Osteoporosis International

, Volume 23, Issue 10, pp 2489–2498

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

  • B. J. Edwards
  • A. D. Bunta
  • J. Anderson
  • A. Bobb
  • A. Hahr
  • K. J. O’Leary
  • A. Agulnek
  • L. Andruszyn
  • K. A. Cameron
  • M. May
  • N. H. Kazmers
  • N. Dillon
  • D. W. Baker
  • M. V. Williams
Original Article



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.


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


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


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.


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.


Gap in medical care Physician attitudes Adiographs Information technology Quality improvement Prevention 


  1. 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, RockvilleGoogle Scholar
  2. 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 47:651–654PubMedCrossRefGoogle Scholar
  3. 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 109:326–328PubMedCrossRefGoogle Scholar
  4. 4.
    Orleans CT, George LK, Houpt JL, Brodie KH (1985) Health promotion in primary care: a survey of US family practitioners. Prev Med 14:636–647PubMedCrossRefGoogle Scholar
  5. 5.
    Wagner EH, Austin BT, Von Korff M (1996) Improving outcomes in chronic illness. Manag Care Q 4:12–25PubMedGoogle Scholar
  6. 6.
    Scheff TJ (1984) Decisions in medicine. Being mentally ill: a sociological theory. Aldine, New York, pp 77–89Google Scholar
  7. 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–S20PubMedCrossRefGoogle Scholar
  8. 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):179–183Google Scholar
  9. 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):821–828Google Scholar
  10. 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):221–227PubMedCrossRefGoogle Scholar
  11. 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):522–532PubMedCrossRefGoogle Scholar
  12. 12.
    Galindo-Ciocon D, Ciocon JO, Galindo D (1995) Functional impairment among elderly women with osteoporotic vertebral fractures. Rehabil Nurs 20(2):79–83PubMedCrossRefGoogle Scholar
  13. 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):599–605Google Scholar
  14. 14.
    Kado DM, Browner WS, Palermo L et al (1999) Vertebral fractures and mortality in older women: a prospective study. Arch Intern Med 159:1215–1220PubMedCrossRefGoogle Scholar
  15. 15.
    Audet AM, Doty MM, Shamasdin J, Schoenbaum SC (2005) Measure, learn, and improve: physicians' involvement in quality improvement. Health Aff (Millwood) 24:843–853CrossRefGoogle Scholar
  16. 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 289:434–441PubMedCrossRefGoogle Scholar
  17. 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):584–590PubMedCrossRefGoogle Scholar
  18. 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):88–93CrossRefGoogle Scholar
  19. 19.
    Harrison JP, Palacio C (2006) The role of clinical information systems in health care quality improvement. Health Care Manag (Frederick) 25(3):206–212Google Scholar
  20. 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):25–28PubMedCrossRefGoogle Scholar
  21. 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):302–308PubMedCrossRefGoogle Scholar
  22. 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):431–437PubMedCrossRefGoogle Scholar
  23. 23.
    Bodenheimer T, Wagner EH, Grumbach K (2002) Improving primary care for patients with chronic illness. JAMA 288:1775–1779PubMedCrossRefGoogle Scholar
  24. 24.
    Bodenheimer T, Wagner E, Grumbach K (2002) Improving primary care for patients with chronic. The chronic care model, Part 2. JAMA 288:1909–1914PubMedCrossRefGoogle Scholar
  25. 25.
    Rothman AA, Wagner EH (2003) Chronic illness management: what is the role of primary care? Ann Intern Med 138:256–261PubMedGoogle Scholar
  26. 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 280:1339–1346PubMedCrossRefGoogle Scholar
  27. 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 79:579–612PubMedCrossRefGoogle Scholar
  28. 28.
    Balas EA, Boren SA, Griffing G. (1998) Computerized management of diabetes: a synthesis of controlled trials. Proc AMIA Symp. 295-9Google Scholar
  29. 29.
    Wagner TH (1998) The effectiveness of mailed patient reminders on mammography screening: a meta-analysis. Am J Prev Med 14:64–70PubMedCrossRefGoogle Scholar
  30. 30.
    Balas EA, Weingarten S, Garb CT et al (2000) Improving preventive care by prompting physicians. Arch Intern Med 160:301–308PubMedCrossRefGoogle Scholar
  31. 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 317:465–468PubMedCrossRefGoogle Scholar
  32. 32.
    Grol R, Grimshaw J (2003) From best evidence to best practice: effective implementation of change in patients' care. Lancet 362:1225–1230PubMedCrossRefGoogle Scholar
  33. 33.
    Von Korff M, Gruman J, Schaefer J et al (1997) Collaborative management of chronic illness. Ann Intern Med 127:1097–1102Google Scholar
  34. 34.
    Hibbard J (2003) Engaging health care consumers to improve the quality of care. Med Care 41(1Suppl):161–170Google Scholar
  35. 35.
    Improving chronic illness care. The Chronic Care Model. http://www.improvingchroniccare.org. Accessed May 25, 2006, 2006
  36. 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 345:965–970PubMedCrossRefGoogle Scholar
  37. 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 292:2366–2371PubMedCrossRefGoogle Scholar
  38. 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 128:102–110PubMedGoogle Scholar
  39. 39.
    Kucher N, Koo S, Quiroz R et al (2005) Electronic alerts to prevent venous thromboembolism among hospitalized patients. New Engl J Med 352:969–977PubMedCrossRefGoogle Scholar
  40. 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 12:269–274PubMedCrossRefGoogle Scholar
  41. 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):523–530PubMedCrossRefGoogle Scholar
  42. 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):41–47PubMedCrossRefGoogle Scholar
  43. 43.
    Wagner EH, Von Korff M (1996) Organizing care for patients with chronic illness. Milbank Q 74:511–544PubMedCrossRefGoogle Scholar
  44. 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):56–66PubMedGoogle Scholar
  45. 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–S15PubMedCrossRefGoogle Scholar
  46. 46.
    Epping-Jordan JE, Pruitt SD, Bengoa R, Wagner EH (2004) Improving the quality of health care for chronic conditions. Qual Saf Health Care 13:299–305PubMedCrossRefGoogle Scholar
  47. 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):260–266PubMedCrossRefGoogle Scholar
  48. 48.
    R Development Core Team. R. (2009) A language and environment for statistical computing. In: Team RDC (ed.) R Foundation for Statistical ComputingGoogle Scholar
  49. 49.
    Cable G (2001) Enhancing causal interpretations of quality improvement interventions. Qual Health Care 10(3):179–186PubMedCrossRefGoogle Scholar
  50. 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):208–215PubMedCrossRefGoogle Scholar
  51. 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:18–23CrossRefGoogle Scholar
  52. 52.
    Silver Wallace L, Ballard JE (2003) Osteoporosis coverage in selected women's magazines and newspapers 1998-2001. Am J Health Behav 27:75–83CrossRefGoogle Scholar
  53. 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):344–350PubMedCrossRefGoogle Scholar
  54. 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):267–274Google Scholar
  55. 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):1309–1317PubMedCrossRefGoogle Scholar
  56. 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):450–457PubMedCrossRefGoogle Scholar
  57. 57.
    McLellan AR (2003) Identification and treatment of osteoporosis in fractures. Curr Rheum Rep 5(1):57–64CrossRefGoogle Scholar
  58. 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):198–204PubMedCrossRefGoogle Scholar
  59. 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):37–42PubMedCrossRefGoogle Scholar
  60. 60.
    Dell R (2011) Fracture prevention in Kaiser Permanente Southern California. Osteoporos Int 22(Suppl 3):457–460PubMedCrossRefGoogle Scholar
  61. 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 1Google Scholar
  62. 62.
    Marsh D, Akesson K, Beaton DE et al (2011) Coordinator-based systems for secondary prevention in fragility fracture patients. Osteoporos Int 22(7):2051–2065PubMedCrossRefGoogle Scholar
  63. 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):1968–1974PubMedCrossRefGoogle Scholar
  64. 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):25–34PubMedCrossRefGoogle Scholar
  65. 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):569–575CrossRefGoogle Scholar
  66. 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):624–631PubMedCrossRefGoogle Scholar
  67. 67.
    van Walraven C, Seth R, Laupacis A (2002) Dissemination of discharge summaries. Not reaching follow-up physicians. Can Fam Physician 48:737–742PubMedGoogle Scholar
  68. 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 17:186–192PubMedCrossRefGoogle Scholar
  69. 69.
    Pantilat SZ, Lindenauer PK, Katz PP, Wachter RM (2001) Primary care physician attitudes regarding communication with hospitalists. Dis Mon 111(9B):15S–20SGoogle Scholar
  70. 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. 71.
    Rigotti NA, Munafo MR, Stead LF. (2007) Interventions for smoking cessation in hospitalized patients. Cochrane Databases Syst Rev. (3):CD001837Google Scholar
  72. 72.
    Fedson DS, Harward MP, Reid RA, Kaiser DL (1990) Hospital based pneumococcal immunization. Epidemiologic rationale from the Shenandoah study. JAMA 264(9):1117–1122PubMedCrossRefGoogle Scholar
  73. 73.
    Agulnek AN, O'Leary KJ, Edwards BJ (2009) Acute vertebral fracture. J Hosp Med: An Off Publ Soc Hosp Med 4(7):E20–E24Google Scholar
  74. 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):560–564PubMedCrossRefGoogle Scholar
  75. 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):58–68Google Scholar
  76. 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):2635–2645PubMedCrossRefGoogle Scholar
  77. 77.
    Leatherman S, Berwick DM (2000) The NHS through American eyes. BMJ 321(7276):1545–1546PubMedCrossRefGoogle Scholar
  78. 78.
    Grol R, Grimshaw J (2003) From best evidence to best practice: effective implementation of change in patients' care. Lancet 362(9391):1225–1230PubMedCrossRefGoogle Scholar
  79. 79.
    Grol R, Berwick DM, Wensing MS (2008) On the trail of quality and safety in health care. BMJ 336(7635):74–76PubMedCrossRefGoogle Scholar

Copyright information

© International Osteoporosis Foundation and National Osteoporosis Foundation 2012

Authors and Affiliations

  • B. J. Edwards
    • 1
  • A. D. Bunta
    • 2
  • J. Anderson
    • 3
  • A. Bobb
    • 3
  • A. Hahr
    • 1
  • K. J. O’Leary
    • 4
  • A. Agulnek
    • 4
  • L. Andruszyn
    • 1
  • K. A. Cameron
    • 5
  • M. May
    • 2
  • N. H. Kazmers
    • 2
  • N. Dillon
    • 1
  • D. W. Baker
    • 5
  • M. V. Williams
    • 4
  1. 1.Bone Health and Osteoporosis Center, Medicine, Feinberg School of MedicineNorthwestern UniversityChicagoUSA
  2. 2.Bone Health and Osteoporosis Center, Department of Orthopaedic Surgery, Feinberg School of MedicineNorthwestern UniversityChicagoUSA
  3. 3.Northwestern Memorial HospitalChicagoUSA
  4. 4.Division of Hospital Medicine, Feinberg School of MedicineNorthwestern UniversityChicagoUSA
  5. 5.Division of General Internal Medicine, Feinberg School of MedicineNorthwestern UniversityChicagoUSA

Personalised recommendations