Outpatient electronic health records and the clinical care and outcomes of patients with diabetes mellitus

Abstract

Background: Physicians can receive federal payments for meaningful use of complete certified electronic health records (EHRs). Evidence is limited on how EHR use affects clinical care and outcomes.

Objective: To examine the association between use of a commercially available certified EHR and clinical care processes and disease control in patients with diabetes.

Design: Quasi-experimental design with outpatient EHR implementation sequentially across 17 medical centers. Multivariate analyses adjusted for patient characteristics, medical center, time trends, and facility-level clustering.

Setting: Kaiser Permanente Northern California, an integrated delivery system.

Patients: 169 711 patients with diabetes mellitus.

Intervention: Use of a commercially available certified EHR.

Measurements: Drug treatment intensification and hemoglobin A(1c) (HbA(1c)) and low-density lipoprotein cholesterol (LDL-C) testing and values.

Results: Use of an EHR was associated with statistically significant improvements in treatment intensification after HbA(1c) values of 9% or greater (odds ratio, 1.10 [95% CI, 1.05 to 1.15]) or LDL-C values of 2.6 to 3.3 mmol/L (100 to 129 mg/dL) (odds ratio, 1.06 [CI, 1.00 to 1.12]); increases in 1-year retesting for HbA(1c) and LDL-C levels among all patients, with the most dramatic change among patients with the worst disease control (HbA(1c) levels ≥9% or LDL-C levels ≥3.4 mmol/L [≥130 mg/dL]); and decreased 90-day retesting among patients with HbA(1c) levels less than 7% or LDL-C levels less than 2.6 mmol/L (<100 mg/dL). The EHR was also associated with statistically significant reductions in HbA(1c) and LDL-C levels, with the largest reductions among patients with the worst control (0.06-mmol/L [2.19-mg/dL] reduction among patients with baseline LDL-C levels ≥3.4 mmol/L [≥130 mg/dL]; P < 0.001).

Limitation: The EHR was implemented in a setting with strong baseline performance on cardiovascular care quality measures.

Conclusion: Use of a commercially available certified EHR was associated with improved drug treatment intensification, monitoring, and physiologic control among patients with diabetes, with greater improvements among patients with worse control and less testing in patients already meeting guideline-recommended glycemic and lipid targets.

Primary funding source: National Institute of Diabetes and Digestive and Kidney Diseases.

Figure. Staggered EHR implementation by medical center: quasi-experimental study with concurrent controls

This figure shows the schedule of staggered outpatient EHR implementation across all study medical centers during the study period (2004–2009; dark shade) and the number of study patients at each medical center. After implementation, the EHR completely replaced the paper medical chart and a limited patchwork of preexisting nonintegrated health information technology tools. Use of those early health information technology tools was limited because paper-based alternatives were still in use. EHR = electronic health record.