The Use of an Electronic Medical Record to Improve Documentation and Treatment of Obesity

Background And Objectives: Physicians underdocument and undertreat obesity. Electronic medical records (EMR) reminders have improved other preventive services such as cancer screening and immunizations. We explored whether an EMR automatic calculation of body mass index (BMI) improved clinician documentation and treatment of overweight and obesity.

Methods: We conducted a retrospective cross-sectional study of randomly selected patient charts before and after the implementation of an EMR. The primary outcome was documentation of overweight or obesity in the assessment/plan section or problem list section of the record. The secondary outcome was evidence in the medical record of treatment (defined as nutrition or exercise counseling or referral to a nutritionist) of overweight/obese patients.

Results: Documentation of obesity (BMI ? 30) improved from 31% to 71% (prevalence ratio [PR]=2.30, 95% confidence interval [CI]=1.44--3.68) of obese patients after the implementation of an EMR calculation of BMI. Documentation of treatment of obese patients also improved, from 35% to 59%, (PR=1.84, 95% CI=1.19--2.86), but documentation and treatment of overweight patients (BMI>25<30) did not significantly improve.

Conclusions: These findings support the effectiveness of an EMR automatic BMI calculation to improve documentation and treatment of obese patients but suggest that software modification and alternative strategies are needed to improve documentation and treatment for overweight patients.