Recent Publications

Electronic Health Records Produce Better Diabetes Care

Diabetes patients treated by pro-
viders using electronic health
records received better quality
of care and achieved better
intermediate outcomes than 

patients treated by providers
using paper medical charts.
(File photo)

People treated for diabetes by providers using electronic health records (EHRs) were significantly more likely to achieve outcomes in line with diabetes care standards than patients whose doctors relied on paper records.

The study published in this week’s issue of the New England Journal of Medicine suggests that the federal investment in electronic health records will likely produce benefits in both quality of care and better outcomes.

Led by Dr. Randall Cebul, professor of medicine at Case Western Reserve University, the study involved 27,207 adults with diabetes in the Cleveland area. (Link to published site)
Patients were treated in a variety of settings by more than 569 primary care physicians in 46 practices of 7 care organizations. The practices covered 1.3 million residents of Cuyahoga County including people in affluent suburbs and inner-city “safety-net” neighborhoods. All of the physicians participate in Better Health Greater Cleveland, a regional quality improvement collaborative.

“We compared EHRs with paper-based records in a long-term regional collaborative that seeks to improve care and outcomes for patients with chronic conditions,” the researchers wrote. “EHR sites were associated with higher levels of achievement of and improvement in regionally vetted standards for diabetes care and outcomes.”

The study focused on the 12-month period from July 2009 to June 2010. A total of 24,547 patients were treated by providers using electronic health records and 2,660 were treated in practices using paper-based medical records. The researchers used a special study code for each patient and provider and measured achievement of a set of four agreed-upon standards of care and five standards of intermediate outcomes for patients with either type 1 or type 2 diabetes.

The measures of care included glycated hemoglobin, kidney management, eye examination and pneumococcal vaccination. Intermediate outcome measures included achieving glycated hemoglobin levels of less than 8 percent, blood pressure less than 140/80 mm HG, LDL cholesterol less than 100 mg/dl or use of statin drug, and a BMI less than 30, and non-smoking.

Practices using EHRs submitted data electronically on all eligible diabetes patients. Practices using paper records sent copies to a central data management center with trained chart abstractors. More than 95 percent of patients had charts available for review.

In unadjusted analyses, between July 2009 and June 2010, 50.9 percent of patients at EHR sites, as compared with 6.6 percent of patients at paper-based sites, received care for diabetes that met all four standards of care, representing a difference of 44.3 percentage points.

EHR sites showed higher achievement on all components of the composite standard for care. For overall diabetes outcomes, 43.7 percent of patients at EHR sites and 15.7 percent of those at paper-based sites had outcomes that met at least four of the five intermediate outcomes standards, a difference of 28.0 percentage points.

Achievement of intermediate outcomes was higher for EHR sites on all but one outcome standard. For HbA1c 68.3 percent of all practices achieved the glycated hemoglobin standard, with 70.5 percent of EHR practices meeting the standard compared to 48 percent of the paper-based practices. Among the EHR practices 55.8 percent met the blood pressure standard compared to 38.9 percent of the paper-based practices. Similarly 87 percent of the EHR practices met the cholesterol standard compared to 66.1 percent of the paper-based practices. For the BMI standard, 32.8 percent of the EHR practices met the standard compared to 34.1 percent of the paper-based practices.

These findings were similar but somewhat blunted in analyses that adjusted for insurance type, age, sex, race or ethnic group, language preference, estimated household income, and educational level. When they adjusted for safety-net patients, for example, the difference for care and outcomes across all patients was 35.1 percent in favor of the electronic records practices.

The researchers said their study contrasted sharply with prior studies that showed no difference between EHR practices and paper records for four reasons. They said the previous studies relied on older data from the National Ambulatory Medical Care Survey and older, less sophisticated EHR systems. Earlier studies also reviewed random samples of patient visits without determining continuity or mutual commitment to longitudinal care. Patients in the current study had to visit the same practice at least twice during the study period to be included in the analysis. Previous studies included single-visits and patients who discontinued care.

By Michael O’Leary, contributing writer, Health Imaging Hub