Bonnie Gance -Cleveland PhD, RNC, PNP, FAAN

2. Bonnie Gance-Cleveland PhD, RNC, PNP, FAAN

3. Health Promotion Across the Lifespan:Childhood Obesity 38th American Academy of Nursing Annual Meeting & Conference October 13 – 15, 2011 Washington, DC Bonnie Gance-Cleveland PhD, RNC, PNP, FAAN Director, Center for Improving Health Outcomes in Children, Teens & Families

4. Prevalence of Obesity Among Children and Adolescents BMI ≥ 95% Ogden, et al. (2002; 2006; 2008; 2010) Last Updated: October 18, 2011 Health Information Technology to Support Clinical Decision Making in Obesity Care AHRQ # 1R18HSO18646-01A1 Page 4

5. Ethnic Disparities in Childhood Overweight & Obesity 1st bar ≥ 85% 2nd bar ≥ 95%

6. Ethnic Disparities in Childhood Severely Obese

7. Health Risks of Being Overweight Potential Problems in Childhood Additional Potential Problems in Adulthood Heart Attack Stroke Cancer Gallbladder Disease Kidney Stones Osteoarthritis Pregnancy Complications Type II Diabetes Joint Problems High Blood Pressure High Cholesterol/Lipids Asthma/Sleep Apnea Depression/Self-Esteem Eating Disorders Last Updated: October 18, 2011 Health Information Technology to Support Clinical Decision Making in Obesity Care AHRQ # 1R18HSO18646-01A1 Page 7

8. Impact on School Achievement • Overweight student achieved lower grades (p< 0.001) and lower physical fitness test scores (p< 0.0001) • Overweight students GPA was 0.4 letter grade lower than nonoverweight • Overweight students had more detentions, worse school attendance, tardiness and less participation in school athletics Shore, Sachs, Lidicker, Brett, Wright, & Libonati, 2008. Obesity 16, 1535-1538. Last Updated: October 18, 2011 Health Information Technology to Support Clinical Decision Making in Obesity Care AHRQ # 1R18HSO18646-01A1 Page 8

9. Healthy People 2020 • Improve health, fitness, and quality of life through daily physical activity.

10. Healthy People 2020 • Promote health and reduce chronic disease risk through the consumption of healthful diets and achievement and maintenance of healthy body weights.

11. First Lady’s Campaign

12. Expert Panel Recommendations NHLBI Pediatric Hypertension AAP Bright Futures NAPNAP Healthy Eating & Activity Together (HEAT) Current Recommendations & Guidelines Maternal Child Health Bureau Center for Disease Control and Prevention Pediatric Metabolic Syndrome Working Group Recommendations

13. Family History • Early CV events • Hypertension • Diabetes Universal Recommendations • Using MI Discuss • Growth • Activity • Eating habits • Growth Charts • H/W • BMI, BMI% for age>2yrs • Infant weight/length ratio Last Updated: October 18, 2011 Health Information Technology to Support Clinical Decision Making in Obesity Care AHRQ # 1R18HSO18646-01A1 Page 13

14. Chronic Care Model

15. The Challenge • Research indicates widespread failure to implement guidelines • Clinicians have not been trained in MI • Despite the recommendations to screen BMI • BMI documented in 5% of initial visits for children dx with obesity during WCC visit (Mabry, 2005) • <1% (0.93%) of WCC visits documented a diagnosis of obesity (Cook, 2005) • Chart audit of 191 WCC visits (20% of population) at a SBHC (Gance-Cleveland, 2010) • 98% had a weight and height documented • 20% had a BMI documented • 17% had a BMI % • 84% of those ≥ 3 years old had a BP • 1% had BP % for age Last Updated: October 18, 2011 Health Information Technology to Support Clinical Decision Making in Obesity Care AHRQ # 1R18HSO18646-01A1 Page 15

16. Specific Aims Comparative effectiveness trial • To evaluate the effectiveness of web-based training with and without computerized clinical decision support on provider’s process and outcome behaviors related to implementing the current guidelines for prevention of obesity and related conditions. • To explore the role of HIT in the processes of system change for implementation of the guidelines for prevention of obesity and related conditions including the facilitators, barriers, and impact of the care model on change. Last Updated: October 18, 2011 Health Information Technology to Support Clinical Decision Making in Obesity Care AHRQ # 1R18HSO18646-01A1 Page 16

17. Intervention • Using the health disparities collaborative approach to training • Use of chronic care model • PDSA cycles • Web-based training on guidelines using social network • With or without technology support HSK Last Updated: October 18, 2011 Health Information Technology to Support Clinical Decision Making in Obesity Care AHRQ # 1R18HSO18646-01A1 Page 17

18. Health DisparitiesCollaborative Approach Four learning sessions over one year • Overview of recommendations • Motivational Interviewing • Culturally sensitive care and community collaboration • Sharing lessons learned Last Updated: October 18, 2011 Health Information Technology to Support Clinical Decision Making in Obesity Care AHRQ # 1R18HSO18646-01A1 Page 18

19. Technology Approach • Formative Considerations: • Accessibility • Transparency • Usability • Cost, Expertise

20. Learning Community • Why NING? • Social website • Scalable • Centralized • Flexible • Familiar Web-based Learning Community NING Last Updated: October 18, 2011 Health Information Technology to Support Clinical Decision Making in Obesity Care AHRQ # 1R18HSO18646-01A1 Page 20

21. Training Modules Training modules • What is it? • “With just a few clicks in PowerPoint, you can transform drab presentations into engaging Adobe® Flash® multimedia experiences. Easily add narration, animations, interactivity, quizzes, and software simulations to eLearning courses.” (adobe.com/products/presenter) • Why Presenter? • Available • Flexible • Familiar • Variety Adobe Presenter Last Updated: October 18, 2011 Health Information Technology to Support Clinical Decision Making in Obesity Care AHRQ # 1R18HSO18646-01A1 Page 21

22. Tailor Intervention Based on Stage of Change

23. Case-based Scenarios with Videos

24. HEART SMART KIDS www.heartsmartkids.com

26. Patient Interview • Self-guided • 2-6 minutes to gather behavioral information

27. Family History of CV Risk

30. 28

31. Sample • 24 SBHC providers from six states (AZ, CO, MI, NC, NM, NY) • Measures • Providers – self report survey of knowledge and behavior in managing overweight. Pre, post, 1 year post. • Providers conduct chart audit pre, post, 1 year post on 32 charts. • Parents complete a satisfaction survey (n=32) independent sample after well child visit at same intervals. • Focus groups of adopters and non-adopters at the end. Last Updated: October 18, 2011 Health Information Technology to Support Clinical Decision Making in Obesity Care AHRQ # 1R18HSO18646-01A1 Page 31

32. Analysis • Growth mixture model (Mplus) for both group-level and individual level effects. • Constant comparison method of analysis for the focus group data. Last Updated: October 18, 2011 Health Information Technology to Support Clinical Decision Making in Obesity Care AHRQ # 1R18HSO18646-01A1 Page 32

33. Health Information Technology to Support Clinical Decision Making in Obesity Care AHRQ # 1R18HSO18646-01A1 About this Project Health Information Technology to Support Clinical Decision Making in Obesity Care This project was supported by grant number 1R18HSO18646-01A1 from the Agency for Healthcare Research and Quality (AHRQ), an agency of the U.S. Department of Health and Human Services. The content expressed in this module is solely the responsibility of the author(s) and does not necessarily represent the official views of the Agency for Healthcare Research and Quality.