Study examines how EHR data can identify patients' fall risk

Repurposed EHR data collected during office visits can identify patient risk factors and prevent unintentional falls in seniors, according to findings published in Perspectives in Health Information Management, the online research journal of the American Health Information Management Association (AHIMA).

"Nationally, nearly 40 percent of community-dwelling adults age 65 and older fall at least once a year, making unintentional falls the leading cause of both fatal and nonfatal injuries among this age group," wrote the authors, led by Adam Baus, PhD, MA, MPH, assistant director of the Office of Health Services Research at West Virginia University School of Public Health in Morgantown, W.V.

This nonexperimental retrospective study examines the utility of importing EHR data into an external clinical information system to systematically identify older patients at risk of falls among select West Virginia primary care centers.

The authors identified three categories of modifiable risk factors associated with falls among older adults: biological, behavioral, and environmental. "The primary risk criteria for falls included in this study are biological and behavioral because these data elements are intrinsic to the patient and therefore more apt to be gleaned from EHR data," they wrote. 

Key variables of interest were: age greater than or equal to 65 years; female gender; gait or balance impairment; history of falls; fear of falling; vision impairment; hearing impairment; diagnosis of Parkinson’s disease; dizziness/vertigo; cognitive impairment; use of a walking aid or device; current prescription for a sedative medication; current prescription for an antiepileptic medication; current prescription for an antihypertensive medication; and polypharmacy (currently taking four or more medications). 

This core set of variables was expanded to include a set of secondary variables based on a literature review of potential fall risk factors, including race, ethnicity, insurance status, fall assessment, fall guidance, hypertension, hypotension, dementia, osteoporosis, muscle weakness, rheumatoid arthritis, type 1 diabetes, type 2 diabetes, diabetic retinopathy, diabetic neuropathy, epilepsy, height, weight, body mass index (BMI), systolic blood pressure and diastolic blood pressure. 

The datasets from the two primary care organizations included in this study comprised nine unique locations excluding school-based health centers and dental clinics. Among these nine sites, 50,433 unique patients were identified. Of these, 43,531 patients (86.3 percent) were determined to be active on the basis of having at least one documented office visit, service or laboratory test within three years of the date of data extraction (March 31, 2014). Among the 43,531 active patients, 3,933 patients (9.03 percent) were age 65 and older. 

Researchers found 238 instances of falls documented among patients age 65 and older. These falls were documented across 133 unique patients. Falls range from a minimum of one documented fall among 80 patients (60.1 percent) to a maximum of 16 documented falls in one patient (0.7 percent), with a median of one documented fall. Free-text information was especially important in the identification of patients with a history of falls, they said, with 33.8 percent of all cases added through free-text notes. Even with this expanded search method, however, only 133 patients (3.4 percent) had an indication in their medical records of having had an unintentional fall at some point in the past. This is likely a low estimate, Baus et al. wrote, because one of three adults aged 65 and older nationwide experiences a fall each year, yet less than half of these individuals talk with their healthcare providers about falling. 

Only 23 patients (0.6 percent) have documentation in their medical records of a fall risk assessment at some point in the past, the authors found. CPT coding alone missed 26.1 percent of all fall risk assessments. The value added by free-text notes alone is 13.0 percent of all assessments. Further, only two patient records (0.05 percent) indicated that the patient received anticipatory fall guidance at any time. 

This study indicates the need for increased emphasis on fall prevention during routine office visits. "While low documentation of falls is an issue, this problem is combined with documentation practices that make it difficult to retrieve data that have been recorded," the authors wrote, calling for more targeted quality improvement efforts and practice-based research.