Electronic medical records improve continuity of care for osteoporosis

Electronic medical records and outreach programs of e-mail messages, letters and phone calls to patients and their primary care providers after a bone fracture can dramatically improve the diagnosis and management of the patients' osteoporosis, according to a Kaiser Permanente study in the September issue of the Journal of the American Geriatrics Society.

This is the largest study to show that electronic medical records improve the continuity of care for osteoporosis.

“Often when a patient sustains a fracture, there is a disconnect between the treating orthopedist and the patient's primary care physician. With Kaiser Permanente's computerized database and integrated care delivery system, we can closely monitor and follow patients with fractures and prevent that disconnect,” said Adrianne Feldstein, MD, MS, an investigator at the Kaiser Permanente Center for Health Research (CHR) in Portland and the lead author of the study. “This intervention has broad applicability to a large group of health care providers – from local health departments to HMOs to PPOs – with access to electronic billing or clinical data. Armed with that data, these health organizations can make sure their patients with fractures get appropriate bone density screening follow up.”

This study of 3,588 women shows that an outreach program targeted to patients with a previous fracture meant there was an improvement from 13.4 percent to 44 percent of patients being evaluated and/or treated for osteoporosis. Osteoporosis management is the receipt of a bone mineral density (BMD) measurement or osteoporosis medication in the six months after a fracture. If widely implemented, this approach could substantially improve the secondary prevention of osteoporosis, according to the study authors.

Osteoporosis, a bone disease that leads to increased risk of fracture, is a prevalent condition in older adults, and affects about 20 percent of women 65 and older. Medication can reduce fracture risk in people with osteoporosis significantly, yet many patients, even those who already sustained a previous fracture, do not receive the necessary BMD screening and subsequent treatment. It is estimated that in 2005 there were 2 million fractures at a cost of $17 billion in the United States; by 2025, this number is expected to increase by 50 percent as the population ages.

“Osteoporosis now causes more deaths annually than breast cancer and ovarian cancer combined," said Dr. Feldstein “This study shows that we can cost-effectively improve management with interventions as simple as e-mails, letters and phone calls. That in turn should reduce fractures and mortality, and improve quality of life.”

Researchers at the Kaiser Permanente Center for Health Research used the organization's integrated databases to analyze medical records of 3,588 women aged 67 and older who sustained qualifying clinical fractures. The women were members of the health plan in Oregon and had not received a BMD measurement or osteoporosis treatment in the 12 months before the fracture.

The goal of the study was to evaluate the effect of the interventions on the National Center for Quality Improvement, Health Employer Data and Information Set (HEDIS) measure that evaluates the proportion of women age 67 and older who sustained a qualifying clinical fracture and had not received a BMD measurement or osteoporosis treatment in the 12 months before the fracture and who received either of these six months after the fracture.

The study was conducted in two phases: In Phase 1, primary care physicians with eligible patients were sent an electronic medical record (EMR) in-basket message that contained patient-specific clinical guideline advice consistent with national guidelines, as well as offered outreach to the patient. If the PCP elected, patients were then contacted via an introductory letter and phone call by outreach staff, who completed a patient record review, counseled the patients regarding risk of osteoporosis and future fractures, and ordered laboratory testing, medication, or a BMD measurement. During Phase 2 clinicians and staff were eligible for a financial incentive for quality improvement based on the osteoporosis HEDIS measure.

“Although the financial incentive helped staff define what the organizational priority was, being a team player is what drove behavior,” said Dr. Feldstein. “The increase in performance resulted from re-engineering the patient's care and ensuring continuity of care from orthopedist and primary care physician.”