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1.  Implementing Quality Improvement in Small, Autonomous Primary Care Practices: Implications for the Patient Centered Medical Home 
Quality in Primary Care  2011;19(5):289-300.
Background
Implementing improvement programs to enhance quality of care within primary care clinics is complex, with limited practical guidance available to help practices during the process. Understanding how improvement strategies can be implemented in primary care is timely given the recent national movement towards transforming primary care into patient-centered medical homes (PCMH). This study examined practice members’ perceptions of the opportunities and challenges associated with implementing changes in their practice.
Methods
Semi-structured interviews were conducted with a purposive sample of 56 individuals working in 16 small, community-based primary care practices. The interview consisted of open-ended questions focused on participants’ perceptions of: (1) practice vision, (2) perceived need for practice improvement, and (3) barriers that hinder practice improvement. The interviews were conducted at the participating clinics and were tape-recorded, transcribed, and content analyzed.
Results
Content analysis identified two main domains for practice improvement related to: (1) the process of care, and (2) patients’ involvement in their disease management. Examples of desired process of care changes included improvement in patient tracking/follow-up system, standardization of processes of care, and overall clinic documentations. Changes related to the patients’ involvement in their care included improving (a) health education, and (b) self care management. Among the internal barriers were: staff readiness for change, poor communication, and relationship difficulties among team members. External barriers were: insurance regulations, finances and patient health literacy.
Practice Implications
Transforming their practices to more patient-centered models of care will be a priority for primary care providers. Identifying opportunities and challenges associated with implementing change is critical for successful improvement programs. Successful strategy for enhancing the adoption and uptake of PCMH elements should leverage areas of concordance between practice members’ perceived needs and planned improvement efforts.
PMCID: PMC3313551  PMID: 22186171
primary care practice; quality improvement; qualitative analysis
2.  Genomewide Linkage Scan for Diabetic Renal Failure and Albuminuria: The FIND Study 
American Journal of Nephrology  2011;33(5):381-389.
Background
Diabetic nephropathy (DN) is a leading cause of mortality and morbidity in patients with type 1 and type 2 diabetes. The multicenter FIND consortium aims to identify genes for DN and its associated quantitative traits, e.g. the urine albumin:creatinine ratio (ACR). Herein, the results of whole-genome linkage analysis and a sparse association scan for ACR and a dichotomous DN phenotype are reported in diabetic individuals.
Methods
A genomewide scan comprising more than 5,500 autosomal single nucleotide polymorphism markers (average spacing of 0.6 cM) was performed on 1,235 nuclear and extended pedigrees (3,972 diabetic participants) ascertained for DN from African-American (AA), American-Indian (AI), European-American (EA) and Mexican-American (MA) populations.
Results
Strong evidence for linkage to DN was detected on chromosome 6p (p = 8.0 × 10−5, LOD = 3.09) in EA families as well as suggestive evidence for linkage to chromosome 7p in AI families. Regions on chromosomes 3p in AA, 7q in EA, 16q in AA and 22q in MA displayed suggestive evidence of linkage for urine ACR. The linkage peak on chromosome 22q overlaps the MYH9/APOL1 gene region, previously implicated in AA diabetic and nondiabetic nephropathies.
Conclusion
These results strengthen the evidence for previously identified genomic regions and implicate several novel loci potentially involved in the pathogenesis of DN.
doi:10.1159/000326763
PMCID: PMC3078269  PMID: 21454968
Albuminuria; Diabetes mellitus; Renal failure; End-stage renal disease; Linkage; Allelic association
3.  The Gly(972)Arg Variant of Human IRS1 Gene Is Associated With Variation in Glomerular Filtration Rate Likely Through Impaired Insulin Receptor Signaling 
Diabetes  2012;61(9):2385-2393.
The objective of this study is to identify and characterize the genetic variants related to the glomerular filtration rate (GFR) linkage on 2q37. Of the positional candidate genes, we selected IRS1 and resequenced its 2-kb promoter region and exons for sequence variants in 32 subjects. A total of 11 single nucleotide polymorphisms (SNPs) were identified. To comprehensively cover the 59-kb-long intron-1, eight additional tagging SNPs were selected from the HapMap. All the 19 SNPs were genotyped by TaqMan Assay in the entire data set (N = 670; 39 families). Association analyses between the SNPs and GFR and type 2 diabetes–related traits were performed using the measured genotype approach. Of the SNPs examined for association, only the Gly(972)Arg variant of IRS1 exhibited a significant association with GFR (P = 0.0006) and serum triglycerides levels (P = 0.003), after accounting for trait-specific covariate effects. Carriers of Arg972 had significantly decreased GFR values. Gly(972)Arg contributed to 26% of the linkage signal on 2q. Expression of IRS1 mutant Arg972 in human mesangial cells significantly reduced the insulin-stimulated phosphorylation of IRS1 and Akt kinase. Taken together, the data provide the first evidence that genetic variation in IRS1 may influence variation in GFR probably through impaired insulin receptor signaling.
doi:10.2337/db11-1078
PMCID: PMC3425400  PMID: 22617042
4.  Genetic variants in Transient Receptor Potential cation channel, subfamily M 1 (TRPM1) and their risk of albuminuria-related traits in Mexican Americans 
Background
Evidence for linkage of albuminuria to GABRB3 marker region on chromosome 15q12 was previously reported in Mexican Americans. The objective of this study is to scan a positional candidate gene, Transient Receptor Potential cation channel, subfamily M 1 (TRPM1), for genetic variants that may contribute to the variation in albumin-to-creatinine ratio (ACR).
Methods
To identify the sequence variants, the exons and 2 kb putative promoter region of TRPM1 were PCR amplified and sequenced in 32 selected individuals. Identified variants were genotyped in the entire data set (N=670; 39 large families) by TaqMan assays. Association analyses between the sequence variants and ACR, type 2 diabetes (T2DM) and related phenotypes were carried out using a measured genotype approach as implemented in the program SOLAR.
Results
Sequencing analysis identified 18 single nucleotide polymorphisms (SNPs) including 8 SNPs in the coding regions, 7 SNPs in the promoter region and 3 SNPs in introns. Of the 8 SNPs identified in the coding regions, 3 were non synonymous [Met(1)Thr, Ser(32)Asn, Val(1395)Ile] and one SNP caused stop codon (Glu1375/*). Of the SNPs examined, none of them exhibited statistically significant association with ACR after accounting for the effect of age, sex, diabetes, duration of diabetes, systolic blood pressure and anti-hypertensive medications. However, a SNP (rs11070811) located in the putative promoter region showed a modest association with triglycerides levels (P = 0.039).
Conclusion
The present investigation found no evidence for an association between sequence variation at the TRPM1 gene and ACR in Mexican Americans, although it appears to have modest influence on T2DM risk factors.
doi:10.1016/j.cca.2011.03.024
PMCID: PMC3206641  PMID: 21439949
TRPM1; Type 2 diabetes; Albumin to creatinine ration; polymorphisms; association analysis; Mexican Americans
5.  The 27-bp repeat polymorphism in intron 4 (27 bp-VNTR) of endothelial nitric oxide synthase (eNOS) gene is associated with albumin to creatinine ratio in Mexican Americans 
Molecular and cellular biochemistry  2009;331(1-2):201-205.
The T-786C, Glu298Asp, and 27 bp variable number of tandem repeats (27 bp-VNTR-a/b) polymorphsims of the endothelial nitric oxide synthase (eNOS) gene are thought to alter nitric oxide production and contribute to the development of vascular and renal disease risk. The objective of this study is to investigate whether these three polymorphisms examined previously by others are associated with cardiovascular and renal disease risk in Mexican Americans. Study participants (N = 848; 21 families) were genotyped for T-786C, Glu298Asp, and 27 bp-VNTR-a/b polymorphisms by PCR followed by restriction digestion. Association analyses were performed by a measured genotype approach implemented in the program SOLAR. Of the phenotypes (type 2 diabetes, hypertension, body mass index, waist circumference, total cholesterol, high density lipoprotein cholesterol, triglycerides, systolic and diastolic blood pressure, albumin to creatinine ratio (ACR), and estimated glomerular filtration rate) examined for association, the 27 bp-VNTR-a/b variant exhibited statistically significant association with ACR (P = 0.047) after accounting for the trait specific covariate effects. In addition, the promoter variant (T-786C) showed a significant association with triglycerides (P = 0.034) after accounting for covariate influences. In conclusion, the present study adds evidence to the role of eNOS candidate gene polymorphisms in modulating the risk factors related to cardiovascular-renal disease in Mexican Americans although the magnitude of the genetic effect is small.
doi:10.1007/s11010-009-0159-5
PMCID: PMC3428139  PMID: 19468830
eNOS; Genetic polymorphisms; Association analyses; ACR; Triglycerides; Mexican Americans
6.  Endothelial Nitric Oxide Synthase (eNOS) gene polymorphisms and their association with Type 2 diabetes related traits in Mexican Americans 
Genetic variants of the eNOS gene such as T-786C, Glu298Asp, and 27bp-VNTR have been examined for their association with type 2 diabetes (T2DM)-related traits in different populations but not in Mexican Americans. However, the results from such studies have been controversial. This study investigated whether these three polymorphisms are associated with T2DM and its related traits in Mexican Americans, a population at high risk for T2DM and its complications. The study participants (N = 670; 39 families) were genotyped for the three polymorphisms using polymerase chain reaction followed by restriction fragment length polymorphism assay. Association analyses between these polymorphisms and T2DM and its related phenotypes were carried out using a measured genotype approach as implemented in the computer program SOLAR. Of the variants examined, only the 27bp-VNTR variant exhibited significant association with high density lipoprotein cholesterol (HDL-C) (P = 0.04) and diastolic blood pressure (DBP) levels (P = 0.02) after accounting for trait-specific covariates. The carriers of the rare allele (27bp-VNTR-4a) are associated with decreased HDL-C and increased DBP levels. In conclusion, of the genetic polymorphisms examined at the eNOS locus, only 27bp-VNTR appears to be a minor contributor to the variation in T2DM-related traits in Mexican Americans.
doi:10.3132/dvdr.2008.018
PMCID: PMC3336872  PMID: 18537098
eNOS gene; type 2 diabetes; genetic polymorphisms; association analyses; Mexican Americans
7.  Genome-wide linkage scans for type 2 diabetes mellitus in four ethnically diverse populations; significant evidence for linkage on chromosome 4q in African Americans: the Family Investigation of Nephropathy and Diabetes (FIND) Research Group 
Background
Previous studies have shown that, in addition to environmental influences, type 2 diabetes mellitus (T2DM) has a strong genetic component. The goal of the current study is to identify regions of linkage for T2DM in ethnically diverse populations.
Methods
Phenotypic and genotypic data were obtained from African American (AA; total number of individuals (N)=1004), American Indian (AI; N=883), European American (EA; N=537), and Mexican American (MA; N=1634) individuals from the Family Investigation of Nephropathy and Diabetes. Nonparametric linkage analysis, using an average of 4,404 SNPs, was performed in relative pairs affected with T2DM in each ethnic group. In addition, family-based tests were performed to detect association with T2DM.
Results
Statistically significant evidence for linkage was observed on chromosomes 4q21.1 (LOD=3.13; genome-wide p=0.04) in AA. In addition, a total of eleven regions showed suggestive evidence for linkage (estimated at LOD>1.71), with the highest LOD scores on chromosomes 12q21.31 (LOD=2.02) and 22q12.3 (LOD=2.38) in AA, 2p11.1 (LOD=2.23) in AI, 6p12.3 (LOD=2.77) in EA, and 13q21.1 (LOD=2.24) in MA. While no region overlapped across all ethnic groups, at least five loci showing LOD>1.71 have been identified in previously published studies.
Conclusions
The results from this study provide evidence for the presence of genes affecting T2DM on chromosomes 4q, 12q, and 22q in AA, 6p in EA, 2p in AI, and 13q in MA. The strong evidence for linkage on chromosome 4q in AA provides important information given the paucity of diabetes genetic studies in this population.
doi:10.1002/dmrr.1031
PMCID: PMC2783577  PMID: 19795399
FIND; Type 2 Diabetes; linkage analysis; ethnicity
8.  Evaluation of Gremlin1 (GREM1) as a candidate susceptibility gene for albuminuria-related traits in Mexican Americans with Type 2 Diabetes 
Metabolism: clinical and experimental  2009;58(10):1496-1502.
Several novel genes that are up regulated in the kidney in diabetes have been identified including GREM1, which encodes gremlin 1. GREM1 maps to human chromosome 15q12, a region previously found to be linked to albumin to creatinine ratio (ACR) in Mexican Americans. The objective of this study is to investigate whether genetic variants in GREM1, a positional candidate gene, contribute to variation in ACR. By sequencing 32 individuals for both exons and 2 kb putative promoter region of GREM1, we identified 19 genetic variants including 5 in the promoter region and 13 in the 3′UTR. Of 19 polymorphisms identified, 13 polymorphisms were genotyped in the entire cohort (N=670; 39 large families) either by restriction fragment length polymorphism or by TaqMan Assays. Association analyses between the genotypes and ACR, type 2 diabetes and related phenotypes were carried out using a measured genotype approach as implemented in the variance component analytical tools (SOLAR). Of the variants examined for association, none exhibited statistically significant association with ACR after accounting for the effects of covariates such as age, sex, diabetes, duration of diabetes, systolic blood pressure and anti-hypertensive medications. However, two novel variants at the 3′ UTR showed significant association with estimated glomerular filtration rate (P = 0.010 and P = 0.049) and body mass index (P = 0.013 and P = 0.019) after accounting for trait-specific covariate influences. Also, a novel variant located in the promoter exhibited a significant association with systolic (P = 0.038) and diastolic blood pressure (P = 0.005) after adjusting for the effects of age, sex, diabetes, and antihypertensive medications. In conclusion, the variants examined at GREM1 are not significant contributors to variation in ACR in Mexican Americans, although they appear to minimally influence risk factors related to ACR.
doi:10.1016/j.metabol.2009.04.039
PMCID: PMC2913546  PMID: 19577778
9.  Evaluation of polymorphisms in Paraoxonase 2 (PON2) gene and their association with Cardiovascular-Renal disease risk in Mexican Americans 
Kidney & blood pressure research  2009;32(3):200-204.
Background/Aims
Genetic polymorphisms in the PON2 gene thought to alter its activity and contribute to the development of cardiovascular and renal disease risk. The purpose of this study is to determine whether the Arg148Gly, Cys311Ser and rs12794795 polymorphisms of PON2 examined previously by others, are associated with type 2 diabetes (T2DM), and subclinical measures of cardiovascular and renal disease risk in Mexican Americans.
Methods
Study participants (N=848; 21 families) were genotyped for the three polymorphisms by TaqMan assay. Association between the genotypic and phenotypic data were performed by measured genotype approach as implemented in the variance component analytical tools.
Results
The Arg148Gly variant was found to be monomorphic in our data set. Of the phenotypes examined for association, the A/C variant located in intron-1 (rs12794795) exhibited statistically significant association only with diastolic blood pressure (P = 0.018) after accounting for the trait specific covariate effects. The Cys311Ser variant failed to show statistically significant association with any of the phenotypes examined.
Conclusion
In conclusion, the variants examined at the PON2 locus in Mexican Americans do not appear to be a major contributor to T2DM, cardiovascular or renal disease risk, although it exhibited a small effect on the blood pressure values.
doi:10.1159/000225943
PMCID: PMC2759102  PMID: 19546579
PON2; genetic polymorphisms; association analyses; systolic blood pressure; Mexican Americans
10.  Genetic variants in the Renin-Angiotensin System genes are associated with Cardiovascular-Renal-related risk factors in Mexican Americans 
Human genetics  2008;124(5):557-559.
The aim of this study was to examine whether the ACE-I/D, AGT-M235T, and AT1R-A1166C polymorphisms of the renin-angiotensin system (RAS) genes are associated with cardiovascular and renal-related risk factors in Mexican Americans. Study participants (N=848) were genotyped by Taqman assays. Association analyses were performed by measured genotype approach. Of the phenotypes examined, the ACE-I/D, AGT-M235T, and AT1R-A1166C polymorphisms exhibited significant association with systolic blood pressure, glomerular filtration rate and body mass index, respectively. The data suggest that the polymorphisms examined in the RAS may modulate the risk factors associated with cardiovascular-renal disease.
doi:10.1007/s00439-008-0581-x
PMCID: PMC2785727  PMID: 18985387
ACE; AGT; AT1R; polymorphisms; association analysis; SBP; GFR; BMI; Mexican Americans
11.  A genome-wide search for linkage to chronic kidney disease in a community-based sample: the SAFHS 
Nephrology Dialysis Transplantation  2008;23(10):3184-3191.
Background. Chronic kidney disease (CKD) phenotypes such as albuminuria measured by urinary albumin creatinine ratio (ACR), elevated serum creatinine (SrCr) and/or decreased creatinine clearance (CrCl) and glomerular filtration rate (eGFR) are major risk factors for renal and cardiovascular diseases. Epidemiological studies have reported that CKD phenotypes cluster in families suggesting a genetic predisposition. However, studies reporting chromosomal regions influencing CKD are very limited. Therefore, the purpose of this study is to identify susceptible chromosomal regions for CKD phenotypes in Mexican American families enrolled in the San Antonio Family Heart Study (SAFHS).
Methods. We used the variance components decomposition approach (implemented in the software package SOLAR) to perform linkage analysis on 848 participants from 26 families. A total of 417 microsatellite markers were genotyped at an average interval of 10 cM spanning 22 autosomal chromosomes.
Results. All phenotypes were measured by standard procedures. Mean ± SD values of ACR, SrCr, CrCl and eGFR were 0.06 ± 0.38, 0.85 ± 0.72 mg/dl, 129.85 ± 50.37 ml/min and 99.18 ± 25.69 ml/min/1.73 m2 body surface area, respectively. All four CKD phenotypes exhibited significant heritabilities (P < 0.0001). A genome-wide scan showed linkage on chromosome 2p25 for SrCr, CrCl and eGFR. Significant linkage was also detected on chromosome 9q21 for eGFR [logarithm of the odds (LOD) score = 3.87, P = 0.00005] and SrCr (LOD score = 2.6, P = 0.00026). ACR revealed suggestive evidence for linkage to a region on chromosome 20q12 (LOD score = 2.93, P = 0.00020).
Conclusion. Findings indicate that chromosomal regions 2p25, 9q21 and 20q12 may have functional relevance to CKD phenotypes in Mexican Americans.
doi:10.1093/ndt/gfn215
PMCID: PMC2720810  PMID: 18443212
chronic kidney disease; genome-wide search; SAFHS
12.  Heritability of the Severity of Diabetic Retinopathy: The FIND-Eye Study 
PURPOSE
Diabetic retinopathy (DR) and diabetic nephropathy (DN) are serious microvascular complications of diabetes mellitus. Correlations between severity of DR and DN and computed heritability estimates for DR were determined in a large, multiethnic sample of diabetic families. The hypothesis was that (1) the severity of DR correlates with the presence and severity of nephropathy in individuals with diabetes mellitus, and (2) the severity of DR is under significant familial influence in members of multiplex diabetic families.
METHODS
The Family Investigation of Nephropathy and Diabetes (FIND) was designed to evaluate the genetic basis of DN in American Indians, European Americans, African Americans, and Mexican Americans. FIND enrolled probands with advanced DN, along with their diabetic siblings who were concordant and discordant for nephropathy. These diabetic family members were invited to participate in the FIND-Eye study to determine whether inherited factors underlie susceptibility to DR and its severity. FIND-Eye participants underwent eye examinations and had fundus photographs taken. The severity of DR was graded by using the Early Treatment Diabetic Retinopathy Study Classification (ETDRS). Sib–sib correlations were calculated with the SAGE 5.0 program FCOR, to estimate heritability of retinopathy severity.
RESULTS
This report summarizes the results for the first 2368 diabetic subjects from 767 families enrolled in FIND-Eye; nearly 50% were Mexican American, the largest single ethnicity within FIND. The overall prevalence of DR was high; 33.4% had proliferative DR; 7.5%, 22.8%, and 9.5% had severe, moderate, and mild nonproliferative DR, respectively; 26.6% had no DR. The severity of DR was significantly associated with severity of DN, both by phenotypic category and by increasing serum creatinine concentration (χ2 = 658.14, df = 20; P < 0.0001). The sib–sib correlation for DR severity was 0.1358 in the total sample and 0.1224 when limited to the Mexican-American sample. Broad sense heritabilities for DR were 27% overall and 24% in Mexican-American families. The polygenic heritability of liability for proliferative DR approximated 25% in this FIND-Eye sample.
CONCLUSIONS
These data confirm that the severity of DR parallels the presence and severity of nephropathy in individuals with diabetes mellitus. The severity of DR in members of multiplex diabetic families appears to have a significant familial connection.
doi:10.1167/iovs.07-1633
PMCID: PMC2583147  PMID: 18765632
13.  Evaluation of Polymorphisms in Paraoxonase 2 (PON2) Gene and Their Association with Cardiovascular-Renal Disease Risk in Mexican Americans 
Kidney & blood pressure research  2009;32(3):200-204.
Background/Aims
Genetic polymorphisms in the paraoxonase 2 (PON2) gene are thought to alter its activity and contribute to the development of cardiovascular and renal disease risk. The purpose of this study is to determine whether the Arg148Gly, Cys311Ser and rs12794795 polymorphisms of PON2 examined previously by others, are associated with type 2 diabetes (T2DM), and subclinical measures of cardiovascular and renal disease risk in Mexican Americans.
Methods
Study participants (n = 848; 21 families) were genotyped for the three polymorphisms by TaqMan assay. Association between the genotypic and phenotypic data was performed by measured genotype approach as implemented in the variance component analytical tools.
Results
The Arg148Gly variant was found to be monomorphic in our dataset. Of the phenotypes examined for association, the A/C variant located in intron-1 (rs12794795) exhibited statistically significant association only with diastolic blood pressure (p = 0.018) after accounting for the trait-specific covariate effects. The Cys311Ser variant failed to show statistically significant association with any of the phenotypes examined.
Conclusion
In conclusion, the variants examined at the PON2 locus in Mexican Americans do not appear to be a major contributor to T2DM, cardiovascular or renal disease risk, although they exhibited a small effect on the blood pressure values.
doi:10.1159/000225943
PMCID: PMC2759102  PMID: 19546579
PON2; Genetic polymorphisms; Association analyses; Systolic blood pressure; Mexican Americans
14.  A group randomized trial of a complexity-based organizational intervention to improve risk factors for diabetes complications in primary care settings: study protocol 
Background
Most patients with type 2 diabetes have suboptimal control of their glucose, blood pressure (BP), and lipids – three risk factors for diabetes complications. Although the chronic care model (CCM) provides a roadmap for improving these outcomes, developing theoretically sound implementation strategies that will work across diverse primary care settings has been challenging. One explanation for this difficulty may be that most strategies do not account for the complex adaptive system (CAS) characteristics of the primary care setting. A CAS is comprised of individuals who can learn, interconnect, self-organize, and interact with their environment in a way that demonstrates non-linear dynamic behavior. One implementation strategy that may be used to leverage these properties is practice facilitation (PF). PF creates time for learning and reflection by members of the team in each clinic, improves their communication, and promotes an individualized approach to implement a strategy to improve patient outcomes.
Specific objectives
The specific objectives of this protocol are to: evaluate the effectiveness and sustainability of PF to improve risk factor control in patients with type 2 diabetes across a variety of primary care settings; assess the implementation of the CCM in response to the intervention; examine the relationship between communication within the practice team and the implementation of the CCM; and determine the cost of the intervention both from the perspective of the organization conducting the PF intervention and from the perspective of the primary care practice.
Intervention
The study will be a group randomized trial conducted in 40 primary care clinics. Data will be collected on all clinics, with 60 patients in each clinic, using a multi-method assessment process at baseline, 12, and 24 months. The intervention, PF, will consist of a series of practice improvement team meetings led by trained facilitators over 12 months. Primary hypotheses will be tested with 12-month outcome data. Sustainability of the intervention will be tested using 24 month data. Insights gained will be included in a delayed intervention conducted in control practices and evaluated in a pre-post design.
Primary and secondary outcomes
To test hypotheses, the unit of randomization will be the clinic. The unit of analysis will be the repeated measure of each risk factor for each patient, nested within the clinic. The repeated measure of glycosylated hemoglobin A1c will be the primary outcome, with BP and Low Density Lipoprotein (LDL) cholesterol as secondary outcomes. To study change in risk factor level, a hierarchical or random effect model will be used to account for the nesting of repeated measurement of risk factor within patients and patients within clinics.
This protocol follows the CONSORT guidelines and is registered per ICMJE guidelines:
Clinical Trial Registration Number
NCT00482768
doi:10.1186/1748-5908-3-15
PMCID: PMC2291070  PMID: 18321386
15.  Self-Care Communication during Medical Encounters: Implications for Future Electronic Medical Records 
Objective
The growing importance of electronic medical records (EMRs) to healthcare systems is evident, yet the debate concerning their impact on patient-provider communication during encounters remains unresolved. For this study, we hypothesize that providers' use of the EMR will improve patientprovider communication concerning self-care during the medical encounter.
Design
Cross-sectional, observational study.
Setting
A primary-care outpatient clinic of the South Texas Veterans Health Care System in San Antonio, TX, USA.
Methods
A convenience sample of 50 patient/physician encounters was videotaped, transcribed verbatim, and analyzed to determine the time that the physician spent using the EMR and self-care topics discussed. Self-care topics included medication use, recognition of disease symptoms, diet, exercise, management of physical and emotional distress, self-monitoring activities, cigarette smoking, alcohol consumption, and family support/community resources. Two observers independently coded for the kind of self-care topics (kappa = 0.91) using the Atlas.ti software package.
Results
Encounters averaged 22.6 minutes (range: 5–47, SD = 8.9). We identified two encounter types based on EMR usage: low use (n = 13), with EMR use of two minutes or less, and moderate to high EMR use (n = 37), with EMR use of five minutes or more. Average time for encounters was 25 minutes for moderate to high EMR use encounters and 16 minutes for low EMR use encounters (t test, p < 0.001). Issues pertaining to facets of self-care management were discussed in every physician-patient interaction (100 percent). The most frequently discussed self-care topics were medication use (100 percent), physical distress (76 percent), and disease symptoms (76 percent). Self-monitoring activities, exercise, and diet were discussed in 62 percent, 60 percent, and 46 percent of the 50 encounters respectively. Emotional distress (26 percent), smoking (30 percent), family support/community resources (26 percent), and alcohol consumption (20 percent) were the least discussed issues.
Encounters were similar with respect to the kinds of self-care elements discussed. However, EMR use encounters were more likely to include a higher number of self-care topics raised by physicians than low EMR use encounters, particularly on disease symptoms (odds ratio = 4.4, p = 0.05), and physical distress (odds ratio = 7.4, p = 0.006). A significant correlation was observed between the number of self-care elements discussed and time spent on the EMR (r = 0.6, p < 0.05), but no correlation was observed between the length of the encounter and self-care discussion (r = 0.009, p = 0.90).
Conclusions
The use of an EMR during encounters is associated with an increase in the number of self-care topics raised by physicians. EMRs offer the opportunity to involve patients and physicians in discussion of self-care during patients' visits. Given the current emphasis on the widespread implementation of EMRs, future EMRs should be designed to systematically facilitate the integration of EMRs into clinical exchanges about self-care.
PMCID: PMC2047306  PMID: 18066361
electronic medical records; self-care; clinical communication

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