Implementation of an outpatient electronic health record and emergency department visits, hospitalizations, and office visits among patients with diabetes

JAMA. 2013 Sep 11;310(10):1060-5. doi: 10.1001/jama.2013.276733.


Importance: The US federal government is spending billions of dollars in physician incentives to encourage the meaningful use of electronic health records (EHRs). Although the use of EHRs has potential to improve patient health outcomes, the existing evidence has been limited and inconsistent.

Objective: To examine the association between implementing a commercially available outpatient EHR and emergency department (ED) visits, hospitalizations, and office visits for patients with diabetes mellitus.

Design, setting, and population: Staggered EHR implementation across outpatient clinics in an integrated delivery system (Kaiser Permanente Northern California) between 2005 and 2008 created an opportunity for studying changes associated with EHR use. Among a population-based sample of 169,711 patients with diabetes between 2004 and 2009, we analyzed 4,997,585 person-months before EHR implementation and 4,648,572 person-months after an EHR was being used by patients' physicians.

Main outcomes and measures: We examined the association between EHR use and unfavorable clinical events (ED visits and hospitalizations) and office visit use among patients with diabetes, using multivariable regression with patient-level fixed-effect analyses and adjustment for trends over time.

Results: In multivariable analyses, use of the EHR was associated with a statistically significantly decreased number of ED visits, 28.80 fewer visits per 1000 patients annually (95% CI, 20.28 to 37.32), from a mean of 519.12 visits per 1000 patients annually without using the EHR to 490.32 per 1000 patients when using the EHR. The EHR was also associated with 13.10 fewer hospitalizations per 1000 patients annually (95% CI, 7.37 to 18.82), from a mean of 251.60 hospitalizations per 1000 patients annually with no EHR to 238.50 per 1000 patients annually when using the EHR. There were similar statistically significant reductions in nonelective hospitalizations (10.92 fewer per 1000 patients annually) and hospitalizations for ambulatory care-sensitive conditions (7.08 fewer per 1000 patients annually). There was no statistically significant association between EHR use and office visit rates.

Conclusions and relevance: Among patients with diabetes, use of an outpatient EHR in an integrated delivery system was associated with modest reductions in ED visits and hospitalizations but not office visit rates. Further studies are needed to quantify the association of EHR use with changes in costs.

Publication types

  • Research Support, N.I.H., Extramural
  • Research Support, U.S. Gov't, P.H.S.

MeSH terms

  • Adolescent
  • Adult
  • Aged
  • Ambulatory Care Facilities
  • California
  • Child
  • Child, Preschool
  • Cohort Studies
  • Delivery of Health Care, Integrated
  • Diabetes Mellitus / therapy*
  • Electronic Health Records / statistics & numerical data*
  • Emergency Service, Hospital / statistics & numerical data*
  • Female
  • Health Maintenance Organizations
  • Hospitalization / statistics & numerical data*
  • Humans
  • Infant
  • Male
  • Middle Aged
  • Multivariate Analysis
  • Office Visits / statistics & numerical data*
  • Outpatients
  • Registries / statistics & numerical data
  • Young Adult