Osteoporosis is treatable and fractures can be prevented [
1]. However, it remains largely undiagnosed and untreated [
2‐
4]. Fewer than 20% of women and 10% of men experiencing a fragility fracture receive therapies to prevent further fractures [
2,
3,
5]. Canadian clinical practice guidelines (CPGs) for the assessment and management of osteoporosis specify that management should be guided by an assessment of patients’ absolute risk of fractures [
1]. Recommendations from these guidelines include, obtaining a history and physical examination to identify risk factors for falls and fractures that would warrant further radiographic imaging, bone mineral density (BMD testing), and calculation of 10-year risk of major osteoporotic fractures (i.e., fracture of the hip, clinical vertebra, forearm or proximal humerus). Fracture risk assessment can be conducted with either the Fracture Risk Assessment tool (FRAX®) [
6] or the Canadian Association of Radiologists and Osteoporosis Canada (CAROC) absolute fracture risk assessment [
7]. Those deemed at high risk should be considered for both pharmacological (antiresorptive agents, bone-forming agents, calcium and vitamin D supplementation) and non-pharmacological (exercise, falls prevention, smoking cessation) interventions [
1]. The use of FRAX® has been included in many osteoporosis CPGs to facilitate osteoporosis case-finding and treatment decisions [
1,
8‐
10]. Despite the availability of fracture risk assessment tools and advances in pharmacological therapies, osteoporosis continues to be underdiagnosed and undertreated [
11‐
13]. Barriers to the use of osteoporosis CPG include clinician uncertainty about fracture risk assessment, lack of clinical protocols and organizational processes to support use of best practices [
11,
14,
15], concerns about medication side effects [
16,
17], and lack of knowledge on medication use (drug holidays, when to stop) [
11]. Fracture liaison services have been demonstrated to improve communication, management, and outcomes; however, these discharge coordination initiatives are rare in Canadian hospitals [
18]. Much of the research on improving treatment in osteoporosis has focused on interventions in specialized fracture clinics [
18], but very little has been conducted at the primary care level. Family physicians have identified a need for clinical support tools that identify potential risk factors, calculate fracture risk, and advice on treatment options [
19]. In a study of 1054 family physicians in Ontario, 77% identified the lack of electronic medical record (EMR) tools as a significant barrier to implementing the osteoporosis CPG [
20]. The absence of EMR reminders and recalls for medications requiring regularly scheduled injections has been identified as decreasing adherence and causing discontinuation [
11].
There is evidence in the literature that clinical decision support systems that integrate decision support tools within EMR software can improve care processes and health outcomes [
21‐
23]. A review of research on EMR dashboards found that they provide a significant opportunity for efficiently and accurately gathering and processing patient data and improving quality of care [
24]. A proof of concept study on an EMR quality dashboard focused on 17 health care clinical indicators, not including osteoporosis, found that within 90 days of training, documentation (coding) of patient diagnoses (diabetes, hypertension), screening results (colorectal cancer, breast cancer), and smoking and body mass index status increased by up to 4% [
25]. Similar quality improvements were found with the use of a diabetes-specific EMR dashboard [
26]. Consistent with these types of dashboards and building on the identified needs of Canadian family physicians for more education on the assessment and management of osteoporosis and their desire for EMR-based tools to support guideline implementation [
20], we developed the D
ashboar
d Initiati
ve for Qu
ality Improveme
nt in the M
ana
gement of Pati
ents with
Osteo
porosis (ADVANTAGE OP). The ADVANTAGE OP dashboard serves as a mechanism for alerting physicians of patients’ potential fracture risk to improve screening and management. In this study, we used this EMR-based osteoporosis decision-support tool to identify potential care gaps in the implementation of best practice recommendations in patients with or at risk for fracture and assess the management of these patients by Canadian primary care physicians.