In this new era after the Health Information Technology for Economic and Clinical Health (HITECH) Act of 2009, the literature on lessons learned with electronic health record (EHR) implementation needs to be revisited. Our objective was to describe what implementation of a commercially available EHR with built-in quality query algorithms showed us about our care for diabetes and hypertension populations in four safety net clinics, specifically feasibility of data retrieval, measurements over time, quality of data, and how our teams used this data. A cross-sectional study was conducted from October 2008 to October 2012 in four safety-net clinics located in the Midwest and Western United States. A data warehouse that stores data from across the U.S was utilized for data extraction from patients with diabetes or hypertension diagnoses and at least two office visits per year. Standard quality measures were collected over a period of two to four years. All sites were engaged in a partnership model with the IT staff and a shared learning process to enhance the use of the quality metrics. While use of the algorithms was feasible across sites, challenges occurred when attempting to use the query results for research purposes. There was wide variation of both process and outcome results by individual centers. Composite calculations balanced out the differences seen in the individual measures. Despite using consistent quality definitions, the differences across centers had an impact on numerators and denominators. All sites agreed to a partnership model of EHR implementation, and each center utilized the available resources of the partnership for Center-specific quality initiatives. Utilizing a shared EHR, a Regional Extension Center-like partnership model, and similar quality query algorithms allowed safety-net clinics to benchmark and improve the quality of care across differing patient populations and health care delivery models.

External influences on community-based drug treatment program outcomes have not been adequately accounted by either treatment providers or evaluators. In 2001-2003, a cohort of 197 African American and Latino crack cocaine and heroin users was interviewed at intake into the Free-at-Last's treatment program in East Palo Alto, California. The goal of this research was to identify, and then measure, the impact of a series of theory-based, hypothesized external influences on 3 client treatment outcomes: (1) program completers, (2) dropouts, and (3) referrals to more intensive inpatient treatment. All program clients were interviewed using the Government Performance and Results Act and the California Alcohol and Drug Data System questionnaires. Supplemental questions hypothesized the external influences and were based on prior research and staff focus groups. There were statistically significant differences in treatment outcomes based on employment status, homelessness, living situation, and jail time. Regression analyses indicated that the strongest outcome predictors were treatment intensity, followed by prior crack use, homelessness, income, and number of illegal drugs used. Path analysis showed that former crack use and time in jail formed a particularly strong cluster of external influences on treatment outcomes. This cluster was the result of court-mandated treatment of arrested crack users who chose treatment over incarceration. If users failed treatment, they went back to jail. In a community such as East Palo Alto, court-mandated referrals had a powerful external influence on treatment and, therefore, need to be considered when evaluating a treatment program.

Free-at-Last is a drug treatment program in East Palo Alto, California, a low-income predominantly African American community in Silicon Valley. In this research, a cohort of treatment clients was compared to a random sample of community residents. Both groups used drugs. Two-way analysis of variance was used to identify factors that predicted the number of drugs used, controlling for client or community sample status. Significant predictors turned out to be perception of race discrimination, ever selling drugs, contact with the police, the number of relatives who died suddenly as a juvenile, ever having thoughts of suicide, and marital status. Path analysis was used to show the relationship between predictors of the number of drugs used for treatment clients; a second path was done for community clients. By comparing each path analysis, we were able to show how treatment clients arrived at significantly higher drug use than peers in the community.

THE MIXTURE of nonpatient-residents living with patient-residents in the near-natural atmosphere of a psychiatric halfway house seemed instrumental in the general improvement of a majority of the patients in their socialization and self-understanding. Conard House, a comfortable Victorian mansion located in the Pacific Heights section of San Francisco, was founded as a psychiatric halfway house in 1960 with the aim of aiding a former mental patient's tenuous transition into the community by providing a residential facility that afforded an informal, warm, and supportive milieu. At the inception of this facility a plethora of mental patients was being released from hospitals. They were trying to integrate and establish themselves as members of the community, often under difficult circumstances. Conard House hoped to provide some of this population with the means of reentering the community as functioning members. The study arose then in recognition of the need to help the patient over a tenuous period in his transition into the community and as an effort to demonstrate the value of the Conard House facility for this purpose. The primary project goal was to reveal the efficacy of a halfway house setting which integrates patients with nonpatients. There were four subaims in the project (i.e., to determine what types of former psychiatric patients and mentally retarded persons could most successfully be rehabilitated in this ecological setting, to determine what milieu factors contribute to the rehabilitation of former patients, to develop evaluative measuring devices for use in this setting, and to develop techniques in coordinating these services with other agencies and community services). The assumption was made that the former mental patient and mentally retarded person both experience a similar insecurity upon returning to the community, and as individuals they can achieve strength and autonomy by drawing from the specialized residence milieu of a halfway house. Historically, halfway houses have long been in existence although not technically labeled as such.' Probably the first and most famous facil-