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EHR screen, test, and refer to HFMH DPP

Cite this dataset

Aquino, Gina (2022). EHR screen, test, and refer to HFMH DPP [Dataset]. Dryad.


Objective: Determine if certified electronic health record technology (CEHRT) can be used to identify and refer patients with prediabetes to lifestyle change programs (LCPs) recognized by the National Diabetes Prevention Program (DPP).

Materials and Methods: This pilot utilized a prediabetes registry, patient portal, and clinical decision support to increase referrals.

Results: Data from 36 primary care providers showed 4,930 patients were eligible for DPP LCP, 293 referrals were generated, compared to 20 referrals in the baseline period, and 116 patients enrolled. Referral to enrollment conversion rates were 41% in the study period and 69% in the post-study 1-year period.

Discussion: CEHRT functionalities can support systematic identification and management of prediabetes.  The referral rate increased seven-fold compared to the baseline period, with high referral to enrollment conversion rates.

Conclusions: CEHRT coupled with active provider engagement can serve as a tool to identify prediabetes patients and facilitate LCP referrals and enrollment.


Data were extracted from the EHR to obtain de-identified aggregated counts of patients attributed to the providers in the pilot study.