Electronic Health Messaging Improves Diagnosis, Management of Patients With High Cholesterol

Electronic health record (EHR) messaging via a best-practice advisory (BPA) alert for physicians when a patient’s low-density lipoprotein cholesterol (LDL-C) was 190 mg/dL or higher improved diagnosis rates for hyperlipidemia, increased the use of lipid-lowering therapies (LLTs), and reduced LDL-C levels. The data was gathered in a retrospective study published by investigators in the Journal of Clinical Lipidology.¹

Why Are Greater Efforts to Identify High Cholesterol Necessary?

Hypercholesterolemia is characterized by elevated LDL-C levels, often called “bad” cholesterol because it contributes to plaque in the cardiovascular system, increasing the risk of adverse cardiovascular outcomes. Despite its known risk and contribution towards the development of atherosclerotic cardiovascular disease, over 90% or more of patients remain undiagnosed. An even smaller proportion of diagnosed patients receive proper LLT.^2,3

Patients with familial hypercholesterolemia (FH), a genetic disease, face extremely abnormal LDL-C levels that begin at a young age. For these patients—specifically among undiagnosed patients with suspected FH—LDL-C treatment is suboptimal. Less than 2/3rds of patients in this population are on statins. This is contrary to the recommendations of guidelines such as the 2018 American Heart Association/American College of Cardiology/Multisociety, which suggest high-intensity statin use for patients with LDL-C of 190 mg/dL or higher. Beyond statins, additional nonstatin therapy is recommended for patients with especially stubborn LDL-C levels.^1,4

Methods to heighten FH early detection have evolved in recent years, but there remains a major unmet need for better identification and awareness, especially among physicians. Through greater physician recognition of abnormally high lipid levels early on in a patient’s lifespan, adverse cardiovascular outcomes could be avoided in numerous patients. In this regard, processes that meet physicians where they are could be investigated and optimized to better suit hyperlipidemia identification and management.¹

EHRs are a promising avenue for such optimization. Physicians and pharmacists rely on EHRs to inform them about a patient’s disease and medication history and help guide treatment decisions. Not only can the EHR allow for better identification of potential patients with FH and their current treatment patterns, but notifications could be directly embedded within the EHR to alert providers when a patient’s LDL-C is extremely high. This would allow for prompt and tailored LLT initiation.¹

Did a Best Practice Advisory Improve Lipid Management and Diagnosis?

The current investigators implemented an EHR best-practice advisory (BPA) system within the University of California, Irvine health system to address the undertreatment and underdiagnosis of FH. The BPA prompted physicians to evaluate patients with an LDL-C test result of 190 mg/dL or higher to further assess for possible FH and consider appropriate LLT. A retrospective analysis was conducted to assess whether BPAs were associated with improved FH diagnoses, increased LLT use, and reduced LDL-C levels.¹

In total, 665 individuals with an initial LDL-C BPA alert between August 2021 and June 2024 were included. A single BPA was received by 29.2% of patients, while 70.28% had at least 2 BPAs.¹

LLT use demonstrably increased following the implementation of a BPA. Prior to the BPA, 262 patients (39.4%) reported statin use; after, this increased to 410 (61.7%), with high-intensity statin use (22.9% versus 39.0%) and low-to-moderate intensity statin use (16.5% to 22.7%) following in suit. In a significant development, 207 patients—51.4% of whom were not on statin therapy at baseline—began statin therapy following BPA alerts, with 148 (28.9%) initiating high-intensity therapy.¹

LDL-C levels demonstrated a mean reduction of 85.2 mg/dL (95% CI, 77.9–92.6; P < .0001), and non-high-density lipoprotein cholesterol (non-HDL-C) decreased by 88.8 mg/dL (95% CI, 81.1–96.5; P < .0001) following BPA implementation. On a related note, a consistent magnitude and significance was found among statin initiation rates post-BPA according to age group, sex, and baseline LDL-C category. There was also a major increase in the diagnosis of FH, from 2.3% pre-BPA to 6.0% post-BPA, with further increases in diagnosed hyperlipidemia, diabetes, and hypertension.¹

Implementing BPA alerts into EHRs could ensure pharmacists are properly notified of patients with dangerous cholesterol levels and enable these patients to be adequately treated. EHRs are known to most pharmacists, and they are experienced in navigating and analyzing such databases. With these results, pharmacies could consider implementing EHR-level notifications to ensure LLT is initiated promptly.

REFERENCES

1. Fan Y, Li L, Fan W, et al. The impact of electronic health messaging on diagnosis of familial hypercholesterolemia and management of patients with LDL-C ≥190 mg/dL. J Clin Lipid. Published online November 2, 2025. Accessed December 3, 2025. doi:10.1016/j.jacl.2025.10.074

2. Hill MF, Bordoni B. Hyperlipidemia. In: StatPearls [Internet]. Treasure Island (FL): StatPearls Publishing; 2025 Jan-. Updated August 8, 2023. Accessed December 3, 2025. https://www.ncbi.nlm.nih.gov/books/NBK559182/

3. Birnbaum RA, Horton BH, Gidding SS, et al. Closing the gap: Identification and management of familial hypercholesterolemia in an itegrated health care delivery system. J Clin Lipid. 2021;15(2):347-357. doi:10.1016/j.jacl.2021.01.008

4. Sayed A, Navar AM, Slipczuk L et a. Prevalence, awareness, and treatment of elevated LDL cholesterol in US adults, 1999-2020. JAMA Cardiol. 2023;8(12):1185-1187. doi:10.1001/jamacardio.2023.3931