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Development of an electronic medical record based intervention to improve medical care of osteoporosis

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Abstract

Summary

Osteoporosis is infrequently addressed during hospitalization for osteoporotic fractures. An EMR-based intervention (osteoporosis order set) was developed with physician and patient input. There was a trend toward greater calcium supplementation from July 2008 to April 2009 (s = 0.058); however, use of antiresorptives (13%) or discharge instructions for BMD testing and osteoporosis treatment (10%) remained low.

Introduction

Osteoporosis is infrequently addressed during hospitalization for osteoporotic fractures. The study population consisted of patients over 50 years of age.

Methods

Northwestern Memorial Hospital is a tertiary care academic hospital in Chicago. This study was conducted from September 1, 2007 through June 30, 2009.

Results

Physicians reported that barriers to care comprised nonacute nature of osteoporosis, belief that osteoporosis should be addressed by the PCP, low awareness of recurrent fractures, and radiographs with terms such as “compression deformity”, “wedge deformity”, or “vertebral height loss” which in their opinion were not clearly indicative of vertebral fractures. An EMR-based intervention was developed with physician and patient input. Over the evaluation period, 295 fracture cases in individuals over the age of 50 years in the medicine floors were analyzed. Mean age was 72 ± 11 years; 74% were female. Sites of fracture included hip n = 78 (27%), vertebral n = 87 (30%), lower extremity n = 61 (21%), upper extremity n = 43 (15%) and pelvis n = 26 (9%). There was no increase in documentation of osteoporosis in the medical record from pre- to post-EMR implementation (p = 0.89). There was a trend toward greater calcium supplementation from July 2008 to April 2009 (p = 0.058); however, use of antiresorptives (13%) or discharge instructions for BMD testing and osteoporosis treatment (10%) remained low.

Conclusion

An electronic medical record intervention without electronic reminders created with physician input achieves an increase in calcium supplementation but fails to increase diagnosis or treatment for osteoporosis at the time of hospitalization for a fragility fracture.

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References

  1. US Department of Health and Human Services (2004) Bone health and osteoporosis: a report of the Surgeon General. U.S. Department of Health and Human Services, Office of the Surgeon General, Rockville

    Google Scholar 

  2. Harrington JT, Broy SB, Derosa AM, Licata AA, Shewmon DA (2002) Hip fracture patients are not treated for osteoporosis: a call to action. Arthritis Rheum 47:651–654

    Article  PubMed  Google Scholar 

  3. Kamel HK, Hussain MS, Tariq S, Perry HM, Morley JE (2000) Failure to diagnose and treat osteoporosis in elderly patients hospitalized with hip fracture. Am J Med 109:326–328

    Article  PubMed  CAS  Google Scholar 

  4. Orleans CT, George LK, Houpt JL, Brodie KH (1985) Health promotion in primary care: a survey of US family practitioners. Prev Med 14:636–647

    Article  PubMed  CAS  Google Scholar 

  5. Wagner EH, Austin BT, Von Korff M (1996) Improving outcomes in chronic illness. Manag Care Q 4:12–25

    PubMed  CAS  Google Scholar 

  6. Scheff TJ (1984) Decisions in medicine. Being mentally ill: a sociological theory. Aldine, New York, pp 77–89

    Google Scholar 

  7. Austin B, Wagner E, Hindmarsh M, Davis C (2000) Elements of effective chronic care: a model for optimizing outcomes for the chronically ill. Epilepsy Behav 1:S15–S20

    Article  PubMed  Google Scholar 

  8. Williams AL, Al-Busaidi A, Sparrow PJ, Adams JE, Whitehouse RW. (2009) Under-reporting of osteoporotic vertebral fractures on computed tomography. Eur J Radiol 69(1):179–183

    Google Scholar 

  9. Black DM, Arden NK, Palermo L, Pearson J, Cummings SR (1999) Prevalent vertebral deformities predict hip fractures and new vertebral deformities but not wrist fractures. Study of Osteoporotic Fractures Research Group. J Bone Miner Res 14(5):821–828

    Google Scholar 

  10. Cooper C, Atkinson EJ, O'Fallon WM, Melton LJ 3rd (1992) Incidence of clinically diagnosed vertebral fractures: a population-based study in Rochester, Minnesota, 1985–1989. J Bone Miner Res 7(2):221–227

    Article  PubMed  CAS  Google Scholar 

  11. Delmas PD, Genant HK, Crans GG et al (2003) Severity of prevalent vertebral fractures and the risk of subsequent vertebral and nonvertebral fractures: results from the MORE trial. Bone 33(4):522–532

    Article  PubMed  CAS  Google Scholar 

  12. Galindo-Ciocon D, Ciocon JO, Galindo D (1995) Functional impairment among elderly women with osteoporotic vertebral fractures. Rehabil Nurs 20(2):79–83

    Article  PubMed  CAS  Google Scholar 

  13. Kotowicz MA, Melton LJ 3rd, Cooper C, Atkinson EJ, O'Fallon WM, Riggs BL (1994) Risk of hip fracture in women with vertebral fracture. J Bone Miner Res 9(5):599–605

    Google Scholar 

  14. Kado DM, Browner WS, Palermo L et al (1999) Vertebral fractures and mortality in older women: a prospective study. Arch Intern Med 159:1215–1220

    Article  PubMed  CAS  Google Scholar 

  15. Audet AM, Doty MM, Shamasdin J, Schoenbaum SC (2005) Measure, learn, and improve: physicians' involvement in quality improvement. Health Aff (Millwood) 24:843–853

    Article  Google Scholar 

  16. Casalino L, Gillies RR, Shortell SM et al (2003) External incentives, information technology, and organized processes to improve health care quality for patients with chronic diseases. JAMA 289:434–441

    Article  PubMed  Google Scholar 

  17. Campbell MK, Torgerson DJ, Thomas RE, McClure JD, Reid DM (1998) Direct disclosure of bone density results to patients: effect on knowledge of osteoporosis risk and anxiety level. Osteoporos Int 8(6):584–590

    Article  PubMed  CAS  Google Scholar 

  18. O'Toole MF, Kmetik KS, Bossley H et al (2005) Electronic health record systems: the vehicle for implementing performance measures. Am Heart Hosp J 3(2):88–93

    Article  Google Scholar 

  19. Harrison JP, Palacio C (2006) The role of clinical information systems in health care quality improvement. Health Care Manag (Frederick) 25(3):206–212

    Google Scholar 

  20. Gross PA, Bates DW (2007) A pragmatic approach to implementing best practices for clinical decision support systems in computerized provider order entry systems. J Am Med Inform Assoc 14(1):25–28

    Article  PubMed  Google Scholar 

  21. Singh H, Thomas EJ, Khan MM, Petersen LA (2007) Identifying diagnostic errors in primary care using an electronic screening algorithm. Arch Intern Med 167(3):302–308

    Article  PubMed  Google Scholar 

  22. Sequist TD, Gandhi TK, Karson AS et al (2005) A randomized trial of electronic clinical reminders to improve quality of care for diabetes and coronary artery disease. J Am Med Inform Assoc 12(4):431–437

    Article  PubMed  Google Scholar 

  23. Bodenheimer T, Wagner EH, Grumbach K (2002) Improving primary care for patients with chronic illness. JAMA 288:1775–1779

    Article  PubMed  Google Scholar 

  24. Bodenheimer T, Wagner E, Grumbach K (2002) Improving primary care for patients with chronic. The chronic care model, Part 2. JAMA 288:1909–1914

    Article  PubMed  Google Scholar 

  25. Rothman AA, Wagner EH (2003) Chronic illness management: what is the role of primary care? Ann Intern Med 138:256–261

    PubMed  Google Scholar 

  26. Hunt DL, Haynes RB, Hanna SE, Smith K (1998) Effects of computer-based clinical decision support systems on physician performance and patient outcomes: a systematic review. JAMA 280:1339–1346

    Article  PubMed  CAS  Google Scholar 

  27. Glasgow RE, Orleans CT, Wagner EH et al (2001) Does the chronic care model serve also as a template for improving prevention? Milbank Q 79:579–612

    Article  PubMed  CAS  Google Scholar 

  28. Balas EA, Boren SA, Griffing G. (1998) Computerized management of diabetes: a synthesis of controlled trials. Proc AMIA Symp. 295-9

  29. Wagner TH (1998) The effectiveness of mailed patient reminders on mammography screening: a meta-analysis. Am J Prev Med 14:64–70

    Article  PubMed  CAS  Google Scholar 

  30. Balas EA, Weingarten S, Garb CT et al (2000) Improving preventive care by prompting physicians. Arch Intern Med 160:301–308

    Article  PubMed  CAS  Google Scholar 

  31. Bero LA, Grilli R, Grimshaw JM et al (1998) Getting research findings into practice: closing the gap between research and practice: an overview of systematic reviews of interventions to promote the implementation of research findings. BMJ 317:465–468

    Article  PubMed  CAS  Google Scholar 

  32. Grol R, Grimshaw J (2003) From best evidence to best practice: effective implementation of change in patients' care. Lancet 362:1225–1230

    Article  PubMed  Google Scholar 

  33. Von Korff M, Gruman J, Schaefer J et al (1997) Collaborative management of chronic illness. Ann Intern Med 127:1097–1102

    Google Scholar 

  34. Hibbard J (2003) Engaging health care consumers to improve the quality of care. Med Care 41(1Suppl):161–170

    Google Scholar 

  35. Improving chronic illness care. The Chronic Care Model. http://www.improvingchroniccare.org. Accessed May 25, 2006, 2006

  36. Dexter PR, Perkins S, Overhage JM, Maharry K, Kohler RB, McDonald CJ (2001) A computerized reminder system to increase the use of preventive care for hospitalized patients. N Engl J Med 345:965–970

    Article  PubMed  CAS  Google Scholar 

  37. Dexter PR, Perkins SM, Maharry KS, Jones K, McDonald CJ (2004) Inpatient computer-based standing orders vs. physician reminders to increase influenza and pneumococcal vaccination rates: a randomized trial. JAMA 292:2366–2371

    Article  PubMed  CAS  Google Scholar 

  38. Dexter PR, Wolinsky FD, Gramelspacher GP et al (1998) Effectiveness of computer-generated reminders for increasing discussions about advance directives and completion of advance directive forms: a randomized, controlled trial. Ann Int Med 128:102–110

    PubMed  CAS  Google Scholar 

  39. Kucher N, Koo S, Quiroz R et al (2005) Electronic alerts to prevent venous thromboembolism among hospitalized patients. New Engl J Med 352:969–977

    Article  PubMed  CAS  Google Scholar 

  40. Galanter WL, Didomenico RJ, Polikaitis A (2005) A trial of automated decision support alerts for contraindicated medications using computerized physician order entry. J Am Med Inform Assoc 12:269–274

    Article  PubMed  Google Scholar 

  41. Bates DW, Kuperman GJ, Wang S et al (2003) Ten commandments for effective clinical decision support: making the practice of evidence-based medicine a reality. J Am Med Inform Assoc 10(6):523–530

    Article  PubMed  Google Scholar 

  42. Bobb AM, Payne TH, Gross PA (2007) Viewpoint: controversies surrounding use of order sets for clinical decision support in computerized provider order entry. J Am Med Inform Assoc 14(1):41–47

    Article  PubMed  Google Scholar 

  43. Wagner EH, Von Korff M (1996) Organizing care for patients with chronic illness. Milbank Q 74:511–544

    Article  PubMed  CAS  Google Scholar 

  44. Wagner EH, Davis C, Schaefer J, Von Korff M, Austin B (1999) A survey of leading chronic disease management programs: are they consistent with the literature? Manag Care Q 7(3):56–66

    PubMed  CAS  Google Scholar 

  45. Wagner EH, Bennett SM, Austin B, Greene SM, Schaeffer JK, Von Korff M (2005) Finding common ground: patient-centeredness and evidence-based chronic illness care. J Altern Complement Med 11:S7–S15

    Article  PubMed  Google Scholar 

  46. Epping-Jordan JE, Pruitt SD, Bengoa R, Wagner EH (2004) Improving the quality of health care for chronic conditions. Qual Saf Health Care 13:299–305

    Article  PubMed  CAS  Google Scholar 

  47. Edwards BJ, Iris M, Ferkel E, Feinglass J (2006) Postmenopausal women with minimal trauma fractures are unapprised of the existence of low bone mass or osteoporosis. Maturitas 53(3):260–266

    Article  PubMed  Google Scholar 

  48. R Development Core Team. R. (2009) A language and environment for statistical computing. In: Team RDC (ed.) R Foundation for Statistical Computing

  49. Cable G (2001) Enhancing causal interpretations of quality improvement interventions. Qual Health Care 10(3):179–186

    Article  PubMed  CAS  Google Scholar 

  50. Hamel ME, Sebaldt RJ, Siminoski K et al (2005) Influence of fracture history and bone mineral density testing on the treatment of osteoporosis in two non-academic community centers. Osteoporos Int 16(2):208–215

    Article  PubMed  Google Scholar 

  51. Skedros JG, Holyoak JD, Pitts TC (2006) Knowledge and opinions of orthopaedic surgeons concerning medical evaluation and treatment of patients with osteoporotic fracture. J Bone Joint Surg Am 88A:18–23

    Article  Google Scholar 

  52. Silver Wallace L, Ballard JE (2003) Osteoporosis coverage in selected women's magazines and newspapers 1998-2001. Am J Health Behav 27:75–83

    Article  Google Scholar 

  53. Williams B, Cullen L, Barlow JH (2002) “I never realized how little I knew!” A pilot study of osteoporosis knowledge, beliefs, and behaviors. Health Care Women Int 23(4):344–350

    Article  PubMed  Google Scholar 

  54. Edwards BJ, Bunta AD, Madison LD et al (2005) An osteoporosis and fracture intervention program increases the diagnosis and treatment for osteoporosis for patients with minimal trauma fractures. Jt Comm J Qual Patient Saf 31(5):267–274

    Google Scholar 

  55. Bliuc D, Eisman JA, Center JR (2006) A randomized study of two different information-based interventions on the management of osteoporosis in minimal and moderate trauma fractures. Osteoporos Int 17(9):1309–1317

    Article  PubMed  CAS  Google Scholar 

  56. Feldstein A, Elmer PJ, Smith DH et al (2006) Electronic medical record reminder improves osteoporosis management after a fracture: a randomized, controlled trial. J Am Geriatr Soc 54(3):450–457

    Article  PubMed  Google Scholar 

  57. McLellan AR (2003) Identification and treatment of osteoporosis in fractures. Curr Rheum Rep 5(1):57–64

    Article  Google Scholar 

  58. Harrington JT, Barash HL, Day S, Lease J (2005) Redesigning the care of fragility fracture patients to improve osteoporosis management: a health care improvement project. Arthritis Rheum 53(2):198–204

    Article  PubMed  Google Scholar 

  59. Ayoub WT, Newman ED, Blosky MA, Stewart WF, Wood GC (2009) Improving detection and treatment of osteoporosis: redesigning care using the electronic medical record and shared medical appointments. Osteoporos Int 20(1):37–42

    Article  PubMed  CAS  Google Scholar 

  60. Dell R (2011) Fracture prevention in Kaiser Permanente Southern California. Osteoporos Int 22(Suppl 3):457–460

    Article  PubMed  Google Scholar 

  61. Majumdar SR, Johnson JA, Bellerose D, et al. (2010) Nurse case-manager vs. multifaceted intervention to improve quality of osteoporosis care after wrist fracture: randomized controlled pilot study. Osteoporos Int. Apr 1

  62. Marsh D, Akesson K, Beaton DE et al (2011) Coordinator-based systems for secondary prevention in fragility fracture patients. Osteoporos Int 22(7):2051–2065

    Article  PubMed  CAS  Google Scholar 

  63. Streeten EA, Mohamed A, Gandhi A et al (2006) The inpatient consultation approach to osteoporosis treatment in patients with a fracture. Is automatic consultation needed? J Bone Joint Surg Am 88(9):1968–1974

    Article  PubMed  Google Scholar 

  64. Bogoch ER, Elliot-Gibson V, Beaton DE, Jamal SA, Josse RG, Murray TM (2006) Effective initiation of osteoporosis diagnosis and treatment for patients with a fragility fracture in an orthopaedic environment. J Bone Joint Surg Am 88(1):25–34

    Article  PubMed  Google Scholar 

  65. Majumdar SR, Johnson JA, McAlister FA et al (2008) Multifaceted intervention to improve diagnosis and treatment of osteoporosis in patients with recent wrist fracture: a randomized controlled trial. CMAJ: Can Med Assoc J = J de l'Assoc Med Can 178(5):569–575

    Article  Google Scholar 

  66. van Walraven C, Mamdani M, Fang J, Austin PC (2004) Continuity of care and patient outcomes after hospital discharge. J Gen Intern Med 19(6):624–631

    Article  PubMed  Google Scholar 

  67. van Walraven C, Seth R, Laupacis A (2002) Dissemination of discharge summaries. Not reaching follow-up physicians. Can Fam Physician 48:737–742

    PubMed  Google Scholar 

  68. van Walraven C, Seth R, Austin PC, Laupacis A (2002) Effect of discharge summary availability during post-discharge visits on hospital readmission. J Gen Intern Med 17:186–192

    Article  PubMed  Google Scholar 

  69. Pantilat SZ, Lindenauer PK, Katz PP, Wachter RM (2001) Primary care physician attitudes regarding communication with hospitalists. Dis Mon 111(9B):15S–20S

    CAS  Google Scholar 

  70. ISCD. ISCD and DXA Task force meet with CMS officials regarding DXA cuts. 2007; http://www.iscd.org/sitesearch/searchresults.cfm. Accessed July 7, 2010

  71. Rigotti NA, Munafo MR, Stead LF. (2007) Interventions for smoking cessation in hospitalized patients. Cochrane Databases Syst Rev. (3):CD001837

  72. Fedson DS, Harward MP, Reid RA, Kaiser DL (1990) Hospital based pneumococcal immunization. Epidemiologic rationale from the Shenandoah study. JAMA 264(9):1117–1122

    Article  PubMed  CAS  Google Scholar 

  73. Agulnek AN, O'Leary KJ, Edwards BJ (2009) Acute vertebral fracture. J Hosp Med: An Off Publ Soc Hosp Med 4(7):E20–E24

    Google Scholar 

  74. Mauck KF, Cuddihy MT, Trousdale RT, Pond GR, Pankratz VS, Melton LJ 3rd (2002) The decision to accept treatment for osteoporosis following hip fracture: exploring the woman's perspective using a stage-of-change model. Osteoporos Int 13(7):560–564

    Article  PubMed  CAS  Google Scholar 

  75. Yoon RS, Macaulay W, Torres G et al (2008) Assessment of inpatient fragility fracture education and outpatient follow-up at an urban tertiary care institution. Endocrin Pract: Off J Am College Endocrin Am Assoc Clin Endocrin 14(1):58–68

    Google Scholar 

  76. McGlynn EA, Asch SM, Adams J et al (2003) The quality of health care delivered to adults in the United States. N Engl J Med 348(26):2635–2645

    Article  PubMed  Google Scholar 

  77. Leatherman S, Berwick DM (2000) The NHS through American eyes. BMJ 321(7276):1545–1546

    Article  PubMed  CAS  Google Scholar 

  78. Grol R, Grimshaw J (2003) From best evidence to best practice: effective implementation of change in patients' care. Lancet 362(9391):1225–1230

    Article  PubMed  Google Scholar 

  79. Grol R, Berwick DM, Wensing MS (2008) On the trail of quality and safety in health care. BMJ 336(7635):74–76

    Article  PubMed  Google Scholar 

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Conflicts of interest

Edwards is a consultant at Amgen, Eli Lilly, Speaker's Bureau Amgen, Warner, Eli Lilly. Bunta, Anderson, Bobb, Hahr, O'Leary, Agulnek, Andruszyn, Cameron, May, Dillon, Baker and Williams declare no conflicts of interest.

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Authors and Affiliations

  1. Bone Health and Osteoporosis Center, Medicine, Feinberg School of Medicine, Northwestern University, 645 North Michigan, Suite 630, Chicago, IL, 60611, USA

    B. J. Edwards, A. Hahr, L. Andruszyn & N. Dillon

  2. Bone Health and Osteoporosis Center, Department of Orthopaedic Surgery, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA

    A. D. Bunta, M. May & N. H. Kazmers

  3. Northwestern Memorial Hospital, Chicago, IL, USA

    J. Anderson & A. Bobb

  4. Division of Hospital Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA

    K. J. O’Leary, A. Agulnek & M. V. Williams

  5. Division of General Internal Medicine, Feinberg School of Medicine, Northwestern University, Chicago, IL, USA

    K. A. Cameron & D. W. Baker

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  1. B. J. Edwards
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  2. A. D. Bunta
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  3. J. Anderson
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  9. K. A. Cameron
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  10. M. May
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  12. N. Dillon
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  14. M. V. Williams
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Correspondence to B. J. Edwards.

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Edwards, B.J., Bunta, A.D., Anderson, J. et al. Development of an electronic medical record based intervention to improve medical care of osteoporosis. Osteoporos Int 23, 2489–2498 (2012). https://doi.org/10.1007/s00198-011-1866-9

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