Chuang, J., Gupta, A., Tapper, S., Lai, S., Yu, P., Ritchie, C., Tai-Seale, M. American Journal of Hospice and Palliative Medicine®. PMID: 28196448. doi: 10.1177/1049909117693578. Epub 2017 Feb 15.
• An evaluation of two interventions to enhance patient-physician communication using the observer OPTION5 measure of shared decision making. Dillon, EC, Stults CD, Wilson C, Chuang J, Meehan A, Li M, Elwyn G, Frosch DL, Yu E, Tai-Seale M. Patient Education and Counseling. 2017; 100(10):1910-1917. PMID: 28532861 DOI: 10.1016/j.pec.2017.04.020
• Community-based palliative care and advance care planning documentation: Evidence from a multispecialty group. Tai-Seale M, Yang Y, Dillon E, et al.Journal of the American Geriatrics Society. 2017: doi: 10.1111/jgs.15145. [Epub ahead of print].
• Measuring the impact of patient-engaged research: How a methods workshop identified critical outcomes of research engagement. Dillon EC, Tuzzio L, Madrid S, Olden H, Greenlee RT. J Patient Cent Res Rev. 2017;4(4):237-246. doi: 10.17294/2330-0698.1458
• Using unlicensed health coaches to improve care for insured patients with diabetes and hypertension: patient and physician perspectives on recruitment and uptake. Dillon E, Panattoni L, Meehan A, Chuang J, Wilson C, Tai-Seale M. Population Health Management. Oct 2016;19(5):332-340. PMID: 26674597. doi: 10.1089/pop.2015.0095. Epub 2015 Dec 16.

Shining Light on Multiple Sclerosis With Precision Medicine: Floodlight Mobile

Project Lead: J.B. Jones, PhD, MBA, CHSR Principal Investigator, East Campus

The Challenge: Multiple sclerosis (MS) is a potentially disabling immunologic disease of the central nervous system. More than 2.3 million people have MS worldwide, including over 450,000 people in the U.S. Despite new research, the specific immunologic cause remains unknown and the disease has no cure. Most people with MS manage a relapsing-remitting course of the illness with disease-modifying therapies to slow disease progression. People with a less common form of the illness, called primary progressive MS, steadily decline in function.

Most neurologists see their MS patients once every six to 12 months. In each visit, it’s unlikely patients can convey a summary of their daily mobility experience and secondary symptoms with the precision needed to guide treatment decision making. So neurologists lack comprehensive data to deliver precise care.

CHSR Approach: We launched Floodlight™, a mobile application to leverage patient-generated data for new insights on MS progression in individual patients. Developed by Roche and pilot tested by Sutter Health, Floodlight™ collects patient data through digital questionnaires and online sensors that assess cognition, coordination and motor skills, mood, gait, and mobility in MS patients. We are collaborating with Sutter clinicians to design displays of the data that are clinically informative and actionable.

Approximately 100 Sutter Health patients will be recruited to test the mobile application; ongoing refinements through Summer 2019 will help ensure its use and validity in real-world settings.

The Impact: Floodlight™ will give neurologists meaningful, actionable patient data to help them provide more precise, personalized treatment to MS patients with varying disease subtypes.

Project Team: J.B. Jones, PhD, MBA, Iva Popova, Diamonne Mitchell, Jackie Liu, Gil Flamino, Frank Velasco, Jerry Chen, Jennifer Pearce.

Funding Sources: Sutter Health, Roche Diagnostics, and the California Initiative to Advance Precision Medicine

Publications:

The Wired Patient: Patterns of “Web Portal” Use Among Patients With Caridac Disease or Diabetes. Jones JB, Weiner JP, Jones JW, Shah NR, Stewart WF. J Med Int Res. 2015 Feb 20;17(2):e42.

The Preference-Based Care Tool: Using HIT to Integrate Patient Choice Into Primary Care CVD Management. Jones JB, Bruce CA, Shah NR, Steward WF. Translational Behavioral Medicine. 2011 March; 1(1); 123-133.

Meaningful Use of EHRs by Incorporating Quantitative Patient-Specific Risk Information During Routine Primary Care. Jones JB, Shah NR, Bruce CA, Stewart WF. Am J Prev Med. 2011 May;40(5 Suppl 2):S179-86.

Measuring Adherence and Outcomes in the Treatment of Patients With Multiple Sclerosis. Hao J, Pitcavage J, Jones J, Hoegerl C, Graham J. J Am Osteopath Assoc2017;117(12):737–747. doi: 10.7556/jaoa.2017.145.

CM-SHARE: Development, Integration, and Adoption of an Electronic Health Record–Linked Digital Health Solution to Support Care for Diabetes in Primary Care. Jones JB, Liang S, Husby HM, Delatorre-Reimer JK, Mosser CA, Hudnut AG, Knobel K, MacDonald K, Yan XS. Clinical Diabetes 2019 May; cd180057. https://doi.org/10.2337/cd18-0057

Improving Early Detection of Lung Cancer

Project Lead: Jiang Li, PhD, MPH, CHSR Principal Investigator, West Campus

The Challenge: Lung cancer is the leading cause of cancer-related deaths in the U.S. Annual screening with low-dose computed tomography (LDCT-LCS) is recommended for heavy smokers and people at high risk for lung cancer.* Despite national guidelines on lung cancer screening, there is little data on the adoption of LDCT-LCS in large U.S. healthcare systems.

CHSR Approach: We launched the three-year Multilevel Study of Lung Cancer Screening Implementation (MUST) study. MUST filled critical knowledge gaps in the implementation of lung cancer screening and smoking cessation interventions, and identified multilevel barriers among patients and providers.

We compiled Sutter-wide electronic health record data from patients aged 55-80 years with no history of lung cancer who visited a primary care provider between 2010 and 2017. We studied implementation of LDCT-LCS and smoking cessation interventions, and multilevel factors associated with receiving a medical order of screening and counseling.

The Impact:

• Documentation of smoking history, smoking cessation interventions, and LDCT-LCS referrals increased since the U.S. Preventive Services Task Force recommended LDCT screening for lung cancer.
• Even after the policy implementation, only 7% of LCS-eligible patients were referred for LDCT-LCS.
• Lung cancer screening practice varied across primary care providers.
• Eligible patients seeing their regular primary care provider were significantly more likely to receive lung cancer screening referrals. Older, former smokers who had severe or moderate major comorbidities were significantly less likely to receive lung cancer screening referrals.

We are conducting in-depth interviews with patients and providers. Insights from our interviews will advance knowledge of patient and provider motivations and barriers for implementing LDCT-LCS and smoking cessation interventions.

*The National Lung Screening Trial demonstrated that, among individuals with a high risk of lung cancer, a 20% relative reduction in lung cancer mortality was observed with low-dose computed tomography for lung cancer screening (LDCT-LCS) compared to chest X-ray. In 2013, the U.S. Preventive Services Task Force (USPSTF) recommended annual screening for lung cancer with LDCT -LCS for heavy smokers aged 55-80 years. The guidelines included tobacco cessation interventions in parallel with LDCT-LCS. Despite these recommendations, there is little data on the adoption of LDCT-LCS in healthcare systems.

Project Team: Jiang Li, PhD, MPH, Sukyung Chung, PhD, Dorothy Hung, PhD, PhD, MA, MPH, Meghan Martinez, Edward Yu, MD, Alan Chausow, MD.

Funding Sources: The Tobacco-Related Disease Research Program

Publications:

• Promoting men's health within barbershops: barber/owner survey results and implications for intervention planning. Li J, Linnan LA, Rose J, Hooker E, Boswell M, D’Angelo H, Harrington C. Preventive Medicine, 2011; 53(3):207-208. DOI: 10.1016/j.ypmed.2011.06.001.
• Knowledge and Perceptions of Overweight Employees about Lifestyle-Related Health Benefit Changes. Li J, Linnan LA, Finkelstein EA, Tate DF, Naseer C, Evenson KR. North Carolina Medical Journal, 2011; 72(3): 183-190. PMCID: PMC5082972.
• Access and health services utilization among Koreans in Los Angeles: the mediating role of acculturation. Li J, Maxwell AE, Glenn BA, Herrmann AK, Chang LC, Crespi CM, Bastani R. Int J Soc Sci Res. 2016;4(1):83-97. PMCID: PMC5647155.
• Implementing Smoking Cessation Counseling for Lung Cancer Screening-Eligible Patients. Li J, Chung S, Luft H. Abstracts from the 24th annual Health Care Systems Research Network Conference; April 2018; Minneapolis, MN. J Patient Cent Res Rev. 2017; 5:109. doi: 10.17294/2330-0698.1630.
• New recommendation and coverage of lung cancer screening (LCS) by low dose computed tomography (LDCT): uptake increased but is still dismally low. Li J, Chung S, Wei EK, Luft H. BMC Health Serv Res. 2018;18(1):525. PMCID: PMC6034213.

Improving Lynch Syndrome Screening

Project Lead: Su-Ying Liang, PhD, CHSR Principal Investigator, West Campus

CHSR Approach: We launched a collaborative, multi-site study to understand and compare decision making in Lynch syndrome screening across healthcare systems. The study includes clinical sites with diverse patient populations in various stages of implementing Lynch syndrome screening. Participating sites are: Sutter Health (Palo Alto Medical Foundation), Geisinger, Kaiser Permanente (Colorado, Northwest), Meyers Primary Care Institute, HealthPartners, Harvard Pilgrim Health Care, and Catholic Health Initiatives.

We interviewed patients and providers and used qualitative comparative analyses to identify barriers and facilitators of Lynch syndrome screening. Economic evaluation models were applied to investigate how contextual factors impact organization costs and program success. The five-year study is nearing completion of its second year (8/1/2017 – 7/31/2022).

The Impact: Study findings will advance understanding of how contextual factors impact Lynch syndrome screening across healthcare systems.

Project Team: Su-Ying Liang, PhD, Martina Li, MPH, and Tony Chen.

Funding Sources: National Institutes of Health/National Cancer Institute

Publications:

• Implementing universal Lynch syndrome screening (IMPULSS): protocol for a multi-site study to identify strategies to implement, adapt, and sustain genomic medicine programs in different organizational contexts. Rahm AK, Cragun D, Hunter JE, Epstein MM, Lowery J, Lu CY, Pawloski PA, Sharaf RN, Liang SY, Burnett-Hartman AN, Gudgeon JM, Hao J, Snyder S, Gogoi R, Ladd I, Williams MS. BMC Health Serv Res. 2018 Oct 30;18(1):824. doi: 10.1186/s12913-018-3636-2.
• The Healthcare Systems Research Network (HCSRN) as an Environment for Dissemination and Implementation Research: A Case Study of Developing a Multi-Site Research Study in Precision Medicine. Rahm AK, Ladd I, Burnett-Hartman AN, Epstein MM, Lowery JT, Lu CY, Pawloski PA, Sharaf RN, Liang SY, Hunter JE. EGEMS (Wash DC). 2019 Apr 12;7(1):16. doi: 10.5334/egems.283.

Improving Migraine Management with Mindfulness: A Pilot Trial

Project Lead: Alice Pressman, PhD, MS, CHSR Co-Director, Principal Investigator, East Campus

The Challenge: Migraine headache is one of the most common neurological disorders and a leading cause of disability worldwide. Medications are typically the standard therapy, but are only moderately effective and cause side effects; newer, more effective medications are expensive.

CHSR Approach: We investigated the effectiveness of Mindfulness-Based Stress Reduction (MBSR) in patients with moderate-to-severe migraine. MBSR has demonstrated clinically meaningful benefit in several chronic-pain syndromes and has shown promising results for migraine therapy in small case series and pilot studies.

We conducted a pragmatic* two-arm randomized controlled pilot trial of MBSR for the treatment of moderate-to-severe migraine. Our recruitment goal was approximately 60 participants with moderate-to-severe episodic migraine. The feasibility outcomes included ability and time required to recruit, adherence to the MBSR treatment, and demonstrated ability to measure outcomes. The active intervention consisted of an eight-week community-based mindfulness-based stress reduction (MBSR) class plus usual care, and the wait-list control group was usual care alone.

We recruited 66 participants; seven (11%) withdrew before the intervention began (six in the MBSR arm). Adherence to MBSR was high. Of the 28 who registered for MBSR, 26 (93%) attended at least five classes. We measured headache days and collected four-month questionnaire data on 50 (76%). We are analyzing the questionnaire data to understand participant experience with MBSR to help design the fully-powered trial.

The Impact: To our knowledge, this is the first pragmatic trial of MBSR for migraine in the U.S. It provided an excellent background for the design and implementation of fully-powered trials to determine the effectiveness of MBSR for reducing headache frequency in patients with moderate-to-severe migraine. The results will help us design and conduct a fully-powered, multi-center trial at Sutter Health in collaboration with Kaiser, UC San Francisco, and Stanford.

*Pragmatic trial in this case is defined as a trial that is designed to evaluate the effectiveness of an intervention under real-life routine practice conditions, as opposed to an explanatory trial which aims to test whether an intervention works under optimal conditions. In this case, the intervention was a broadly-available community MBSR class.

Project Team: Alice Pressman, PhD, MS, Heather Law, MA, Sylvia Sudat, PhD, Alice Jacobson, MS, Alex Scott, MA(Edin), Lisa Dean, MS, MBA, Nina Szwerinski, MSc, Angelica Obillo, and Michelle Goodreau, MPH, and two external co-investigators: Andy Avins, MD, MPH from Kaiser Permanente Northern California, and Bob Stahl, PhD from Insight Santa Cruz a Buddhist Meditation Community.

Funding Sources: National Center for Complementary and Integrative Health (1R01AT009081)

Publications:

• Conducting a pilot randomized controlled trial of community-based mindfulness-based stress reduction versus usual care for moderate-to-severe migraine: protocol for the Mindfulness and Migraine Study. (M&M) Pressman A, Law H, Stahl R, Scott A, Jacobson A, Dean L, Sudat S, Obillo A, Avins A. Trials 2019 May 6 20:257 https://doi.org/10.1186/s13063-019-3355-y
• Prevalence of migraine in a diverse community – electronic methods for migraine ascertainment in Kaiser Permanente, a large integrated health plan. Pressman AR, Jacobson A, Eguilos R, Gelfand A, Huynh C, Hamilton L, Avins A, Bakshi N, Merikangas K. Cephalalgia. 2016 Apr;36(4):325-34. https://doi.org/10.1177/0333102415590242
• Should we reconsider the routine use of placebo controls in clinical research? Avins AL, Cherkin DC, Sherman KJ, Goldberg H, Pressman A. Trials 2012 Apr 27;13:44 https://doi.org/10.1186/1745-6215-13-44

Improving Patient-centered Communication in Primary Care

Project Lead: Cheryl Stults, PhD, Principal Investigator, West Campus

The Challenge: Research suggests patients rarely talk openly with care providers because they fear retribution or being labeled ‘difficult’. On the ‘flip side’, healthcare providers are sometimes unprepared to answer all questions posed by their patients.

CHSR Approach: We launched the Open and Ask study to improve patient-centered communication in primary care.* We compared three interventions that empower patients to communicate honestly and that enable physicians to respond effectively: Open Communication High Touch, Open Communication High Tech, and ASK. The interventions are being tested at the University of California at San Diego, Sutter Health, and Reliant Medical Group in Massachusetts.

The four-year study will conclude in March 2021.

The Impact: The interventions are randomized at the clinic level to one of three communication approaches:

• Open Communication High Touch — Patients use an electronic system (MyHealthOnline) to prepare for office visits and communicate with their doctors through a questionnaire assessing health concerns. Doctors receive in-person training on how to discuss what matters most to patients.
• Open Communication High Tech — Patients use the Open Communication High Touch approach. Doctors receive training via a mobile app, versus in person.
• ASK — Clinics place posters in exam rooms that encourage patients to ask their doctors “What are my options? What are the possible risks and benefits of each option? How likely are the benefits of each option to occur to me?”

* This study builds on a previous pilot study conducted at the Palo Alto Medical Foundation of an approach called Open Communication. The study showed that patients and doctors who used open communication had better communication than patients who received standard care.

Project Team: UC San Diego (Ming Tai-Seale), Reliant Medical Group (Kathy Mazor). Sutter Health Team: Cheryl Stults, PhD, Dominick Frosch, PhD, Albert Chan, MD, and Ed Yu, MD. Clinician Stakeholders: Dominique Quincy, MD, Peter Cheng, MD, Jimmy Hu, MD, ad Kelly Reilly, MD. Patient Stakeholders: Patricia Alexander and Erez Baron. Research Team Members: Amy Meehan, MPH, and Martina Li, MPH.

Funding Sources: Patient-Centered Outcomes Research Institute (PCORI)

Publications:

• Enhancing shared decision making through carefully designed interventions that target patient and provider behavior. Tai-Seale M, Elwyn G, Wilson CJ, Stults C, Dillon EC, Li M, Chuang J, Meehan A, Frosch DL.Send to:, Health Aff (Millwood). 35(4):605-12. doi: 10.1377/hlthaff.2015.1398., 2016 Apr 01
• An evaluation of two interventions to enhance patient-physician communication using the observer OPTION5 measure of shared decision making. Dillon EC, Stults CD, Wilson C, Chuang J, Meehan A, Li M, Elwyn G, Frosch DL, Yu E, Tai-Seale M., Patient Educ Couns. pii: S0738-3991(17)30254-9. doi: 10.1016/j.pec.2017.04.020. [Epub ahead of print], 2017 May 01
• Using CollaboRATE, a brief patient-reported measure of shared decision making: results from three clinical settings in the United States. Forcino RC, Barr PJ, O'Malley AJ, Arend R, Castaldo MG, Ozanne EM, Percac-Lima S, Stults CD, Tai-Seale M, Thompson R1, Elwyn G., Health Expect. doi: 10.1111/hex.12588. [Epub ahead of print], 2017 Jul 05
• How do primary care physicians respond when patients cry during routine ambulatory visits? Stults CD, Elston Lafata J, Diamond L, MacLean L, Stone AL, Wunderlich T, Frankel RM, Tai-Seale M., J Comm Healthcare. 7(1):17-24. DOI: http://dx.doi.org/10.1179/1753807614Y.0000000044, 2014 Mar 01

Machine Learning for Early Detection of Sepsis

Project Lead: Sylvia Sudat, PhD, CHSR Principal Investigator, East Campus

The Challenge: Sepsis — a potentially life-threatening condition caused by the body's response to an infection — is the leading cause of in-hospital mortality, and is associated with substantial healthcare costs. Early detection and treatment of sepsis is critical, yet its early symptoms are not easily detected.

CHSR Approach: We developed a predictive model identifying emerging sepsis using artificial intelligence and machine learning. This project leveraged in-hospital and ambulatory data from the Sutter Health electronic health record. The data will help summarize patients’ health at the time of hospital admission.

The Impact: Predictive modelling can help prevent sepsis-related complications and mortality among the 200,000 Northern California patients admitted to Sutter Health hospitals annually. Our project demonstrates how machine learning algorithms can be used to decrease U.S. healthcare costs and improve the care of patients nationwide.

Project Team: Sylvia Sudat, PhD, Alice Pressman, PhD, MS, Shruti Vaidya, MS, Ridhima Nerlekar, MS, Alexandra Scott, MA, Phillippe Boileau (intern).

Funding Sources: Greathouse Family Foundation, Sutter Health Philanthropy

Publications:

• Predicting need for advanced illness or palliative care in a primary care population using electronic health record data. Jung K, Sudat SE, Kwon N, Stewart WF, Shah NH. J Biomed Inform. 2019 Apr; 92:103115. doi: 10.1016/j.jbi.2019.103115. Epub 2019 Feb 10. PubMed PMID: 30753951.
• Predicting all-cause risk of 30-day hospital readmission using artificial neural networks. Jamei M, Nisnevich A, Wetchler E, Sudat S, Liu E, Upadhyaya K. PLoS One. 2017 Jul 14; 12(7):e0181173. doi: 10.1371/journal.pone.0181173. eCollection 2017. PubMed PMID: 28708848; PubMed Central PMCID: PMC5510858.

Advancing Safe, Effective Opioid Prescription Stewardship

Project Lead: Sherry Yan, PhD, MS, Principal Investigator, East Campus

The Challenge: Addiction and deaths from opioid use pose an enormous public health burden across the U.S. Emergency departments (EDs) and urgent care clinics across Sutter Health face significant challenges to curb opioid over-prescribing.

CHSR Approach: We launched the Opioid Reduce Trial to promote opioid prescription stewardship. The randomized study will assess the change in opioid default pills count in electronic health records (EHRs), and the use of social comparison feedback to decrease opioid prescription pill burden in Sutter Health EDs and urgent care clinics.*

Opioid Reduce is a collaboration between Sutter’s Center for Health Systems Research, Sutter Information Services, William Isenberg, MD (Vice President, Office of Patient Safety, Sutter Health), and Howard Landa, MD (Vice President of Clinical Informatics and EHR, Sutter Health).

The Impact: Interventions (EHR default change and social comparison) in Opioid Reduce are designed to minimize interruption of clinicians’ workflow and represent real-world clinical settings. If we observe a successful intervention, we will scale it across Sutter Health, broadly disseminate findings, initiate further trials, and promote implementations nationwide.

*Default change describes an EHR function change where care providers set a default number of pills for medication.

Project Team: Sherry Yan, PhD, MS, Farah Refai, William Isenberg, MD, Howard Landa, MD, Barbara Bond, MD. University of Pennsylvania Team: Amol Navathe, MD, and Mitesh Patel, MD.

Funding Sources: Donaghue Foundation

Publications:

• CM-SHARE: Development, Integration, and Adoption of an Electronic Health Record– Linked Digital Health Solution to Support Care for Diabetes in Primary Care. JB Jones, S Liang, HM Husby, JK Delatorre-Reimer, CA, Mosser, AG, Hudnut, K Knobel, K MacDonald, X Yan. Clinical Diabetes, 2019 (online published).
• Does transition of urinary incontinence from one subtype to another represent progression of the disease?. Minassian VA, Yan X, Pilzek AL, Platte R, Stewart WF. Int Urogynecol J. 2018 Aug;29(8):1179-1185. doi: 10.1007/s00192-018-3596-4. Epub 2018 Mar 13. PMID: 29536139.
• Using the PARAFAC2 Tensor Factorization on EHR Audit Data to Model Clinician Behavior. Perros I, Yan X, Jones JB, Sun J, Stewart WF. AMIA 2018 Informatics Summit.
• Recurrent neural networks for early detection of heart failure from longitudinal electronic health record data: implications for temporal modeling with respect to time before diagnosis, data density, data quantity and data type. R Chen, WF Stewart, J Sun, K Ng, X Yan. Circulation: Cardiovascular Quality and Outcomes, accepted, 2019.
• Primary Care Diabetes Bundle Management: Three-Year Outcomes for Macro- vascular and Micro-vascular Events. F. Bloom, X. Yan, T. R. Graf, T. Anderer, D. Davis, S. Pierdon, J. Pitcavage, W. F. Steward, G. Steele. 2014, 20(6), e175-e182; PMID: 25180500.