Socio-demographic
|
EMR
|
Sex, age, race, language
| ✓ | | |
Intake
|
Marital status, education, residential status, employment status, income
| ✓ | | |
Social determinants of health
| ✓ | | |
Health Attitudes and Behavior
|
Intake
|
Self-reported health status
| ✓ | | ✓ |
Diabetes risk belief
| ✓ | | ✓ |
Prediabetes awareness
| ✓ | | ✓ |
Physical activity
| ✓ | | ✓ |
Diet
| ✓ | | ✓ |
Awareness of prevention resources
| ✓ | | ✓ |
Patient Activation
|
Intake
|
6-item Patient Activation Measure ®
| ✓ | | ✓ |
Clinical Data
|
EMR
|
Weight
| ✓ | ✓ | ✓ |
BMI
| ✓ | ✓ | ✓ |
Hemoglobin A1C
| ✓ | ✓ | ✓ |
Serum glucose
| ✓ | ✓ | ✓ |
Blood pressure (Systolic/Diastolic)
| ✓ | ✓ | ✓ |
Total cholesterol
| ✓ | ✓ | ✓ |
LDL cholesterol
| ✓ | ✓ | ✓ |
HDL cholesterol
| ✓ | ✓ | ✓ |
Triglycerides
| ✓ | ✓ | ✓ |
Smoking status
| ✓ | ✓ | ✓ |
Health service utilization: # of
|
EMR
|
Primary care encounters
| ✓ | ✓ | ✓ |
Walk-in clinic encounters
| ✓ | ✓ | ✓ |
Emergency Department encounters
| ✓ | ✓ | ✓ |
Hospitalizations
| ✓ | ✓ | ✓ |
Hospital weight loss clinic
| ✓ | ✓ | ✓ |
Nutrition encounters
| ✓ | ✓ | ✓ |
Diagnostic Codes for:
|
EMR
|
Type 2 Diabetes
| ✓ | ✓ | ✓ |
Hypertension
| ✓ | ✓ | ✓ |
Chronic Kidney Disease
| ✓ | ✓ | ✓ |
Cardiovascular Disease
| ✓ | ✓ | ✓ |
Peripheral Artery Disease
| ✓ | ✓ | ✓ |
Obesity
| ✓ | ✓ | ✓ |