NorTex 2022 Spring Newsletter

March 29, 2022 • NorTex

Spring 2022 1


Increasing HPV Vaccination in Tarrant County in Community and Clinic Settings

Spring 2022 2HPV vaccination is recommended for 11-12 years old, and those unvaccinated until age 26, for the prevention of anogenital and oropharyngeal cancers. According to 2018 NIS-Teen immunization data, 45.9% of Tarrant County teens ages 13-17 years of age were up-to-date on their HPV vaccination series. The north Texas region has historically had some of the lowest uptake and completion rates of the HPV vaccine series in Texas. Moreover, lower HPV vaccination delivery occurred in 2020 due to the COVID-19 pandemic resulting in a broader need for HPV vaccination in Tarrant County. The HPV CHAT [Communicating about HPV vaccination to Adults & Teens] project is a collaboration between the UNT Health Science Center and JPS Health Network, NorTex, Tarrant County Public Health, and the Immunization Collaboration of Tarrant County. The goal is to increase HPV vaccination in Tarrant County in community and clinic settings.

The HPV CHAT project works to share communication tools with physicians and healthcare providers to support HPV recommendation and respond to patient concerns, if applicable. Studies have shown that a strong recommendation and motivational interviewing techniques can lead to HPV vaccine uptake. Understanding that HPV vaccination suffers from a severe “vaccination gap” compared to other adolescent vaccines, presumptive provider recommendations with motivational interviewing are crucial to addressing vaccine hesitancy. This project includes the development of evidence-informed training and educational resources that work to foster an open dialogue with patients so that they can make informed decisions about cancer prevention.Spring 2022 3

This initiative is led by Dr. Erika Thompson, the UNT Health Science Center at Fort Worth, and includes partnership with Dr. Sarah Matches (HSC), Dr. Kimberly Fulda (NorTex), Dr. Rachel Meadows (JPS), Dr. Divya Patel (UT System), and Ann Salyer- Caldwell (ICTC).



Prototype of a Harmonized Electronic Healthcare Records Database Across Institutions – Phase 2

Based on findings from a pilot study, NorTex created a method to share limited data sets from electronic health records from partnering medical entities. The datasets consist of patient demographic factors, medical history, chronic conditions, current prescriptions, selected biomarkers, and selected social determinants of health. Additional data collected and categorized include geographical, medical, and behavioral information that influences health. Collaborators include the HSC Health Pavilion Family Medicine Clinic, JPS Family Medicine Clinics, and UT Southwestern Family Medicine Clinics. The goal of this project is to create a sustainable, collaborative data collection method that can result in more data-driven interventions and a smoother continuum of care.

The study objectives are:

  1. Examine intake of medications among primary care patients and associations with chronic diseases (e.g., diabetes mellitus, hypertension, hyperlipidemia).
  2. Examine racial/ethnic disparities among patients receiving treatments for chronic diseases, controlling patient risk factors.
  3. Examine variations in the continuity of care among primary care clinicians for patients with and without higher risk for chronic diseases, stratified by risk factors.
  4. Examine variations in risk factors for chronic diseases among adult patients who visited the partnering medical clinics from January 1, 2016, through December 31st, 2022.

Currently, study investigators have received North Texas Regional IRB approval and are pursuing a three-way data use agreement (DUA) to facilitate the exchange of data. Investigators will use the data of adult patients 18 years of age or older who visited one of the collaborating family medicine clinics in 2019.


Ambulatory Medication Safety in Primary Care – A Systematic Review of Its Measurements and OutcomesRichard Young

Background: The objective of this study was to conduct a review of the literature regarding medication safety in primary care in the electronic health record era, examining the definitions, instruments used, and the primary outcomes.

Methods: A systematic review was conducted using Medline, EMBASE, and SCOPUS from January 1999 to December 2020, supplemented with hand searches. Studies measuring rates and outcomes of medication errors in primary care clinics with electronic prescribing managed by primary care physicians/teams, were included. Four investigators independently reviewed titles and analyzed abstracts with a dual-reviewer review for eligibility, characteristics, and risk of bias. Although all observational studies were considered low risk of bias, there were some biases in the intervention studies.

Results: Of 1,464 articles identified, 56 met inclusion criteria. 42 studies were observational and 14 included an intervention. The majority of the studies (29) used their own definition of error. Others used Beers list (14), Screening Tool of Older Persons’ Prescriptions (STOPP) (13), and other definitions (including 10 that used more than one method). The most common outcomes were potentially inappropriately prescribing/medications (PIP) (42), adverse drug events (ADEs) (12), and potential prescribing omissions (PPO) (5). Most studies only included high-risk sub-populations (38), usually older adults taking > 4 medications. The rate of PIPs varied widely (0.19% to 98.2%). The rate of ADEs was lower (0.47% to 14.7%). Less commonly measured outcomes were ED visits and hospitalization associated with ADEs (6). No studies adjusted for patient shared decision making, nor measured patient-oriented harms such as unnecessary hassle and expense, or decreased trust between physician and patient.

Conclusion: The majority of medication safety studies in primary care were in high-risk populations and measured potential harms rather than actual harms. No study considered individual patient factors in measuring ADEs or prescribing errors. Applying algorithms such as Beers and STOPP lists to primary care prescribing exaggerates the rate of actual harms and does not capture the complexity of primary care medical decision making.

Project Investigators: Richard Young, MD; Tim Kenny, MLS; Noah Hendrix, Anna Espinoza, MD; Kimberly Fulda, DrPH; Yan Xiao, PhD; Ayse Gurses, PhD, MPH, MS


Spring 2022 5The UNT Health Science Center’s Healthy Start program seeks to provide services to improve the health of families before, during, and after pregnancy. Clients referred to Healthy Start receive in-home case management services and are linked to other community resources as needed. Services offered are based on eligibility, needs, and the unique situations of each family to help build family resiliency. Maternal and infant mortality is an important indicator of a population’s health. According to the CDC, the maternal mortality rate in the U.S. has increased to 23.8 deaths per 100,000 births in 2020 compared to 20.1 per 100,000 in 2019, and the maternal mortality rate for Black women was three times that of their White counterparts. While the nation’s 2020 infant mortality rates decreased 2.9% from 2019, there is still much work to be done. Healthy Start helps mobilize communities by confronting the numerous barriers standing in the way of families and the care they need. The program addresses multiple issues including: providing adequate prenatal care, meeting basic health needs, reducing barriers to access, health education, etc. Healthy Start offers the necessary resources to families in Tarrant County to help navigate different systems and empower our families so that every child in our community has the opportunity to grow and thrive.

For additional information about the Healthy Start program, please visit


Asthma is among the most common chronic pediatric conditions, affecting over 6 million US children. Good asthma management can minimize the impact of asthma on a child’s quality of life;
however, the challenge can be overwhelming for those burdened by social determinants of health. Spring 2022 6Asthma 411 is a comprehensive, evidence-based program with a mission to improve outcomes for all children impacted by asthma. Asthma 411 ensures access to quick relief medication when children experience asthma symptoms at school, strengthens self-management education in asthma-friendly schools, and supports links to community resources. The Asthma 411 story began nearly 20 years ago when Asthma 411 was developed, implemented, and evaluated in St. Louis from 2002-2008 as part of the CDC’s, Controlling Asthma in American Cities project. In 2010, efforts began to disseminate the program to North Texas, and in 2017, the Asthma 411 Consortium formed to support area school districts wishing to adopt Asthma 411. Today the Consortium consists of UNTHSC’s SaferCare TX, Cook Children’s Center for Children’s Health, and the JPS Health Network. Currently, 11 School Districts with over 370 campuses and 240,000 students’ partner to implement the Asthma 411 model.

During the 2021-2022 academic year, school nurses provided 477 treatments with quick-relief medication to children experiencing asthma symptoms at school, and 81% of these children returned safely to class rather than being sent home or calling Emergency Management Services. Of critical importance is Asthma 411’s emphasis on ensuring that children and families receive comprehensive care in a medical home and asthma self-management education. Through partnerships and collaboration, Asthma 411 strives to address disparities at the intersection of health and education.

For more information about Asthma 411, please visit



Spring 2022 7Rafael Pomales Jr., MHS, PA-C, DFAAPA is a practicing physician assistant (PA-C) at Clinicas Mi Doctor family practice clinic in East Plano and has been practicing for over 20 years. Currently, he has been in this location for the last 7 years and sees patients from all walks of life, whether for a child annual exam or chronic conditions and sees most insurances, including Medicaid and Medicare, and the ACA and other commercial insurances. He is also a clinical preceptor for PA students, currently from University of North Texas Health Science Center’s PA program for family medicine. Clinicas Mi Doctor Family Practice is a medical group with a mission to provide easy access to health services. Their vision is to create a better everyday life for the community they serve. Along with being a group devoted to the core values of: patient first, respect, improvement, dedication and efficiency. PA Pomales graduated from the University of Oklahoma PA school with a master’s degree in Health Sciences in 2000. He has also been involved with the American Academy of Physician Associates (AAPA) since graduating, and is currently the president for the Physician Associates for Latino Health (PALH). PA Pomales is also a Member at Large with la Academia de Asociados medicos de Puerto Rico, a constituent organization involved in the cause for obtaining the right for the PA to practice in Puerto Rico and decrease the healthcare crisis of the medical provider shortage on the island. In 2018, PA Pomales was awarded the title “Distinguished Fellow” of the AAPA, in recognition of his contributions to the profession through professional achievement, leadership, professional interaction, learning and community service. He is also a scholarship board member with the National Hispanic Health Foundation. His goal is to ensure all people are entitled to quality care without concern for race, creed, gender or legal status. PA Pomales’ other hobbies include competitive bodybuilding, softball, movie watching, and spending time with his wife, Jennifer (also a PA), and his children.