of Epidemiology (LIRE): The Beginning of the End (or The End of the - - PowerPoint PPT Presentation

UW Medicine/ UNIVERSITY of WASHINGTON

Jeffrey (Jerry) Jarvik, MD MPH

Departments of Radiology, Neurological Surgery, Health Services Comparative Effectiveness, Cost and Outcomes Research Center

Patrick Heagerty, PhD

Professor and Chair, Department of Biostatistics Director, Center for Biomedical Statistics

NIH Health Systems Collaboratory Grand Rounds 11/18/16

Lumbar Imaging with Reporting

• f Epidemiology (LIRE): The

Beginning of the End (or The End of the Beginning?)

Disclosures (Jarvik)

• Physiosonix (ultrasound company)

– Founder/stockholder

• Healthhelp (utilization review)

– Consultant

• Evidence-Based Neuroimaging Diagnosis and

Treatment (Springer)

– Co-Editor

• NIH: UH2 AT007766-01; UH3 AT007766
• AHRQ: R01HS019222-01; 1R01HS022972-01
• PCORI: CE-12-11-4469

Acknowledgements

Talk Outline

• Brief review of study goals/design
• Progress to date
• NLP for data extraction from

radiology reports

• Next steps

LIRE (pronounced leer)- From the French verb, “To Read”

Background and Rationale

• Lumbar spine imaging frequently

reveals incidental findings

• These findings may have an

adverse effect on:

–Subsequent healthcare utilization –Pt health related quality of life

Disc Degeneration in Asx

Hypothesis

• For pts referred from primary care,

inserting prevalence benchmark data in lumbar spine imaging reports will reduce:

–subsequent x-sectional imaging (MR/CT) –opioid prescriptions –spinal injections –surgery

Retrospective Pilot Results: Subsequent Imaging Within 1 Yr

P=0.14 OR*=0.22

1/71 12/166

* Adjusted for imaging severity

Retrospective Pilot Results: Narcotic Rx Within 1 Yr

P=0.01 OR*=0.29

5/71 37/166

Intervention Text

The following findings are so common in normal, pain-free volunteers, that while we report their presence, they must be interpreted with caution and in the context of the clinical situation. Among people between the age of 40 and 60 years, who do not have back pain, a plain film x-ray will find that about:

• 8 in 10 have disk degeneration
• 6 in 10 have disk height loss

Note that even 3 in 10 means that the finding is quite common in people without back pain.

Randomization

• Cluster (clinic)
• Stepped wedge (one way

crossover)

Participating Systems

Name # Primary Care Clinics (Original) # Primary Care Clinics (Randomized) # PCPs (Original) # PCPs (Randomized) Kaiser Perm.

• N. California

17 21 1,006 2,243

Henry Ford Health System, MI

26 26 230 187

Group Health Coop of Puget Sound

25 19 303 365

Mayo Health System

61 34 269 400

Total

129 100 1808 3,195

Stepped Wedge RCT

1/13 1/14 1/15 1/16 1/17

LIRE- The Outcome

• A single metric of overall

intensity of resource utilization for spine care based on CPTs converted to RVUs

• Passively collected from EHR

Key Pragmatic Aspects of LIRE

• Broad inclusion criteria
• Waiver of consent
• Centralization of IRB review
• Simple, easily implemented

intervention

• Passive collection of outcomes
• Cluster randomization
• Stepped wedge randomization

LIRE PRECIS

Talk Outline

• Brief review of study goals/design
• Progress to date
• NLP for data extraction from

radiology reports

• Next steps

LIRE: Enrollment

Demographics

Patient age at index image

Female

Race

Hispanic Ethnicity

Imaging Modality

Macro Penetration at Wave 1 Clinics

Shading indicates the number of macros that the patients’ providers have been exposed to

____ ____ _ __ _ _____ _ _ _____ ____ ______ ___ ________ _ _______ ____ ______ ___ _____ __ _____ _ ___ __ __ ____ __ _ __ _ __ ____ ____ _ ____ ____ ________ ______ ____ ___ _ _ ________ _ _______ ____ ______ ____ ___ ____ _______ _ _ ____ ______ ____ __ _____ _ _______ ____ ______ ____ ________ _ _______ _ _ __ __ _ __ ____ ______ ____ ____ ___ _ _______ ____ _ ____ ___ ________ _ _______ __ ___ _ ____ _____ _ ______ _ _ __ _ _ _ _ __ __ _ _ _ _ _ ____ ______ ___ _____ ____ __ __ __ ___ _ _____ _ ___ _ _ __ _ __ ________ _ _______ _ _ _ _ _ _ _ __ __ _ _ __ _ ____ ______ ____ ____ _ __ ___ __ _ __ ________ _ _______ ___ ______ ____ __ __ _ _ _ __ _ _ _ _ __ ____ ______ ____ ________ _ ____ ___ ____ _ __ _ __ __ _ _ __ __ _ _ _ _ _ ____ _ _ ___ _ _ _ ___ ___ ____ ______ _ _ ________ _ _______ ____ __ ____ _ ____ ________ _ _ _ ___ _ _ _ _ __ _____ __ ____ ___ _ _ _ ___ __ ____ ________ _ _______ __ _ _____ ___ ___ _ _ _ __ _ __ _ _ _ _ _ _ __ _ _ __ _ ____ _ _ _ __ _ _______ _ _ _ _ __ _ ______ _ __ _______ ____ __ _ _ _____ _________ _______ ____ __ _ _ _____ _________ _______ ____ __ _ _ _____ _________ _ _____ ____ __ _ _ _____ _ ____ __ ____ __ ___ __ _ _ ___ _______ ____ __ _ _ _____ _________ _______ ____ __ _ _____ _________ _______ ____ __ _ _____ _______ _ _____ _ ___ _ _ _____ ________ _______ ____ __ ____ _____ __ _______ ____ __ _ _ _____ ________ _______ ____ __ _ _ _____ __ ______ _______ ____ __ _ _ _____ _________ _______ ____ __ _ _ _____ _________ _______ ____ __ _ _ _____ _________ _ ____ _ _ _ ___ _ ______ ___ ___ _______ ____ __ _ _ _____ _______ _ ____ ___ __ _ _ __ __ _________ _______ ____ __ _ _ _____ __ ______ __ __ _ _ _ _ ___ ___ _______ ____ __ _ _ _____ _________ _ _ __ ____ __ _ _____ _ ___ ___ _______ ____ __ _ _ _____ ________ _ ___ _ _______ ____ __ _ _ ____ _________ _ _____ __ _ _ _ __ __ _ _ _ ___ ___ _ __ _ ___ _______ _ __ __ ___ __ _ _ __ ___ _____ _______ ____ __ _ _ _____ _________ _______ ____ __ _ _____ _______ _ _ __ ___ _____ ___ ___ ____ __ _ ____ _________ _ __ _ _ _ _ _ _ _ _ _ _ _ _ ___ ___________________ ___ _ __ _____ ________________ _ _ ___ ______ _ _ __ __ __ _ __ _ __ ____ _ _ ___ _______________________ _ ____ ___ __ _ _ _____ _ ___ _______________________ _ _ __ ___________ _ _ _ _ ___ _______________________ _ _ ___ _______________________ _ _______________ ___ ___ _ ___ _ ___ _______________________ _ _ __ _ ___ _______________________ _ _ ___ ___ ___ _____ _____ __ _ _ _ _ ___ _______________________ _ ___ ___________ ___ _______ _ _ _ ___ _______________________ _ _____ __ __ _ ___ _ _ _ ___ _______________________ ___ ____ _ _____ ___ ____ _ _ ___ ___ ______________ __ _ _ ___ _______________________ _ ___ ____________ __ ___________ _____ _ _ __ _____ __ _______ _ ____ _ _ ___ _________________ ____ ___ ___ _________ _______ _ _ __ ____ __________________ _ _ ___ _ _____ ___ ___________ _ _ _ ___ _______________________ _ _ ___ _______________________ _ _ _ __ _______ _____ _ _ _ ___ _______________________ _ __ _ _ ___ _________ ___ _________ _ _ ___ _______________________ _ _ ___ _____ _______ _________ ___ __ ________ __________ ___ __________ _______ ____ ___ ___ ___ ______ ________ _ _ ___ _____ __ _____ __ _ ___ _______________ _______ ___ _ __ _ __ _______________________ _ ___ _______________________ _ _ ___ ___________________ _ ___ _______________________ _ ___ _______________________ _ _ _ _ ___ _______________________ _ _ _ ___ ___ _ _ ___ _______________________ _ ___ ______________ ________ _ _ ___ __ ___ ________________ ___ _________________ __ ____ _ _ ___ _______________________ _ _ _ _ ___ ______ ________________ _ ___ _ _____ ______________ _ _ _ ___ _______________ ______ _ _ _ __________________ __ ___ ___________ _______ ___ _ __ _ _____ _ ______ _ ______________ ______ _ _ _ ___ ________ _____ _______ _ ___ _______________________ _ _ _ __ _______________________ _ _ ___ ___ _______________ ___ ___ _________ _____________ _ ___ _______________________ __ _____ __ _____ _______ _ _ _ _ _ _ _ ___ _______________________ ___ ________________ _____ _ ___ _______________________ _ _ _ _ ___ ___________ ___ _ _ ___ _______________________ __ ______ ____ ________ __ _ _ ___ ___ ____ __ ______ __ _ _ _ ___ _________ _____________ _ _ ___________ _ _____ __ _ ___ _______________________ _ ___ _______________________ _ _ ___ ________ ____ ________ _ ___ _______________________ _ ___ __ __________ _________ _ ___ _______________________ _ _ ___ __ __________ _____ _ _ _ ______________________ ___ ___ ________________ __ _ _ _ _ ________ ______________ _ _ ___ _______________________ _ ___ ____ _________________ _ ___ ____________________ __ _ _ ___ _____ __ ___ ___ ________ _____ ____ _ __ _ ____ ____ ____ ____ _ ___ _______________________ _ ___ _______________________ _ _ ___ ______ ___ _______ ____ ___ _____ ___ ________ __ _ _ _ ___ ______________ ___ _ ___ __ _______ ________ _ _ ___ _______________ _____ _ _ _ _ _ ___ __ _ ______ ___ __ _ _ ___ _______ ______________ _ __ _ _ __ _ ____ _ __ _______ ____ _ _ _ __ __ _ __ ________ ___________ _ ___ __ _ __ _____ ____ __ _ _ ___ ______ _______________ _ ___ _ __ _ _________ _ ____ _ ___ ____________ __________ _ _ ___ _______________________ _ ___ _______________________ _ _ _ ___ ___ _ _____ __ ____ __ ___________ _ _ ___ ______________ ______ _ ___ __________ _ ___ _ ____ _ _____ _ _ _ _ _ ____________ _______ _ ___ _ _____ _____ _____ __ _ ___ _______________________ _ ___ __ ______ ____________ _ _ ___ _______________________ _ ___ _______________________ _ _ _ _ _ __ _ ___ ______________________ _ ___ _______ ______________ _ __ _____________________ ___ __ __ _ _______________ _ ___ _______________________ _ _ ___ ________ _ _ ______ __ _ ___ __________ ____________ _ ___ _____________________ _ _ _ __ ________ ___ _______ ___ ___ _ _ __ _ _________ _ ___ ______________ ________ _ _ ___ _______________________ ___ __ _ _ ___ _______________________ _ _ ___ _______________________ _ _ ___ _______________________ _ ___ _______________________ _ ___ ______ _____ ____ __ _ _ _ ___ _ ____ ___ ___ ______ ___ ___ _____ __ ________ _ _ ___ _______________ __ ___ _ ___ ______________________ _ ___ __ ____ __ ___ ______ _ _ _ ___ _______________________ _ ___ __ _ _ __________ _ ___ _______________________ _ _ ____ __ _ _ _ _ _ ___ _______________________ _ ___ _ ___________________ __ _ ___ ______ _ _ _ ____ ____ _ _ ___ _______________________ _ _ __ _______________________ _ _ _ ___ _______________________ _ _ _ ___ _ __________ _______ _ _ _ ______ _ ___ __ ____ _ ___ ________________ ______ ___ ___ _____ _ ___ _ ___ _ _ ___ _______________________ _ _ __ _ __ __ _ _____ _ ___ ______________ ________ _ _ ___ ______ ___________ _ _ ___ ___________ ______ __ _ _ ___ _____ _ _______ ___ ___ _ _ ___ _______ ____ ________ _ _ __ _____ __ _ _ ___ _ __ ____ _________________ _ __ ____________ _ _ ___ _____ _________________ _ _ ___ ______________________ _ _ _ ___________ _ _ __ ___________________ ___ ___ ____________ __________ _ ___ ____________ __________ _ _ ___ _______ ______ _____ ___ ___ _________ _________ ___ ____________ __ _ _ ___ _______________________ ___ _________ _____________ _ _ ___ _______ _________ ___ ___ __________ _________ _ _ _ _ _ _____ _ ____ __ ___ _ _ _ ___ ___ ___________ _______ _ _ _ _ __ _ ___ _______ _ _____ _ _ _ ___ ___ __________________ _ __ ____ __ ___ ________________ ___ ____ ____ _________ _ _ _ ___ _______________________ _ ___ ____________ __________ _ _ ___ ___________ ___________ ___ __________ ____________ _ __ _ __ ______ __ ______ _ ___ __ ___ _______ ________ _ __ __ ________ ___ _ _ _ ___ ____ __ _ _ _______ _ __ ___ ___ __ ____________ _ ___ _______________________ ___ ______ _____ _________ _ _ ___ __ _ _ ___ _ _______________________ _ ___ __ _______________ __ _ _ _ __ _______________ ____ _ _ ___ ______________________ _ _ ___ _______________________ _ _ _ ___ ___ _ ________________ _ _ _ ___ ___ ____________ __ _ ___ ___ _________ ___ _ _ ___ ___ _________ _______ _ _ _ _ _______________________ _ ___ ______________ __ _ _ _ ___ ___ _ __ ___________ _ __ ___ _____ __ _ _____ _ _ ___ ___ _ ___ _______ _ __ ___ __ _ __ _______________ _ ___ _______________________ _ __ __ _ ___ _ _ _ _ ___ _ _______ _ __ __ ____ _ _ ___ ____ __ _ ___ ____ __ ___ ____ _ _ _ ___ _ ___ ___________ _ _ _ __ ____ _______ _____ ___ __ ___ ______ __ __ _ _ _ __ _______________________ _ _ _ ___ _____________ _________ ___ ______________ ________ __ _________ _____________ _ _ ___ _______________________ _ __ _______ ____ __ ______ _ _ _ _ _____ ________ ______ _ ___ _________________ _____ ___ _______________________ _ ___ _______________________ _ _ _ _ ___ _______________________ _ _ ___ _____ __ __ ___ ___ _ ___ _________________ _____ _ ___ __ _ _ ___ _______________________ _ _ ___ _ ______ __ __________ _ _ _ __ _____ ____________ __ ______ ____ __ __ _ _ ___ ______ _ _______ _ _ ___ ________ _________ ____ _ _ ___ ___________ _ ________ _ _ ___ ____________ _________ _ ____ ___ __ _ ___ __ ___ __ ____ ___ __ _ _ ___ ____________ _____ ____ ___________ ___ ___________ ___________ ___ _ _ _ ___ _ __ __ _ ___ _______________________ _ __ _ ________ ____________ _ __ __ ________ __ __ __ _ ___ ____________ _______ _ _ _ __ ___ __ ___ _ ______ __ _ __ ___ _ ____________ ___ _ ____ _ ___ _______ _ ___ ___ _ _ _ _ _ _____ __________ ______ ___ _______________________ _ ___ _ _ _ ______ __ ___ _ ___ ______________ ________ ___ ____ ____________ ____ __ __ __ ____ __ ____ _ __ ___ __ _ _ _________ _ _ ___ ___ ____ ______________ _ ___ ____ _ ___ _______________________ _ _ _ ___ _______________________ _ ___ _________ _____ ___ _ _____ ___ ______ __ _ _ ___ ______ _ ___ _____ _________ __ ____ _ ___ __ __ ____ ________ __ _ _ _ _ __ __ _ _ _ ___ _____ _ _ ____ ________ _ ___ ______ ___ __ _ _ ___ ___________ __ ________ _ _ ___ _____ ________________ ___ ________ ______________ _ _ _ _ ___ __ __________ _ _ ___ ____________________ __ _ _ ___ _ __ _ ___ _ _ ___ _______________________ _ _ ___ _ __ __ _ _____ __ ___ ______________ ______ _ ___ _______________________ _ _ _ _ _ _ _ ___ __________ ___________ _ ___ ___________ __________ ___ _ _ _____ _ _ _ ___ ___ _______ ___________ _ __ ____ _____ _ _ _______ _ ___ ______ ___ _ __ ___ _ _ _ _ ___ _______________________ _ _ ____ _ _ _ _ _ _ __ _ __ _ ___ _ _ _ _________ ____ _ ___ _______________ _ _ _____ ______ __ __ __ _ __ _______ _______________ __ ___________________ ___ _ _ _ ___ ____________ ____ _ ___ _ ____ ____________ __ _ __ _ _______ __ _ __ __ _ ___ _ __ _ ___ ___________ _ _ _____ ________ __ ______ __ ___ ___ _ _ _ __ _ ___________ _ _ __ _______ __ ________ _ __ ____ _ _ _ __ _ __ ____ __ _ _ __ ________ _ _ __ _ _ _ _ _ _____ ____ ___________ _ ___ _______________________ __ __ _ _ _ _ _ _______ _ _ _ ____ _ ___ _ _____ _ _ __ __ ____ _ ___ ___ _ __ _ ____ __ _ _ _ __ _ ____ _ _ _ _ _ ___________________ ___ _ __ ___ _ _ _ _ _ _ _ __ __ __ _ _______ __ _ _ ___ _______ ___ _ ___ ________ _ _ __ _____ ___ _____ ____ _ __ ______ _ __ _ ___ _ __ _ _ ____ _____ ___ ___ ______ ___ _ _ __ _ _ ___ ___________ ___ ___ _ _ _ __ _ ______ _ ___ ____ ___ _ __ _ ____________ ___ __ ___ _ ____ __ ____ _____ _ __ _ _______ ___ ___ __ ___ ____________ _____ ____ ___ _________ _______ _ _ ___ ________ _ __ _ __ _ ___ _ ___ ____ _ _ _ _ _ _ _ _ __ __ _____ __ _ _ _ _ _ __ ___ _____ _ _ _ _ _ _ ____________ __ __ ___ _ _ __ _ _ _ _ __ __ _ _ _ __ _________________ ____ __ _________ _______ ___ _ _ ___ _ ____ _ ______________ _ _ _ ___________ ________ _ _ ___ _ ___ _____________ _ _ _ _ _ _ ___ __ _ ___ _______________________ _ _______ ___ ___ _ ___ _______________________ _ _ _ ______ __ __ __ _ __ _ ___ _______ ___ _______ __ _ _ _ _ ___ _______ _______________ _ _ _ ___ _ _ _ _ _ _ __ ________ _________ _ _ _ _ _ _ _______________________ ____ __ _ _ ____ _ _____ _____ _ _ ___ ____________ __________ _ ___ __ ____________________ _ _ _ _ _ _ ______________________ _ __ _ _ ____ _ ___ ________ _ _ _ _ _ _ _ _ ___ _______________________ __ _______ __ ___ _ _ _ ___ __________________ ____ _ _ _ ___ _ ______ ________ _____ _ _ ___ _______________________ _ __ _ _ __ _ ___ _ _ _ _ ___ ______ ________________ _ _ ___ _______________________ _ ___ _______________________ _ _ ___ ____________________ _ __ _______________________ __ _ __ __ _ ___ ____ ___ _ __ ___ ________________ _ _ _ __ _ _____ __ _ __ ___ _ _____ __ _______ __ __ _ ___ _______ __ ___ __ __ _______________ ____ _ _ __ ____ ____ _ _____ _ __ _____ _____ ____ _ __ _________ ______ ___ _ ____ _________________ _ _ ______ ___ _ __ ___ ___ _ _ ___ ______ _ ____ __ __ _ _ ____ _ __ _ ___ ________________ _ ___ _ ___ _ __ _ _____ __ __ __ _ _ _ _ _ _ _ ___ _ ___ _ _____ __ __ __ _ _ _ _ _ _ ___ ___ ____ __ _____________ ______________ _________ _____ ____ __ __ ____ ____________ _____ __ __ ____ __ _____ ___ __ __________ __ _ _ _ _ ____________ _ ___ _ _ ___ ___ ______ _____ _ _ _ _ __ _ _ _ _ _ _ _____ ___ __ _ _ __ __ ____ ___ ____ __ __ _ _ __ ___ _ _ __ _ ________ _ __ _______ _ _ _ ___ _ _ _ _ ___ _ _ _ _____ _ __ ___ _ ______ __ ___ __ _ _ ______ __ __ ___ _ _______ _ _ ________ ________ _ _ __ _ _ ____ _____ __ ______ _____ _ _ _ ___ __ _______ __ ___ __ _ __ ___ __ _______ ___ __ _ ___ _ __ __ __ __ _ __ ___ ______ ___ _____ _ __ _ _ __ _ ___ __ __ ___ ___ _ __ _ ___ ___ _____ __ _ ___ _ _____ _ __ _ _ _ _ _ ___ _ _ _ __ _ ____ _ _ ___ ___________ ___ __________ __ __ __ ________ __ ________ _ __ _ _ __ ___ ___ _____ _ ___ ____ ______ _ _ ___ __ _ ____ _ ___ _________ _ _ _ __ ____ _ __ _ _ _ _ ___ ____ _ ___ _ _ ____ ___ ___ ______ _ __ _ ___ ____ ___ ____ _____ _ _ _ __ ___ __ ___ __ _ _ __ ____ ___ ___________ ___ _ ___ _ ___ __________ _ _ _____ _ _ __ ___ __ __ _ _ ______ __ _ _ _ _ _ __ _ ___ ___ _______ _ _ ___ _ __ _ _ _ _ _ __ ___ _ _______ __ ___ _ ___ _____ ___ ___ __ __ _ _ ___ __ ___ ___ __ _____ ___ _ _ ___ __ ___ ______ _ _ ___ __ _ _ _ ___ _ ___ _ __ _ ___ _ _ ___ _ __ __ _ ___ ______ ___ ___ __ __ __ _ __ ___ _ _ ______ ___ __ _ _ _ _ _ _ ___ _ ___ ___ __ _ ___ _ __ _ __ __ _ __ _ ___ __ _ __ __ _ _ _ _ __ __ _ ___ _ __ ___ ___ _____ _ ___ __________ _ _ ___ ____ __ _ _ ____ _ __ __ ____ __ _ _ __ _

25 50 75 50 100 150 500 1000 20 40 60

Group Health Henry Ford Kaiser Mayo

Oct 2013 Jan 2014 Apr 2014 Jul 2014 Oct 2014 Jan 2015 Apr 2015 Jul 2015 Oct 2015 Jan 2016 Apr 2016 Jul 2016

Index Date (through 2016−09−30) Number of Index Images

Provider Macro Views

1 2−3 4−7 >7

Macros Included

_ Wave 1: Monthly Index Images and Provider Macro History

Macro Penetration at Wave 2 Clinics

Shading indicates the number of macros that the patients’ providers have been exposed to

_ _ _ _ __ _ __ ___ _ ___ _ _ __ __ _ _ __ _ ____ ________ _____ _ _ _ __ ______ ________ ______ _ ______ __ __ ___ _ _ __ _ ___ ________ ______ _ _ _ __ __ __ _____ ____ _ _ ______ ________ __ _ _ __ __ _ ___ __ _ _ _ _ __ _____ ______ _ ______ __ _ _ __ _ _ __ _ _ _ __ __ ___ _ __ _ _ __ ______ _______ _____ _ _ _ __ ____ _______ ______ _ _ _ _ _ ___ _ _ __ __ _ _ _ _ __ _ _ __ ____ _ _____ _ _ __ ______ ________ ______ _ _____ __ ___ __ _ __ ______ ____ _ __ ______ ________ ___ __ _ _ __ _ __ ____ _ __ ____ _____ _ _ _ _ _ ______ ________ _____ _ _ __ ______ _ _ _ _ _ _ __ _ _ _ __ _ _ ___ _ _ ______ ______ _ _ __ ___ _ ________ ___ _ _ __ ___ __ _ _ __ ______ _______ ______ _ _ _ __ ____ _ ________ _ ____ _ _ _____ _ _ _ __ _ __ _ _ _ _ _ _ _ __ _ ___ _ _ _ _ __ _ ________ ______ _ _ __ _ ___ ________ ____ _ _ _ _ _ _ _ ____ _ _ __ _ _ _ __ ______ ________ ____ _ _ _ _ __ _ ____ ________ ______ _ _ _ _ _ _ _ _ __ ______ ___ _ _ _ _ _ _ ___ _______ ______ _ _ __ _ ___ ___ __ _ _ ______ _ __ __ _ ______ ______ _ _ _ __ ______ ________ ___ _ __ ______ ________ __ ___ _ _ __ ______ ________ _____ _ _ __ ___ __ __ _ _ _ _ _ __ _ __ ______ _ ______ _ ____ _ _ _ __ ______ ________ ___ __ _ ______ _ __ _ _ _ _ _ _ _ ___ _ __ ____ ________ __ ___ _ __ ___ __ ______ ____ _ _ __ _ _ _ ___ __ _____ _ __ _____ ________ ______ _ __ _ _ __ _ _ __ _ _ _ __ _ ____ _______ ______ _ _ __ _____ ___ ___ ______ _ _ __ _ ____ __ ___ _ ___ _ __ _ __ _ _ _ ____ _ __ _____ _ __ __ _ _ ________ ______ _ __ _ _ _ _ ____ ____ _ __ __ _ _ _ __ _ ______ _ _ _ _ _ _ ____ ________ ______ _ _ _ _ _ _ _ _ ______ _ _____ ______ _ ______ _ _ ___ __ _______ ______ _ _ _ __ _ _ _ _____ __ ____ _ _ _ ____ ______ _ __ _ ____ _ _ __ _ _ _ __ ______ _ _ ___ ______ _ __ ___ _ _ _ ______ _ _ _ _ _ _ _ ___ _ _ _ _ _ __ _ __ _ _ __ _ ___ ______ _ __ _ __ _ _ __ _ _ _ __ _ _ __ _ _ ___ ___________ _ _ __ _ _ ___ _ _ _ _ __ _ _ ___ _______ ___ __ _ _ __ _ __ _ ___ _ _ __ _ _ __ _ ___ __________ _ __ _ _ __ _ ___ _____ ___ _ _ _ _ __ _ ___ ______ __ _ _ _ _ _ ___ __ __ __ __ _ __ _ _ __ _ ___ __ _______ _ _ _ _ __ _ ___ ___________ __ _ _ __ __ _________ _ __ _ _ __ _ _ ___ ___________ _ __ _ __ _ _ ___ ___________ _ __ _ _ _ _ _ ___ ___________ _ __ _ _ __ _ _ ___ __________ _ _ _ ___ __ _ _ _ __ _ _ __ _ _ __ ___________ _ __ _ _ __ _ _ ___ ____ _ __ _ _ __ _ _ ___ ___________ _ __ _ __ _ _ _ _ _________ _ _ _ _ __ _ _ ___ __ _____ __ _ __ _ _ __ _ _ ___ _ _________ _ __ _ _ __ _ ___ ___________ _ __ _ __ _ ___ ___________ _ __ _ _ __ _ _ _ _ _ _ _ __ _ __ _ __ _ _ _ __ _ ___ ___ _ __ _ _ ______ ___ _ __ _ _ __ _ ___ _______ ___ _ __ __ _ __ _ _ __ _ _ __ _ _ __ _______ ___ _ _ _ _ _ ___ _ _ _ ____ _ _ _ _ _ _ _ ____ _ _ _ _ _ _ __ __ _ _ _ __ _ _ ________ _____ _ ____ _____ _____ _____________________ __ ________________________ ________________________ ________________________ _ _____________________ ________________________ ______________________ _ __ ________________ ___ __ _ _ ___ _________ _ ________________________ ________________________ __________ _ __ _ _________ _________ _______ ________________ _ ___ ____________ ___ _ ___ ___________ ___ ____ _ ______________________ ________________________ ____ _ ______________ __________________ __ _____ ______________ ___________________ ________________________ _ _____ ____ _____ _____ _ ________________________ ___________ ____________ __ ___ ______________ ________________ _______ __ __ _ _________ ___ _ _______ __ ______ _ __ ___ __ _ ___ _ __ __________ ______ _ __ ______________ ____ __ __________ _____________ _ ________________________ ________________________ ________________________ ____________ __ ___ _ _____ ______ ___________ _ _ _____________ ______ ______ _ __ __ _____ ___ __________ ________________________ __________________ ____ __________ _____________ ________________________ ________________ _______ _______ __ ____________ _______ _____ _______ ________________________ _____ ______ ________________________ __ ________ ____ ___________________ ________________________ _ __________ _ ________ ___________ ___ _______ ____ ___________________ ______ ___ ____ _ ____ _______ _ _ ________________________ _ __ __ _ ____ __ __________ ________ _ ______ __ _____________ _ ________________________ ________________________ _________ ______________ ____ ______ ________ _ ____________ __________ ________________________ ________________________ ________ _ ____________ ________ _______________ ________ ____ ___________________ __ _ _________ __ _ ____ __ ________ ____________ ________________ __ ____ ________________________ ________________________ _____________ __ __ __ _ __ ________________________ _ _ _ _ _ _ _ _ ________________ ______ ___ _______ ___ _____ _ _ ____________ ___________ __________ __ ___ ______ _______ ____ ______ __ __________________ ______________ ________ _______ ________________ _ ______________ __ ______ ___ ____________________ _______________ ________ ________________________ __________________ _____ ________________________ _ ____ __ _______ ___ ___ ___ _____ __ _ __ __ _______ _____________ ___________ ________ _ ____ ___ _ ___ ________________________ ________________________ _ ___ _ ____________ _ _______ _______________ ______ _ ____ _________ ___ _ __ __ ______ ________________ _ ____ _ _____________ ____ _______________ _ _________ ____ __ ______ ______________ _ ______ ________ _ ____ __ _ __ ___________ ___ _______ _ _______ ___ ___ _____ ________________________ ____ __________ ________ __ _ ____ ___ ______ ________________________ ____________ ___________ _____ ____ ______ __ ___ __ ______________ _ ___ __________ __ _______ _ __________ _____________ ________________________ _ _ _ _ _ __ _ _ ____ ______________ _ ________________________ ________ __ _____ ___ __ _____ _____ _______ ____________ _ ______ _ ________________________ ________________________ _ ________ ______ ____ ________________________ _ _ ____________ _______ __ ___ __________ _____ ____________________ ___ _____________ _____ _ _ _ _ _ _ _ _ _____ _ _____________ _ _ __ __ ________ _ _ __ ________________________ _______ _______ _______ _ ________________________ _____________ __________ ____ ____ __ _ ________ ____________ __ _ ______ ____ ________ _ ______________________ _ ________________________ ____ ________ __ ___ _ _____ ___ __ __ __ __ ___ ___________ ______ _ _____________ ____ _ ______ __ __ ________________________ _____ _ _ ______ __ ___________ _ ______ ____________________ __ ____________ ____ ____ _ __________ _______ _ _ _ __ _ _______________ ________ _ ___ __ __ _____ ___ ____________ __________ _____________ __________ ________________________ __ ___________ _________ _ _____ ____ _____ ____ _ __ __ __ _________ _ _ __ __________ _____ ___ ___ ___________ __ _____ __ _ _ _ __ _ ____ _ _________________ _ ____ ____ _________________ ________________________ ____ _________ _________ _ __________ __________ ___ ___ _ ___ _______________________ __ _ ___ __ _ _______ ___ ___ _______ _______ _____ ____ _____________ ________________ _______ ____ _ ____ _____ ___ __ ______ ______________ __ ______ ___ ___ _ ___ _ __ _ ________ __ ____ _ ____ __ _ ________ _ ______________________ _ ___ ____________________ ________________________ _ ___ ___ _______ __ __ _ __ _ _______ ______ ___ _ __ ________ _ ______ ________________________ ________ __ __ ________ ___ _____ _ ______ _ _ _ _ ___ __ __ ________ _______ _ ___ ______ __ ______ ____ _ __ _ ____ ________________ ____ __ __________________ _____ _ ____________ ______ __________ ____________ _____ _ _ __ _ ___ __ _ ___ ___ ____ ___ _ _________________ __ ______ _____ _______ __ __ ____ __ ________________________ __ _______ __ ______ ___ ___________________ ____ _ _______ ______________ _ _ _____ _______ _ _____________ _______ _____ ______ ___ _ ___ ____ _ _______ _____ __ __ ___ _____ _ ______ __ ___ ____ ___ __ __ _ ______ _ _________ _ ____________ __ ___ _ ________________________ _________ _____ ________ ____ ___ ___ __________ _____________ __________ __ ______________ __ __ __________ _______ _ ___ ____ _ ___ _ ____ __ _ _ __ __ ____ __ _ ___ ___ ____ ______ ___ __ _ ________________________ __________________ _____ _____ ____________ _____ __ ___ ___ _ _____ ___ _____ _____ _ ______ ____ ____ _ ___________________ ________________________ __ ___ _ ________ __ _ __ _ _ _ __ _ ___ ______________ _________ __ ___ __________ _ _ _____________________ _ _____ __________ ___ __________ _____________ _______ _______ ______ _ __ _ ____ __ __ ___ __ __ ____ _______ ___ ____________________ _ ________________________ ____ ____ __ ______ __ ___ ___ ___ _ __ ___ _ _ _ ___ _ _ ___ ____ __ _____ ___ ___ _____ ______ _______ _____ _ _____ _ ____ __ ______ _______________ _ ____ _ __ _ ______ _ ________________________ ____ _ ___ ____ _ _ _ __ _ ____ _____ ___ ____ __ _ __ _____________ _ _____ _____ _ ________ __ _ ______ ______ __ ___ _ ________ _ ______ __ __ __ _ _ _____ _ ____ ________________ _ _____ _ _ _______ _ _______ ______________ _ _____________ _____ _ _______ _______ _ ________ __ __ _ __ __ ____ _______ ___ ___ _________ ______ __ _ _ _ __ ____ __________ ___ _______ _______________ _____ _ __ _ __ __ _ __ _ _ _ _ __ _ __ _ ________________________ _ _____ _______________ __ __ __ _ _ ___ ________________________ _ __ _____ __ _______ _ _______ _ ___________ _ _ ________________________ _____ _ _______________ _ _____ _ __ ________________________ _______ ______ _______ __ ____ _____ ________ _______ _______________ ________________________ ___ _ ____ _ ___ _ __ ______ _____________ _ __________________ _____ ________________________ _______ ______ ____ ___ ____ __ __________ ___ _______ ________________ __ __ _ _________ _ __ _________ ______________ _______ __________ _____ ______ _______ _______ _____ __ _ ______ __ _____ _ _________ _ ___ _______ _____ _________ _______ _ ________ ____ _ ___ ___________ _______ __ ___________ _ _____ _______________ __ _______ ______ ___ ____ _______ _______ _______ _______ ____________ _ __ ___ ____ ____ _____ _______ ________ _____ __ __ _ _______ _______ ____ __ ____ _ ________ _ _ ___ ____ ________ _ __ ___ _______________ _____ ________ _____ __ ____ ______ ____ __ ______ _____ _________ ________________________ _______ ________________ ______ _ ____ _ _______ _ _____ __ _ _ __ _ ___ _____ _ ___ _ __ ___ _ ___ _______ _______________ _______ ___ _______ ___ ___ ___ _ ________ _ _____ ____ __________ _ _ ___ __ __ _ _ _ _____ _ ________________ _____ _ _______________ ______ _ ______ ______ ___ __ ________________ _______ _ ___ __ ___ _ _ _ _ _ _ _ __ __ _ ___ ___ _ _____ ____________ __ _ __ _____________ __ _ ______ ___ __ _______ _ _ _ _ _ _ __ ___ ____ _ __ _ _ ____ _ _ _ _ _ _ _ _ _____ _ _ _ _ ____ _______________ __ _ _ _ ___ _ __ _ _______ _ _____ ____ _ _ __ _______ _ _ _______ ____ __ _____ ___ __ __ ____ ___ ___ _ ___ ______ _ _ ___ _______ __ ____ __________ _ ___________ __ _ __________________ ____ ____________ _ ____ _ __ _____ ___ _________ ___ _ __ _ _ _ __ _ __ _ __ ___ _ ____ _ _ ___ ______ _____________ __ _ ____________ __________ ______ __ _ _________ ________ ____ _ _ _ _ __ __ _ ________________ _________ ___ _____________ _ _________ ____ ___ __________ ____ _________ _ __ ___ _ _ _ __ _ _____________ ______ ____ __ __ ______ _ _ ____ _________ __ _ __ _ __ ______ _ _ _____ _ _ _ _ _ ____ ___ ____ __ __ _ _ _ ___________ _____ ________ ___________ _ __ _ ________ ___ ___________ __ ______ _ _____ ___ _ ____ _____ __ __ _ _ ____________ _ ____ _ _ _ ___ _ _ _ ______ ___ __ _____ __ _____ ___ _____ _ ___ _ __ ________ _ ___ __ _____ _ _ _ _ ____ _ _ ___ _ ___ __ __ _ __ _ ___ _ _ ___ _ _________ __ ___ _ _ _ _ __ _ _ _ _ ___ _ _ __ _ _ ___ _ __ ____ __ __ _ ___ __ _ _ _ _ _ __ _ _ ___ ___________ __ _ _ __ _ ___ _ _______ ___ _ _ ___ __ _ ___ _ ____ ______ __ _ __ __ _ ___ _ _________ _ __ _ ___ __ _ __ _ ___________ _ _ _ _ __ _ ___ _ ___ _ _ _ _ ___ __ _ __ _ _ ___ __ ___ _ __ _____ __ _ _ _ _ _ __ _____ __ __ _ _ ___ _ __ __ ____ __ _ _ __ _ _ _ _ _ _ _ __ __ __ _ _ __ __ _ _ _ ___ _ _ _ ___ _ _ ___ _ _ _ _ _ _ _ ___ _ __ __ __ _ _ __ _ _ ______ _ _ _ ___ __ _ _ __ _ ___ _ _ _ _ ___ _ __ ______ _ _ ___ __ _ _____ __ _ _ _ _ _ ___ _ ___ _ __ _ __ __ _ _ ___ _ _____ __ _ _ __ __ _______ __ __ _ _ _ _ _____ _ _____ _____ __ _ _ _ __ _ _ _ __ ____ _ __ _ _ _ __ _ _ __ _____ _ _ _ _ _ __ _ _ _ __ _ _ _ _ _ __ _ _ ___ _ _ _ _ _ _ _ _ __ _ _ _ _ _ __ _ __ _ _ _ __ _ _ __ _ ___ _____ _ __ _ __ _ __ _ _ __ _ __ _ ___ _ _ ____ _ _ _ __ _ __ __ _ _ ___ ___ _ _ _ _ _ __ __ _ _ __ __ _ __ _ __ _ _____ _ _ ___ _ _________ _ __ _ _ _ ___ _ ___ _ ____ _ __ _ __ _ _ _ __ __ _____ _ __ _ __ _ ___ ____ _ _ _ _ _ __ _ ___ _ _ _ _ ___ _ _ _ _ __ _ _ _ _ _ __ ___ _ _ __ _ __ _ __ __ _ _ _ __ ___ __ __ _ _ _ _ _ _ _ __ __ __ _ _ _ _ _ ___ __ ___ _ ___ __ _ __ _ ___ __ _

50 100 150 200 50 100 150 300 600 900 1200 25 50 75 100

Group Health Henry Ford Kaiser Mayo

Oct 2013 Jan 2014 Apr 2014 Jul 2014 Oct 2014 Jan 2015 Apr 2015 Jul 2015 Oct 2015 Jan 2016 Apr 2016 Jul 2016

Index Date (through 2016−09−30) Number of Index Images

Provider Macro Views

1 2−3 4−7 >7

Macros Included

_ Wave 2: Monthly Index Images and Provider Macro History

Macro Penetration at Wave 3 Clinics

Shading indicates the number of macros that the patients’ providers have been exposed to

___ _______ _____ ____ __ __________ ____ ________ ___ ___ __ __ _______ _ ________ ____ ___ ___ _ _ __ ___ _ _ _ __ ____ ______________ ____ _ ____ _ ____ _ _ ____ ____ ________ _ _ _ _ _ ___ _ ____ _______ ______ __ ______________ _ _ _____ __ __ _ __ __ ______ _ _ _ ___ ___ _ _ _ _ _ ___ __ ___ __ _ __ _ _ _ __ _ ____ ____ _ _ _ ___ _ ______ ____ __ _ __ ____ ____ __ __ ___ ____ _ _ __ _ _ _ _ _ _ __ __ ___ __ _ ____ _ ____ _ ____ ____ __ _ ____ ____ ___ ____ _ _ __ ___ _ __ __ _ ____ ____ ___ _____ _ ____ _ _____ ___ _ _ _ __ _____________ ____ __________ ___ ___ __ ___ _ ___ __ ___________ _ __ __ _ _ __ _ ___ ____ ___ _ _ __ _ _ ______ ____ ____ _______ ____ _ __ ______________ ____ ______________ _ __ _ _ _ _ _ _ _ _ _ _ ________ __ _ _______ _ ____ _ __ ___ __ _ ___ _ _ _____ __ __ _ ___ ________ __ _ __ ____ ___ __ __ _ __ _ _______ __ __ _ ___ _ ________ __ __ _ ___ _ _ _ _ __ __ _ _ __ _ __ _ __ _ _ ___ _ ________ __ __ _ ___ _ ________ _ __ _ _ __ _ __ _ _ _____ __ __ _ ___ ________ __ __ __ _ ___ _ __ _____ __ __ ___ _ ___ ___ __ _ _ _ __ _ ___ _____ _ _ _ ___ __ _ _ __ ___ _____ __ _ _ _ _ _ ___ _ ________ __ _ _ _ _____ _ __ ___ _ _______ _ _ _ __ _ ________ _ _ _ _ _ _ ___ ____ _ _ _ ___ _ ____ ___ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _______________ __ ____________ __ __ _ __ _ _ _______________ __ _ _______________ _ _ _ _____________ _ _ _ _ ____ ________ __ _ _______________ __ _ _ ____________ __ __ _ _ ____ _______ __ _ _ _ _______________ __ _ _ ________ ______ _ _ _ __ ______ __ __ _____ ________ __ _ _ _______________ __ _ _ _ ___ ___________ __ __ _ ___ __ ____ __ ______________ __ _ _ _______________ __ _ _ _______________ __ _ ____ ____ ____ _ _ _ _______________ __ _ _ ___ __ _ _ _______________ __ _ _______________ __ _ _______________ __ _ _______________ __ _ _______________ __ _ _______________ __ _ _ _ _____ _______ __ _ _______ _______ __ ________ __ ___ __ _ _ ____ _____ _ _ __________ ____ __ _ _ _______________ __ _ _ ____________ _ ___ _ _ ____ __ _ ___ ___________ __ _ _ _______________ __ _ _______________ __ _____________ __ _ _ _______________ __ _ _______________ __ _ _ _ ___________ __ __ _ _ _ _ _ __ _ ____ ______ _ __ __ _ _______________ __ _ _______________ __ _ _ ____ _ ____________ __ __ _ _______________ __ _ _______________ __ _ __ _ _ __ _ _____ _ _____ __ _ _______________ __ _ _ ______ ___ __ _ __ _ _______________ __ _ _______________ __ _ _______ _______ _ _ _ ____ _ ____ _ _ _______________ __ _ _______ _____ __ _________ __ _ ______________ __ __ _ _____________ __ _ _ _____________ _ _____ _ _ _______________ __ _ _______________ __ _ _______________ __ _ ______________ __ _ _ _ _ _ _____________ __ _ _ _______________ __ _ _ _ _____________ __ _ _______________ __ _ _______________ __ _ _______________ __ _ _______________ __ _ __________ ____ __ _ _ _______________ __ _ _ _ ___________ __ _ _______________ __ _______________ __ _ _ _ ____________ _ _ _ _ __ __ _ ____ __ _ _____________ _ __ _ __________ ____ __ _ _ ___________ ___ __ _ _ ___ ________ __ _ _____ _ ___ __ _ _ _____________ __ _ _ _ ______ ___ _ _ _ _______________ __ __ _ ____________ __ _ __ _______ ___ _ _ _______________ __ _ _______________ __ _________ __ _ _______________ __ _______ __ _ _ _ _______________ __ __ _ _ _ _ _ _______________ __ _ ___ ___ ______ __ _ _ _ _ _ __ _______ __ _ _ _______________ __ _ ___ ___________ _ _ _ _ ____________ _ __ __ _ _______ ____ __ _ _ _ _______________ __ _ ________ ______ _ _ _ _ ___ ______ ____ __ _ ___________ ___ __ _ _ __ __ _ _______________ __ _ _______________ __ _ _______________ __ _ _ ______________ __ _ __ ___ _ _ __ _ _______________ __ _ _______________ __ _ _________ ___ _ __ _ _ ______ ___ __ _ __ _ ___________ ___ __ _ _______________ __ _ _ _____ __ ___ _ __ __ _ _____________ __ _ _______________ _ _ ___________ ___ __ _ _______ ___ ___ __ _ _______________ __ _ _ ___ __ __ _ _ _ _______________ __ _ ____ _ __ _ _____ _ _____ __ _ _ _ _______________ __ _ _______ _______ _ _ _ _ _______________ __ _ _______________ __ __ _ _______ __ _ _ _ _____ _____ __ _ _ _ _______________ __ __ _ _____ _ _______ __ __ _ _____________ __ _ _______________ __ _ _______________ __ _ _ _ _____ _____ _ __ _ _____________ __ _ _ _______________ _ _ _ __ ______ ___ _ _ _ ____ ______ __ _ _ _ _ _______________ __ _ _______________ __ _ _ _ ___________ __ _ _ _ _ _______________ __ __ _ _ ______ _ _ _______________ _ _ __ _______ __ __ _ _______________ __ _ _ ____ ___ ___ __ _ _ _ _ _____________ __ _ _ _______________ __ _ _ _ _ ____________ __ _ __ ____ _ __ _ __ ____________ __ _ _ _ __ _ _ _ _ _ _ ______ __ __ __ _ _______________ __ _ ___ _________ _ __ _ _ _ ___ ___ ___ __ _ _______________ __ _ _______ _____ _ __ __ _ _ _ _______________ __ _ ______________ __ _ _ _ ___ _ __ _ _____ __ _ _ __ ____________ _ _ _______________ __ _ _______________ __ _ _ _ _______________ __ _ _ _ _____________ __ _ ____ ________ __ _ _ __________ ____ __ _ _ ________ ______ __ _ _ __ _ __________ _ _ _ _ _ _ _______________ __ _ _____________ __ _ ______ ______ __ ___ _ _ _ _ _______________ __ _ _ ____ _____ __ __ _ _ __ _ _____________ __ _ _______________ __ _ _ _ _ ________ _ ____ __ _ _ _ _ _______________ __ __ _ _____ _____ __ _ _ _____________ __ _ _ _______________ __ __ _ _______________ __ _ ______________ __ _ _ ___ _ ___ ____ ____ __ __ _ ____ ________ __ _ _______________ __ __ _ _ _ _ _______________ __ __ _ __________ __ _ _ _______________ __ __ _____________ __ _ ______________ __ _ __ _ __ __________ _ ________ ______ __ _ _________ _____ __ _ _ _____________ __ _ _ _ _________ _____ __ _ _______________ __ _ _______________ __ _ __ ______ __ _ _____________ __ __ ___________ __ __ _ _ _ _______ _ __ _ _______________ __ _ _______________ __ _ _______________ __ _ _ _ ____ __________ __ _ ___ _____ _ __ __ _ _______________ __ _ _ ___________ _ _________ ___ _ _ ________ _____ _ _ ____________ __ __ _ _ __ _ ____________ __ __ _ _ _ _____________ _ __ _ _ __ ___________ __ _ _ ______ ________ __ _ _ _ __________ __ _____ __ __ _ ______ _ ____ __ _ _ _ ______ ________ __ _ _______________ __ _ _ _______________ __ _ ____________ __ __ _ _ _ _____ __ _ _ _ __ _ _______________ __ __ _ ___ ___ ____ __ _ ______ _ __ __ _ _ _____________ __ __ _ _ _ _ ___ ________ _ __ _ _______________ __ _ _______________ __ _ _ _ ___ _ _ _ __ _ _________ _____ _ __ _ ___ ___ ___ __ _ _ _______________ __ _ _ _ _ _ _ _ _______ _______ _ _ _______________ __ _ __ _ ___________ _ __ _ _ ____________ _ _ _ _ _____________ _ __ _ _ ____ _____ __ __ _ _______ _____ __ _ _ _ _ _______ _______ __ _ _________ _____ __ __ ___ _____ __ __ _ _______________ _ _ _______________ __ _ _______________ __ _ ______________ __ _ _ ______________ _ _______________ __ _ _______ _______ __ ____________ __ _ ____________ __ __ _ _ __ __ _ _ _ _______________ __ _ ______ ________ __ _ ____ _ _ _ ______ _ _ _ _ _ ____________ __ _ ___________ _ _ _______________ __ _ _ _____________ __ _ _________ __ _ _ __ ___ _ _ _ _ _ ______ ___ __ _ _ _ ______ ________ __ __ _ __________ _ _ _ __ ____________ __ _ _ ______ ______ __ _ _ _ ______ ________ __ _ _ _____ _ _ __ _______ ____ __ __ _ ____________ _ _ _______________ __ _ _____ _______ __ _ _______________ __ _ _ _____ ________ __ _ _____ _________ _ __ _ _______________ __ __ ___ _ _ _ _ ___ ____ ____ __ _ _ _ _ __ _____ __ _ _____ _____ ___ _ _ _ _ _ _ _ _ _ _ ______ ________ __ _ _______________ __ _ ____ _______ _ __ __ _ ___________ _ __ _ _______ _______ __ _ _______________ __ _ _______________ __ _ _ _______________ __ _ _ _________ _____ __ _ _ ___ ____ _ _ _ __ ___ ___ __ _ __ _________ __ _ ____ ______ __ __ _ _______________ __ _ ___ _ _____ __ __ _ _ _ _ _ _ _ _ _ _ __ ____ _______ __ _ __ ___ _ _ _ __ _ _______________ __ _ _ _ _ _ __ _ ___ __ _____ _ _ __ _ __ ____________ __ _ _ __ _ _ _ __ _ _ ____________ __ _ _ _ _ ____ _ _ _______________ _ _ _ ___ _ _ _ __ _ _______ _ _____ _ __ __ __ _ _ _ ________ _ ____ __ _ _ __ _ __ __ __ __ _ _ _ _________ __ __ _ __ ________ _ __ _ _ __ _ _ ______ _______ _ _ _ ___ _ _____ __ ____ _ _________ ____ _ _ __ __ _ ____ _ _________ _ ___ __ _ _ __ __________ _ __ _ _____ __ _ _ __________ _ _ _ _ _ _ _ __ _ _ _ __ ____ ______ __ _____ __ ___ _ _ __ _____ _ _ _ _ ________ ______ __ _ _ _____________ __ _____ _ ___ _ _ __ ____ _ _ __ _ __ _ _____ ___ _____ __ _ ___ _ _ _ ________ ______ __ _ _______________ __ _ _ __________ _ _ _ _ _ _ _ ____ _ _ __ __ _ _ __ __ _ _ _ ___________ _ _ _ __________ __ _ _____ _________ _ _ _ _ _____ _____ ___ __ _ _ _ _ _______________ __ _ _______________ _ _ _ ____ _ _ _________ ____ __ _ _______________ __ _ ____________ __ __ _ _________ _ _______________ __ _ ______ _____ __ _ _____ _ _______________ __ _ _ _ ______ _ _ _ _ _______________ __ _ ______ ___ ____ __ _ _ ______ ___ __ _ _________ _____ __ _ _ _ __ ____________ _ _ ________ __ _ _ _______________ __ _ _ ___ _ ___ __ _ __ __ _________ __ _ _ _ __ _____ __ __ ________ __ ____ ______ __ _____ _ __ _____________ __ __ _______ _ __ _ __ __ ___ _____ _ _ _________ ___ __ _____________ __ ______________ __ _ _________ _____ __ _______ __ __ _ ____ _ ___ _ ________ __ _ _ _ ___ _______ __ __ _________ __ _______ __ __ __________ __ ______ ___ _ __ _ _ _ _________ _ ________ _ __ _ _ _ _ _ ____________ __ _ __ __ _____ __ ________ _ __ _ _ _ _________ _ __________ __ _ _ _ _ _ _______ __ _____ _ __ _________ __ ____ _ __ _ ______ _ __ _ _____ _ _ ________ __ _ _________ __ ________ __ ____ ___ __ ____ __ _ ___ ______ __ ________ __ ______ __ __ _ ______ __ _______ __ _ _ ___ _ ______ _ _ _ _ __ _ _ ____ __ _ __ __ _ __ _ _ _____ _ _ ___ __ __ __ _ ___ ____ __ _ ___ __ _ __ _ _ _ __ _ __ _ _ __ __ _ _ _ __ _ _ _ _ ___ _ _ _ _ _ ____ _ _ _ ____ _ __ ____ _ _ _ _ _ __ _ _ _ _ _ __ _ _ _ _ ____ _ _ __ __ _ _ _ _ _ ___ _ _ _ ___ __ _ ___ _ _ _ ___ _ _ _ _ __ _ _ _ _ _ _ __ _ _ _ ____ _ _ ____ _ _ _ _ _ _ _ __ _ _ _ _ __ _ _ __ ___ _ _ _ __ __ __ _ _ _ _ _ __ _ __ _ _ _ ____ _ _ _ _ ____ _ _ ___ _ __ _ _ _ _ ___ _ _ ___ __ _ _ _ ___ _ ___ ____ _ _ _ _ _ ____ _ _ ___ ___ _ _ _ _ _ __ _ _ _ ___ _ __ _ _ __ _ _ _ ___ ____ _ _ _ _ ____ _ _ ___ ____ __ _ _ _ ____ _ _ ____ _ _ _ _ _ __ _ _ _ _ _ __ ____ _ _ __ __ _ _ ___ ____ _ _ _ _ __ _ __ _ _ _ _ _ _ _ _ __ _ _ _ ____ _ _ _ _ _ _ _ _ _ _ _ ____ _ _ _ ___ _ ____ _ _ ___ ____ _ _ _ _ _ _ _ _ _ _ __ _ _ _ ____ _ _ __ ____ _ _ __ _ _ _ _ _ _ _ __ __ _ _ _ _ _ _ _ __ _ __ _ _ _ ___ _ _ _ _ _ _ ____ _ _ _ __ _ _ _ ____ _ _ ___ ___ _ _ _ _ _ _ _ __ _ ___ _ ___ ____ _ _ _ _ ____ _ _ __ _ __ _ _ _ _ _ _ __ _ _ _ _ _ __ _ _ ___ _ _ _ _ _ _ _ _ _ __ _ _ _ _ _ __ _ _ _ ___ __ _ ___ __ _ _ ____ _ _ _ _ _ _ _ ____ _ ___ __ _ _ _ _ __ _ _ _ _ _ __ _ _ _ _ _ _ _ _ __ _ _ ___ ____ _ _ _ ___ _ _ __ _ __ _ _ _ _ _ _ _ __ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

25 50 75 100 25 50 75 100 500 1000 1500 30 60 90

Group Health Henry Ford Kaiser Mayo

Oct 2013 Jan 2014 Apr 2014 Jul 2014 Oct 2014 Jan 2015 Apr 2015 Jul 2015 Oct 2015 Jan 2016 Apr 2016 Jul 2016

Index Date (through 2016−09−30) Number of Index Images

Provider Macro Views

1 2−3 4−7 >7

Macros Included

_ Wave 3: Monthly Index Images and Provider Macro History

Macro Penetration at Wave 4 Clinics

Shading indicates the number of macros that the patients’ providers have been exposed to

_ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _

20 40 60 80 25 50 75 100 200 400 600 800 25 50 75 100 125

Group Health Henry Ford Kaiser Mayo

Oct 2013 Jan 2014 Apr 2014 Jul 2014 Oct 2014 Jan 2015 Apr 2015 Jul 2015 Oct 2015 Jan 2016 Apr 2016 Jul 2016

Index Date (through 2016−09−30) Number of Index Images

Provider Macro Views

1 2−3 4−7 >7

Macros Included

_ Wave 4: Monthly Index Images and Provider Macro History

Macro Penetration at Wave 5 Clinics

Shading indicates the number of macros that the patients’ providers have been exposed to

__ _ ___ _ ___ __ ___ _ __ __ _ ___ __ _ ___ __ _ ___ _ _ _ _ __ _ ___ _ _ ___ __ _ __ _ _ _ _ _ __ _ ___ __ _ _ _ __ _ ___ __ _ __ _ _ __ _ __ _ ___ _ _ __ _ ___ __ _ ___ __ __ __ __ _ _ _ _ _ _ _ _ ___ __ _ __ _ _ _ __ _ ___ __ _ ___ _ _ _ _ ______ _ ______ ______ ______ ___ __ ______ ______ _ ______ _____ _ ___ __ _ ______ _ ___ _ ______ _ _ ____ _ _ ______ ___ _ ______ ______ _ ______ _ ______ ______ ______ _ _ _ ____ _ _ __ ______ ___ __ _ _____ ______ ______ ______ _ ___ __ _____ ______ ______ _ _ __ ______ ______ ______ ______ _ ______ ______ _ ____ _ ___ ______ _ ___ _ ______ ______ _ ___ _ ______ _ ______ ______ _ _ ____ _ _ ______ ______ ____ _ _ ______ ______ ______ _ __ _ _ _ ___ _ _____ _ ______ _ ______ ______ _ ______ ______ ______ __ __ ___ _ __ ______ ______ ______ _ _____ ______ ______ _ ____ _ _ ______ ______ _ __ __ _ ___ __ ___ ______ ______ ______ ______ ______ __ ___ __ ___ _ _ _ _ _ _ __ ______ _ ______ ______ __ __ _ ___ __ _ ____ _ _ __ ______ ______ ______ ______ ______ ______ ______ ______ _____ ______ ______ ______ ______ _ ____ ____ _ _ ______ _ ______ _ ____ _ ______ __ ___ _ _____ ______ _ __ __ ______ ___ __ ______ ______ __ __ __ ___ _ __ _ __ ______ ______ __ ___ _____ ______ ______ ______ _ __ _ __ ______ ______ _ ___ __ ______ _ ______ ___ __ _ ______ ______ _ _ __ _ ______ _ ______ ______ ______ ______ ______ _____ ______ ____ _ ______ ______ _ ____ ______ _ _ __ ______ _ ____ _ _ _ _ ______ ______ ______ ______ ______ ______ ___ __ _ __ ___ _ _ ______ ___ __ _ ______ _ ______ _ __ _ _ ___ ______ ___ __ ______ _____ _ ______ ______ ______ ______ ______ _ ___ __ _ ______ __ ______ ___ __ ______ ______ ______ _ ______ ______ ______ _ ____ ______ _ _ _ _ ___ __ ______ _ ______ _____ _ _ ______ ___ __ _ ____ _ _ _ ____ _ __ ____ _ ______ ______ _ ______ ______ ______ ______ _ _ ______ _ _ ______ _ ______ ____ ___ _ ______ _ ____ _ _____ ______ ___ ______ _ ______ ______ ______ ______ ___ _ ______ ______ ______ _ ______ ___ __ _ ____ ______ __ __ _ _ _ _ ______ __ ___ _ ___ __ _ _ ___ __ ______ _ _ __ __ ______ _ ____ ______ _ _ ______ __ _____ ______ ___ _ ___ _ __ _ _ _ ______ ______ _____ ______ ______ _ __ _ ______ _ _ _ ___ _ ____ _ ______ ______ _ _ _ ___ __ ______ _ ___ __ ______ _ ___ __ ______ ______ __ _ _ _ _ __ ____ _ _____ ______ _ _ _ _____ ____ _ _ _ ___ ____ _ ___ __ ______ ______ _____ _ ____ __ ___ _ _ _ ______ _ __ _ _ ______ _ __ __ _ _____ _ __ ______ ______ __ _ _ ____ _ _ __ _ _ _ ______ _____ ______ ______ ______ ______ __ __ ___ __ _ __ ______ ______ __ _ _ _ _ ______ ______ ______ ______ ____ ______ _____ ____ ______ _ _ __ ______ ____ ______ _____ __ _ ______ ______ _ _ ______ __ ______ _____ __ _ ____ _ _ _ ___ _____ _____ ____ _ ______ _____ ______ _ _ ______ _ ______ ____ ______ ______ _ ____ _ ____ _ ___ ___ __ _ _ __ ______ _____ ______ __ ___ ______ _ _ _ _ ______ __ _ ______ _ ______ __ __ _ ____ __ _ __ __ _________ __ __ ___ __ ______ ___ __ ___ _ ______ ______ __ _ ____ __ __ ___ __ ___ __ __ _ _ __ _ __ __ _ ____ _ __ ____ ____ _ ______ ______ _ _ __ _ _ __ _ ____ _ _ _ ___ __ _ _ _ ___ ___ ___ __ ______ _ _ _ _ _ _ __ _ _ _ _ ___ _ _ __ _ __ _ ___ __ _ ___ __ ___ _ __ _ __ ___ ______ ____ _ ___ ___ _ _ ___ _____ ___ _ _____

25 50 75 40 80 120 250 500 750 1000 1250 25 50 75 100

Group Health Henry Ford Kaiser Mayo

Oct 2013 Jan 2014 Apr 2014 Jul 2014 Oct 2014 Jan 2015 Apr 2015 Jul 2015 Oct 2015 Jan 2016 Apr 2016 Jul 2016

Index Date (through 2016−09−30) Number of Index Images

Provider Macro Views

1 2−3 4−7 >7

Macros Included

_ Wave 5: Monthly Index Images and Provider Macro History

Lessons Learned

Lessons Learned

• Provider Issues
• Health System Issues
• EMR Issues

Lessons Learned

• Provider Issues
• Health System Issues
• EMR Issues

People (Provider Issues): Lessons Learned

• Leadership is the start, not the end
• Engagement of as broad a group of

providers as possible is key; for LIRE PCPs and radiologists

• Key individuals are key: mini-revolt for

several weeks by rads at one clinic who didn’t want to include text

Places (System Issues): Lessons Learned

“Change is the only constant in life” Heraclitus

• HFHS & Mayo: clinics defined by PCP, so

needed constant updating of PCP list

• KPNC couldn’t identify PCPs at first, but

persistence pays

• You get what you pay for (Mayo-not

initially paying programmers  less control over priority setting)

Things (EMR Issues): Lessons Learned

• Merging/harmonizing datasets from

different sites challenging

• You’ve seen one, you’ve seen one

(GHC-Epic implementation different/dynamic)

• Pragmatic = complex

Lessons Learned (So Far)

• Keep intervention as simple as

possible

• Minimize burden on health system

partners

• Primary outcome passively collected
• Budget for change

Talk Outline

• Brief review of study goals/design
• Progress to date
• NLP for data extraction from

radiology reports

• Next steps

NLP: The Problem

NLP: The Goal

NLP: Report Annotation

• Multiple

readers

• Data collection
• 871 reports
• QC process

NLP: Feature engineering

• Rules-based synonyms
• Machine learning
• 80/20 for development/test

NLP: results

NLP: Summary

• Katherine Tan (UW Biostatistics)
• Pre-processing / engineering
• Rules-based (REGEX)
• Machine learning included REGEX
• Rare findings need larger sample
• N = 83 * 5 / prev

Talk Outline

• Brief review of study goals/design
• Progress to date
• NLP for data extraction from

radiology reports

• Next steps

Next Steps

• 2017 Jan/Feb: Safety Officer Review
• 2017 1st qtr: NLP for radiology reports paper
• 2017 June: Opioids and RVU methods papers
• 2017 Oct-Nov: Data pull for primary outcome

(12-month spine-related RVU)

• 2018 1st qtr:

– Primary outcome paper – Opioid Rx paper – Cross-sectional imaging use paper

• 2018 3rd qtr: 24 month RVU and costs

Other Papers

• Data quality methods (UW)
• Race/ethnicity/SES from

EMR (UW)

• NLP for rare and serious

findings (UW)

• Long-term opioids (UW)
• Percutaneous spine

interventions (UW)

• Spine surgery (UW)
• Physical therapy (UW)
• Insurance influence on

utilization (HF)

• Disc degeneration and

diabetes (Mayo)

• Disparities and imaging

modalities (Mayo)

• Imaging ordering patterns

and indication (UW)

Key People

• Katie James, PA-C, MPH- PD
• Brian Bresnahan, PhD- Hlth Econ
• Bryan Comstock, MS- Biostats
• Janna Friedly, MD- Rehab
• Laurie Gold, PhD- Radiology
• Patrick Heagerty, PhD- Biostats
• Larry Kessler, PhD- HSR
• Danielle Lavallee, Pharm D, PhD
• Eric Meier, MS- Biostats
• Nancy Organ, MS- Biostats
• Kari Stephens, PhD- Informatics
• Judy Turner, PhD- Psychol/Psych
• Rick Deyo, MD, MPH- OHSU
• Dan Cherkin, PhD- GHRI
• Karen Sherman, PhD- GHRI
• Heidi Berthoud- GHRI
• Brent Griffiths, MD- HFHS
• Dave Nerenz, PhD- HFHS
• Dave Kallmes, MD- Mayo
• Patrick Luetmer, MD- Mayo
• Andy Avins, MD, MPH- KPNC
• Luisa Hamilton- KPNC

Why Pragmatic Trials Are Important

Barriers Scorecard

Barrier Level of Difficulty 1 2 3 4 5

Enrollment and engagement of patients/subjects

X

Engagement of clinicians and Health Systems

X

Data collection and merging datasets

X

Regulatory issues (IRBs and consent)

X

Stability of control intervention

X

1 = little difficulty; 5 = extreme difficulty