Childhood obesity is a growing epidemic. Almost one-third of children in this country are overweight or obese, but how can we stem the tide? One idea is to use electronic health records (EHRs) to help clinicians intervene more aggressively. Programmed alerts could spur caregivers to order key tests and educate patients and families. But how does this approach work in the real world?
In a study published earlier this month in the American Journal of Medical Quality, researchers at UC Davis found mixed results. While EHR alerts definitely changed physician behavior when treating overweight and obese children, they are no magic bullet. The authors believe EHRs must be incorporated into a more comprehensive strategy to help patients overcome their weight issues.
“The alerts led to significant but not dramatic improvements,” said Ulfat Shaikh, lead researcher, pediatrician and director of Healthcare Quality at the UC Davis School of Medicine. “We believe any electronic record intervention must be combined with other approaches.”
To measure whether EHRs enhance practice, the researchers added obesity-related alerts to health records at the UC Davis Health System’s outpatient clinic, which cares for about 12,000 children each year. The alert — highlighted in bright yellow on the screen — warned physicians when a patient’s weight hit the 85th percentile, which is considered "overweight."
The EHR alert guided physicians through a series of steps to address weight issues. They were encouraged to educate patients and families about diet, exercise, screen time and other behaviors associated with obesity, as well as to document these discussions, order lab tests, refer patients to dietitians and schedule follow-ups.
The alerts had a positive impact, increasing the proportion of children diagnosed as overweight or obese from 40 percent in the pre-alert group to 57 percent in the alert group. Lab tests for diabetes and dyslipidemia (abnormal cholesterol and fat levels in the blood) increased from 17 to 27 percent. Follow-up appointment scheduling went from 24 to 42 percent. However, referrals to dietitians remained static at 13 percent.
The researchers also measured whether the physicians recommended obesity counseling, based on their notes in the EHR, with 0 being inadequate and 1 being adequate. Adding the alerts improved the overall score from .28 to .39.
While the alerts did improve clinical practice, the study did not track whether these interventions helped kids shed weight. Shaikh notes that dramatic behavior changes can be difficult to orchestrate, as they require families to completely overhaul their lifestyles.
The study highlights EHRs’ potential to improve practice as well as the barriers to successful implementation.
“There are workflow issues that must be considered,” said Shaikh. “For example, in a busy outpatient clinic, physicians may not update the EHR while the patient is in the exam room. Sometimes they don’t see the alert until the family has left the clinic.”
To prepare physicians for these new EHR tools, the researchers provided a one-hour training class. Shaikh believes that individual training, as opposed to group classes, could improve performance. However, the most important lesson from this study may be that EHRs alone will not radically change practice.
“I think this study sounds a cautionary note,” said Shaikh. “Any kind of electronic record approach must be combined with other interventions, such as real-time feedback and using opinion leaders to carry the message. We need to address EHR alerts in the larger context of clinical practice.”
Other UC Davis authors included: Jeanette Berrong, Jasmine Nettiksimmons and Robert S. Byrd.
This research was funded, in part, by the Agency for Healthcare Research and Quality.