Electronic tools to assist with identification and counseling for overweight patients: a randomized controlled trial

Abstract

Background: Physicians often do not recognize when their patients are overweight and infrequently counsel them about weight loss.

Objective: To evaluate a set of electronic health record (EHR)-embedded tools to assist with identification and counseling of overweight patients.

Design: Randomized controlled trial.

Participants: Physicians at an academic general internal medicine clinic were randomized to activation of the EHR tools (n = 15) or to usual care (n = 15). Patients of these physicians were included in analyses if they had a body mass index (BMI) between 27 and 29.9 kg/m(2).

Intervention: The EHR tool set included: a physician point-of-care alert for overweight (BMI 27-29. 9 kg/m(2)); a counseling template to help physicians counsel patients on action plans; and an order set to facilitate entry of overweight as a diagnosis and to order relevant patient handouts.

Main measures: Physician documentation of overweight as a problem; documentation of weight-specific counseling; physician perceptions of the EHR tools; patient self-reported progress toward their goals and perspectives about counseling received.

Key results: Patients of physicians receiving the intervention were more likely than those of usual care physicians to receive a diagnosis of overweight (22% vs. 7%; p = 0.02) and weight-specific counseling (27% vs. 15%; p = 0.02). Most patients receiving counseling in the intervention group reported increased motivation to lose weight (90%) and taking steps toward their goal (93%). Most intervention physicians agreed that the tool alerted them to patients they did not realize were overweight (91%) and improved the effectiveness of their counseling (82%); more than half (55%) reported counseling overweight patients more frequently (55%). However, most physicians used the tool infrequently because of time barriers.

Conclusions: EHR-based alerts and management tools increased documentation of overweight and counseling frequency; the majority of patients for whom the tools were used reported short-term behavior change.

Figure 1.

Consort diagram for cluster randomized trials depicting the flow of physician clusters and patients through eligibility, assessment, randomization, intervention, and outcome analysis.

Figure 2.

Point-of-Care Best Practice Alert: Best Practice Alerts are passive point-of-care alerts within the patient medical record which notify physicians when preventive or chronic disease management quality care metrics have not been satisfied. We created a point-of-care alert within this existing system for brief counseling for overweight. The alert directs physicians to first go to the “Counsel Overweight Tab” to open the counseling template, and then to subsequently open a linked order set (“Smart Set”).

Figure 3.

Counseling Template: The counseling template opens upon clicking on the “Counsel Overweight Tab.” The template guides physicians through reviewing the patient’s last three recorded weights, assessing the patient’s rated importance of getting weight under control, setting a target weight, selecting from a list of specific strategies to control weight, assessing the patient’s confidence to reach the goal, and opting to have a follow-up letter sent to the patient regarding their specific goals. Physicians can use commands to pull in relevant text and drop down menus within each text box.

Figure 4.

Frequency of physician identification and counseling for overweight by visit type. The p values comparing intervention and control group physicians were calculated using logistic regression with adjustment for clustering. The intra-class correlation coefficient was calculated to be 0.11 for documented diagnosis of overweight and 0.07 for weight-specific counseling. Of the 400 charts reviewed, the breakdown by visit type was 123 new/preventive visits, 199 other visits with PCP, and 89 acute visits not with the PCP.