Table 1.


Individual Data from EPIC
Age at visit
Marital Status
Education Level
Zip Code
Date of Appointment
Primary Care Provider (PCP)
LACE score (a readmission risk score based on hospital admission information, the Charlson Comorbidity index, and emergency department visits within the last 6 to 12 months)
Hospital or emergency department admission risk
Zip-Code Level Regional Data (2019)
Poverty Rate, American Community Survey (ACS)
Median Household Income, ACS
Unemployment Rate, ACS
Percent of population 25 + with various education levels, ACS
Broadband Speed, the Federal Communications Commission (FCC)
  • Note: the full patient dataset from EPIC also includes information on the following, however, some of the data points were missing for many of our patients or the information was redacted for confidentiality reasons: medical record number (MRN), patient name, full address, phone, date of birth, date the appointment was made, the location of the appointment, type of appointment, appointment cancellation reason, no show count, payor/insurance type, financial class, bad debt, reason for the visit/chief complaint, last PCP visit, next PCP visit, next appointment and provider in the department, health maintenance topics due, problem list, primary encounter diagnosis, all encounter diagnoses, patient employer, employer state/zip, urgent care visits/year and in the past 90 days days, emergency department visits in the last year and past 6 months, number of emergency department visits, and number of inpatient admissions.