Use of Electronic Health Records for Addressing Overweight and Obesity in Primary Care (Massachusetts)

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Summary:

Overweight and obesity are significant clinical and public health problems. Over 35 percent of U.S. adults are obese and another 33 percent are overweight. Overweight and obesity are associated with many serious health conditions, including type 2 diabetes, cardiovascular disease, and some cancers. Clinical practice guidelines urge providers to screen for these problems and recommend appropriate treatment options, as even small amounts of weight loss can lead to significant health benefits. However, primary care providers often fail to do so.

Electronic health records (EHRs) have the potential to improve management and treatment of obesity by primary care clinicians, though few tools have been developed or evaluated for this purpose. The objectives of this research study were to develop and evaluate EHR-based tools such as reminders and clinical decision support (CDS) for identification, diagnosis, and treatment of overweight and obese patients.

The specific aims of the project were as follows:

  • Develop EHR-based tools to help primary care clinicians identify, evaluate, and treat patients who are overweight or obese. 
  • Conduct a cluster-randomized controlled trial to assess the effectiveness of EHR-based tools for the identification, evaluation, and treatment of overweight and obesity in primary care. 

Researchers developed and incorporated new obesity CDS elements into EHRs used by primary care practices at Brigham and Women’s Hospital (BWH). These elements included reminders about measuring height and weight, an alert to add overweight or obesity to the problem list, patient-specific management recommendations for primary care providers, a feature to calculate a weight loss goal, an automatic email referral function, and links to handouts and resources for patients. They then conducted a cluster-randomized controlled trial in 12 BWH primary care practices. The study randomized 23 clinical teams within the practices to intervention or control groups. The new features were activated for clinics in the intervention group and were not activated for clinics in the control group.

Study findings suggested that tools can lead to substantial improvements in the diagnosis of overweight and obesity, although there were no significant differences in management outcomes or weight change between patients in the intervention and control groups. Researchers concluded that future studies should focus on creating and evaluating other scalable, low-cost solutions to help address overweight and obesity in the primary care setting.

Use of Electronic Health Records for Addressing Overweight and Obesity in Primary Care - 2012

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    PAR: HS09-087: Mentored Research Scientist Research Career Development Award (K01)
  • Grant Number: 
    K01 HS 019789
  • Project Period: 
    September 2010 – August 2015
  • AHRQ Funding Amount: 
    $127,047
  • PDF Version: 
    (PDF, 321.91 KB)

Summary: Obesity is widely recognized as a critical public health concern that is associated with increased risk of diabetes, cardiovascular disease, cancer, and preventable death. Electronic health records (EHRs) have the potential to improve management and treatment of obesity by primary care clinicians. However, very few EHR-based tools have been developed or evaluated for this purpose.

The objectives of this research study are to develop and evaluate EHR-based tools for identification, diagnosis, and treatment of overweight and obese patients. This includes reminders, clinical decision support (CDS), and information for clinicians and patients. A cluster-randomized controlled trial is testing these tools in 12 diverse ambulatory practices in the Boston, MA area to assess their effectiveness on the identification, evaluation, and treatment of overweight and obese individuals in the primary care setting.

Specific Aims:

  • Develop EHR-based tools to help primary care clinicians identify, evaluate, and treat patients who are overweight or obese. (Achieved)
  • Conduct a cluster-randomized controlled trial to assess the effectiveness of EHR-based tools for the identification, evaluation, and treatment of overweight and obesity in primary care. (Ongoing)

In addition to the specific research aims, as part of this Mentored Research Scientist Research Career Development Award, Dr. Baer is working toward the following long-term career goals: 1) to develop a multidisciplinary research program dedicated to developing and evaluating strategies to address obesity and other modifiable risk factors in the clinical setting; and 2) to teach and mentor individuals who wish to pursue careers in clinical epidemiology or health services research.

2012 Activities: The cluster-randomized controlled trial began in December 2011. The research team incorporated new obesity CDS elements into the EHR including reminders about measuring height and weight, an alert to add overweight or obesity to the problem list, patient-specific management recommendations for primary care providers, a feature to calculate a weight loss goal, an automatic email referral function, and links to handouts and resources for patients. Dr. Baer visited all participating practices that were randomized to the intervention arm to introduce them to the new EHR elements and provided a quick reference sheet explaining the changes. The new elements were activated for 11 of the 23 participating clinical teams from 12 primary care practices.

In 2011, before the new elements were activated, the research team completed an initial assessment of provider attitudes and practices about weight management. Another survey of providers will be conducted in 2013. In 2012, the team began a nested sub-study to look at patient attitudes about weight management, as well as their weight-related behaviors and clinical outcomes. Criteria for this sub-study included patients who had a recent primary care visit at one of the participating practices and had a body mass index (BMI) of 30 or above or a BMI between 27 and 30 with another risk factor such as hypertension, diabetes, or high cholesterol. Patients in the sub-study return 6 months after their initial primary care visit to have their height, weight, and blood pressure measured and to complete another survey about their weight management attitudes and practices.

Surveys were sent to a random sample of approximately 2,400 eligible patients, asking if they would like to participate in the sub-study. Of the 619 patients who completed the survey, about 300 were scheduled for the 6-month visit. These visits are ongoing.

Primary outcome data will analyze data from the EHR and secondary data will be from the sub-group analysis of patient attitudes and outcomes. The EHR data will indicate whether there are changes in documentation of BMI, diagnosis and management of overweight and obesity, and actual weight among patients in the intervention group compared to the usual-care group. The sub-study analysis will document whether there are changes in attitudes, motivation, and weight-related behaviors among overweight and obese patients as an interim step to changes in weight and blood pressure.

Dr. Baer completed an analysis focusing on documentation and diagnosis of overweight and obesity in the EHR between 2004 and 2008, which will be published in an upcoming issue of JAMA Internal Medicine. In addition, she conducted a systematic review on the use of EHRs for addressing overweight and obesity that is currently under review.

Preliminary Impact and Findings: The provider survey completed in 2011 was sent to 152 clinicians and completed by 85, for a response rate of 56 percent. Among respondents, 51 percent said that they always or often assess overweight and obese patients’ motivation to lose weight, and 49 percent said that they always or often help motivate patients to set a weight loss goal. Only 28 percent said that it was easy to access information about local resources to help patients lose weight. The vast majority (89 percent) said that they would like more help creating appropriate weight loss plans for their patients.

Target Population: Adults, Obesity, Chronic Care*

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve health care decisionmaking through the use of integrated data and knowledge management.

Business Goal: Knowledge Creation.

*This target population is one of AHRQ’s priority populations.

Use of Electronic Health Records for Addressing Overweight and Obesity in Primary Care - 2011

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    PAR: HS09-087: Mentored Research Scientist Research Career Development Award (K01)
  • Grant Number: 
    K01 HS 019789
  • Project Period: 
    September 2010 - August 2015
  • AHRQ Funding Amount: 
    $127,047
  • PDF Version: 
    (PDF, 196.52 KB)

Summary: Obesity is widely recognized as a critical public health concern and is associated with increased risk of diabetes, cardiovascular disease, cancer, and all-cause mortality. Electronic health records (EHRs) have the potential to improve diagnosis and treatment of obesity by primary care clinicians. However, very few EHR-based tools have been developed or evaluated for this purpose.

The objectives of this research study are to develop and evaluate EHR-based tools for identification, diagnosis, and treatment of overweight and obese patients. This includes reminders, clinical decision support (CDS), and information for clinicians and patients. After these tools are developed and tested, a cluster-randomized controlled trial will be conducted in 12 diverse ambulatory clinics in the Boston, Massachusetts area to assess the effectiveness of the EHR-based tools in the identification, evaluation, and treatment of overweight and obese individuals in the primary care setting.

Specific Aims:

  • Develop EHR-based tools to help primary care clinicians identify, evaluate, and treat patients who are overweight or obese. (Ongoing)
  • Conduct a cluster-randomized controlled trial to assess the effectiveness of EHR-based tools for the identification, evaluation, and treatment of overweight and obesity in primary care. (Upcoming)

In addition to the specific research aims, as part of this Mentored Research Scientist Research Career Development Award, Dr. Baer, the Principal Investigator, is working toward the following long-term career goals: 1) to develop a multidisciplinary research program dedicated to developing and evaluating strategies to address obesity and other modifiable risk factors in the clinical setting; and 2) to teach and mentor individuals who wish to pursue careers in clinical epidemiology or health services research.

2011 Activities: The CDS tools for obesity were further developed in terms of specification of the components through review of other CDS tools and obesity research and the technical programming throughout 2011 in preparation for the cluster-randomized controlled trial. The research team completed a needs assessment of current clinical practice guidelines on the identification, evaluation, and management of overweight and obesity diagnosis. Based on this assessment, they developed detailed specifications for the design and content of the new tools within the EHR. An expert panel including primary care clinicians, nutritionists, and informaticians, reviewed and provided feedback on the proposed design and content of the new tools. The panel met twice in March and September 2011.

Dr. Baer presented to the practice leadership team in October to get the buy-in and support for primary care practices to participate in a randomized study of the EHR-based tools for obesity treatment. A survey was distributed to all participating providers to assess baseline data on their approach to weight management. A second survey on the same topic will be completed by providers once intervention is implemented.

The first stage of the evaluation process began in December 2011. Primary care clinics were randomized to the intervention group, which will have access to the new EHR-based tools, or the control group, which will receive care as usual. In the same month, reminders on height and weight were added to the EHR. These reminders are available to all of the clinicians in the intervention group. The research team planned how data that will be abstracted from the EHR and from other data sources for evaluation purposes, with most coming directly from the EHR (i.e., documentation of height and weight, weight management, and changes in clinical outcomes). In May 2012, additional features will be added to the EHR, including a screen that gives the provider options for weight management.

Preliminary Impact and Findings: A baseline survey of providers on their attitudes towards weight management was completed in fall 2011. Provider attitudes are an intermediate outcome of the research study. The survey was sent to 152 clinicians and completed by 85, for a response rate of 55.9 percent. Among respondents, 50.6 percent said that they always or often assess overweight and obese patients' motivation to lose weight, and 48.8 percent said that they always or often help motivated patients set a weight loss goal. Only 27.7 percent said that it was easy to access information about local resources for helping patients to lose weight. The vast majority (89.3 percent) said that they would like more help creating an appropriate weight loss plan for their patients.

Target Population: Adults, Obesity, Chronic Care*

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve health care decisionmaking through the use of integrated data and knowledge management.

Business Goal: Knowledge Creation

* This target population is one of AHRQ's priority populations.

Use of Electronic Health Records for Addressing Overweight and Obesity in Primary Care - 2010

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    PAR: HS09-087: Mentored Research Scientist Research Career Development Award (K01)
  • Grant Number: 
    K01 HS 019789
  • Project Period: 
    September 2010 – August 2015
  • AHRQ Funding Amount: 
    $127,047
  • PDF Version: 
    (PDF, 361.34 KB)


Target Population: Adults, Obesity

Summary: Obesity is widely recognized as a critical public health concern that is associated with increased risk of diabetes, cardiovascular disease, cancer, and all-cause mortality. Electronic health records (EHRs) have the potential to improve diagnosis and treatment of obesity by primary care clinicians. However, very few EHR-based tools have been developed or evaluated for this purpose.

The objectives of this research are to improve diagnosis and treatment of overweight and obese patients by working closely with primary care clinicians to develop better EHR-based tools for identification, diagnosis, and treatment. These may include reminders, clinical decision support, automatic e-mail referrals, and information for clinicians and patients. The EHR-based tools will be piloted in one primary care practice for three months. Based on the pilot, a larger randomized controlled trial at 12 diverse ambulatory clinics in the Boston, Massachusetts area will be conducted to assess the effectiveness of the EHR-based tools for the identification, evaluation, and treatment of overweight and obese individuals in the primary care setting.

Specific Aims:
  • Develop EHR-based tools to help primary care clinicians identify, evaluate, and treat patients who are overweight or obese. (Ongoing)
  • Conduct a randomized controlled trial to assess the effectiveness of EHR-based tools for the identification, evaluation, and treatment of overweight and obesity in primary care. (Upcoming)

In addition to the specific research aims, as part of this Mentored Research Scientist Research Career Development Award, Dr. Baer is working toward the following long-term career goals: 1) to develop a multidisciplinary research program that is dedicated to developing and evaluating strategies to address obesity and other modifiable risk factors in the clinical setting; and 2) to teach and mentor other individuals who wish to pursue careers in clinical epidemiology or health services research.

2010 Activities: The team is learning more about the context of obesity management in adult primary care for which the EHR-based tools will be developed. They are talking to other experts in the field including obesity and EHR experts and, with the help of an expert panel that has been formed, are developing a detailed outline of the features that have the most potential to support obesity assessment and management. In 2011, Dr. Baer will formally present the proposed features to be added to the Longitudinal Medical Record (LMR) Executive Committee and the Clinical Content Committee. Based on their approval, the programming of the new tools in the LMR will begin in spring 2011, for launch in fall 2011. Some of the features under consideration are: 1) reminders to collect height and weight; 2) provider alerts asking the provider to add the diagnosis to the problem list when, based on body mass index, a patient is identified as obese or overweight; and 3) graphs to show weight trends over time and to calculate weight loss goals for patients.

Preliminary Impact and Findings: This project has no findings to date.

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to improve health care decisionmaking through the use of integrated data and knowledge management.

Business Goal: Knowledge Creation

Use of Electronic Health Records for Addressing Overweight and Obesity in Primary Care - Final Report

Citation:
Baer H. Use of Electronic Health Records for Addressing Overweight and Obesity in Primary Care - Final Report. (Prepared by Brigham and Women's Hospital under Grant No. K01 HS019789). Rockville, MD: Agency for Healthcare Research and Quality, 2015. (PDF, 195.45 KB)

The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
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