Rush uses innovative IT to identify patients at risk of fracture
By Charlie Jolie
Of the countless streams of numbers that guide medical care today, few statistics provide more clarity than the sad fact that 24 percent of patients over age 50 will die within one year of fracturing a hip. These “fragility fractures” — a fracture from a standing height or less — often are seen in hindsight as the start of an elderly patient’s downward slope because, in addition to substantial pain, they cause decreased mobility and loss of independence that are directly associated with shortened life expectancy.
However, by using information captured in a patient’s electronic medical record, physicians at Rush University Medical Center now are able to quickly identify the patients most likely to suffer a fragility fracture and to arrange follow up care that steers them off that downward slope. Rush is one of only a few hospitals to have established this kind of collaborative care effort.
Fragility fractures are caused by osteoporosis, a disease that thins and weakens the bones to the point that they become fragile and break easily. “Osteoporosis is a silent disease. People too often don’t know they have weakened bones until a fracture occurs,” says Sanford Baim, MD, director of the Bone Metabolic Disease Program in the Rush Section of Endocrinology, who established and leads Rush’s Fracture Liaison Service.
Summoning more help with a single click
The Fracture Liaison Service uses Rush’s electronic medical record system to screen patients 50 years of age and older to identify the following individuals at risk of fragility fractures:
- Patients who for any reason were admitted to the hospital, admitted for rehabilitatio,n or seen in the emergency room and sent home, who in each case also have a prior history of a fracture that occurred at age 50 or older
- Patients admitted to the hospital for treatment of a fracture (either as the lone condition requiring care or among the conditions being treated)
- A patient who is treated in the emergency department for a fracture that doesn’t require hospitalization and is sent home with instructions to seek follow-up outpatient care from an orthopedic surgeon or neurosurgeon
When an attending physician first opens the electronic record for any such a patient, the system triggers a request for a referral to the fracture liaison service. With one click, the doctor can schedule an ER patient for a follow up appointment with a specialist after, or have an inpatient receive an official Fracture Liaison Service consultation to determine whether the fracture was caused by osteoporosis.
The system is discretionary, allowing the attending doctor to distinguish between, for example, a 50-something hospitalized patient who suffered a fracture in an auto accident (which wouldn’t indicate a need for a consultation) from one who broke a wrist in a fall from a standing height. “It’s a warning sign,” Baim says of the latter instance. “It might an osteoporosis fracture or what is referred to as a pathological fracture due to underlying bone cancer, infection in bone, or other skeletal diseases that weaken the bone and make it susceptible to fracture.”
If needed, the specialist will develop a comprehensive multidisciplinary, post discharge treatment plan that includes therapies and strategies to strengthen bones, reduce falls and prevent future fractures. “While the patient may not know they have osteoporosis, underlying conditions and other information captured in their electronic medical record essentially announce who the patients are that are most at risk of fragility fractures.” Baim adds.
The power of information
The service is unique in its use of the capabilities of the electronic medical record system. Baim and his colleagues can use it to determine which alerts led to a consultation and which did not (either because the patient or the physician declined the consult request) and which patients don’t return after the consultation for follow-up care. They’re developing a long-term study to determine if the service presents fractures by comparing the outcomes of the program’s patients with the typical results for these at-risk individuals.
Physicians working in the fast paced emergency department appreciate the information. Nina Dutta, MD, a Rush hospitalist, recalls how an alert she received while stabilizing an elderly woman for emergency hip fracture surgery enabled her to address longer term concerns with a single click.
“In acute episodes like this woman’s, we are very focused on stabilizing the patient for the immediate next step, which is surgery. We did that, but having the alert pop up in the medical record was not only an important reminder to think about longer term, preventive care, it allowed us to take an action right then,” she says. Baim was able to provide a post-surgery consultation for the patient to discuss post-discharge care and fall prevention strategies, thus “locking in the continuity of care that’s so important in keeping people healthy,” Dutta adds.
From secondary to primary prevention
Since the patient in these cases already has sustained a fracture, this intervention is considered “secondary prevention.” Baim is working on a "primary prevention" effort that will process a wider series of clinical risk factors across the entire inpatient population and automatically generate guidelines aimed at preventing fractures in the first place.
Similar to other prevention programs for costly and deadly chronic diseases like diabetes and heart disease, a primary prevention program for osteoporosis would identify high risk patients and channel the resources needed to prevent a costly, painful and life-shortening fragility fractures. “This is what health care should be — preventing a condition before it severely affects, or ends, a patient’s life,” Baim says.