1. Background Diabetes is the 7 th leading cause of death in the US, and a major contributor to decreased life expectancy, increased rates of heart disease, stroke, kidney failure, lower limb amputations, retinopathy, and adult onset blindness 1-4. WV ranks 3 rd highest nationwide in diabetes prevalence (11.7%) About 25% of state population estimated to have pre-diabetes 5 Community and practice-level screenings time/resource intensive 6-7 Authors: Adam Baus MA, MPH, West Virginia University School of Public Health, Office of Health Services Research; Gina Wood RD, LD, West Virginia Bureau for Public Health, Diabetes Prevention and Control Program; Cecil Pollard MA, West Virginia University School of Public Health, Office of Health Services Research; Belinda Summerfield, RN, West Virginia Bureau for Public Health, Diabetes Prevention and Control Program; Emma White, RN, West Virginia University School of Public Health, Office of Health Services Research Table. Patients identified as at-risk for pre-diabetes, overall and by primary care center Methods Using de-identified data from 14 partnering WV primary care centers, identification of at-risk patients centers on: 1.Standardization of disparate EHR data into a common patient registry 2.Identification of established patients by site (those receiving care for 12+ months) 3.Exclusion of patients with diagnosis of diabetes or pre-diabetes 4.Identification of patients at-risk based on: Age >45 with last BMI >25 Age 25, with HTN, hyperlipidemia, gestational diabetes, family history of diabetes, or cardiovascular disease Last fasting blood glucose in the range of 100-125 Results Analysis indicates that the procedures and analysis tools successfully identify patients at-risk for pre-diabetes (Table). Among the 94,283 established patients without a documented diagnosis of diabetes or pre-diabetes, 10,673 (11.3%) meet one or more inclusion criteria for being at-risk for pre-diabetes. Discussion Primary care organizations can repurpose EHR data into a searchable patient registry to efficiently and systematically identify patients in need of screening or intervention. Streamlines opportunity for patient identification, screening, and follow-up care 8,9 Improving patient care thru enhanced data management and use Supporting meaningful use of EHR data and Patient-Centered Medical Home efforts Increases opportunity for practice-based research Supporting uptake of the National Diabetes Prevention Program, now in 4 pilot sites Adam Baus, MA, MPH; Gina Wood, RD, LD; Cecil Pollard, MA; Belinda Summerfield, RN; and Emma White, RN. “Registry-based Diabetes Risk Detection Schema for the Systematic Identification of Patients at Risk for Diabetes in West Virginia Primary Care Centers.” Perspectives in Health Information Management (Fall 2013): 1-10. Learn more at publichealth.hsc.wvu.edu/ohsr A Health Systems Approach to Systematic Identification and Referral of Patients At-Risk for Diabetes 130,021 active 106,367 established 94,283 no dx of DM or pre-DM The WVU Office of Health Services Research and the WV Bureau for Public Health are building new capacity to facilitate efficient screening and referral in primary care by making use of electronic health record (EHR) data Importing data into a standardized patient registry (CDEMS) for analysis and reporting Partner primary care centers