Early Indicators of Success with the Use of the Electronic Medical Record (EMR) for Implementation of Expert Committee Recommendations on Childhood Overweight in Delaware Gregory D. Benjamin, M.P.H., A.B.D. Jia Zhao, M.S., A.B.D. Vonna Drayton, DrPH Denise Hughes, M.S. Karen Stolle, R.N., B.S.N.

What is Nemours?  Nemours is a non-profit organization dedicated to children's health.  Operates Alfred I. duPont Hospital for Children and outpatient facilities in the Delaware valley and specialty care services in Northern/Central Florida.  In 2003, Nemours redefined its approach to ensure maximum impact: health as well as health care.  Nemours Health and Prevention Services (NHPS) focuses on child health promotion and disease prevention to address root causes of health problems.  NHPS complements and expands the reach of clinicians by providing a broader, community-based approach.

Goals and Objectives  Nemours primary care providers use the EMR to: –Indentify, prevent, and manage childhood overweight and obesity (Expert Committee Recommendations)*  Classify body mass index (BMI) for every child  Counsel children and families on healthy eating and physical activity – Almost None * Barlow, S.E. & Dietz, W.H., 1998

Nemours’ Application of Expert Committee Recommendations

Why Implement the Expert Committee Recommendations via the EMR?  In 2006, approximately 37% of DE children (2-17 yrs) had a BMI greater than or equal to the 85 th percentile (e.g., overweight and obese).  Both nationally and here in Delaware, there is a need to adequately screen for childhood overweight.  Providers lacked the necessary tools and skills to… –Identify, prevent, and manage childhood overweight* –Promote healthy eating and physical activity among patients * Barlow, S.E. & Dietz, W.H., 1998

What is the Quality Improvement Initiative (QII)?  May 2007-present: Implementation of the Delaware Primary Care Initiative on Childhood Overweight (“the QII”) – Purpose: to equip healthcare providers with the skills and tools needed to promote healthy eating and physical activity among children. – Composed of Nemours clinics, school-based wellness centers, private pediatric offices, and federally qualified health centers (n=23 sites) – Note : Only Nemours clinic providers are used for all analyses reported here.

QII Sample  QII group: The original 11 providers from –Care for 29,784 children  Non-QII group: Providers who have never participated in the QII from –Care for 35,909 children

Hypothesis 1: Change in Provider Behavior  Those Nemours providers who participate in the QII (“QII group”) will demonstrate more positive behaviors (e.g., weight classification and healthy lifestyle counseling) than Nemours providers who do not participate in the QII (“Non-QII group”).

Methods  Methodology to test Hypothesis 1 – N=34,932; provider-level,  Methodology used to test Hypothesis 2 – N=1,805; patient-level, – Patient had at least 1 well child visit per year for 2007, 2008, and 2009  Analyses were done using SPSS 17.0® and SAS Enterprise Guide 4.2®

Provider Behavior 1: Weight Classification CMH=114.49, df=1, p<0.0001

Provider Behavior 2: Healthy Lifestyle Counseling CMH= , df=1, p<0.0001

Hypothesis 1: True  As one can see from the results of the weight classification and healthy lifestyle counseling, QII providers demonstrated more positive behaviors than their non-QII counterparts.

Hypothesis 2: Change in Patients’ BMI  The main objective of the QII is to positively change provider behavior.  However, there is some hope that with a sustained change in provider behavior, there may be an observed effect on their patients’ BMI.  The mean BMI percentile of those children who see a QII-participating provider will be significantly lower than those patients who see non-QII providers. – Note : Causality cannot be inferred. There are many other factors that can cause a difference in mean BMI percentile, other than the work done by the provider during a patient’s visit.

Mean BMI Percentiles for Patients, QII vs. Non-QII Providers ( )  No statistically significant difference in mean BMI percentiles among patients who see providers in QII vs. those who do not.  2009 represents first time where mean BMI percentile for non-QII patients is slightly greater than QII group--but not significant.

Mean BMI Percentiles for Overweight/Obese Patients, QII vs. Non-QII Providers ( )  No statistically significant difference in mean BMI percentiles among overweight/obese patients who see providers in QII vs. those who do not.

Hypothesis 2: False  Alternative Hypothesis: The mean BMI percentile of those children who see a QII-participating provider will not be significantly lower than those patients who see non-QII providers.

Overweight/Obesity Rates in Patients by QII Status and Age 39.7% of Delaware children ages 2-17 are overweight/obese in 2008.* *2008 Delaware Survey of Children’s Health (n=2242) Prevention!

Discussion  Success of integrating Committee Recommendations into Nemours’ EMR  What the future holds? –Pull data for additional provider behaviors: breastfeeding counseling, blood pressure, and bullying.  Limitations to study –Sample size of final data set (Hypothesis 2) –Only able to use data from Nemours providers in the QII –Not able to infer causality for differences in mean BMI percentile of patients

Recognition  Zhongcui Gao, M.S., statistician, Nemours Health and Prevention Services (NHPS)  NHPS’ Primary Care team  Those providers who participate in the Quality Improvement Initiative  Arnel Mercado, Report Developer, Nemours Data Warehouse

For more info, please contact: Gregory D. Benjamin, M.P.H., A.B.D. Evaluation Scientist (p) (e)