EHRs Improve Care, Outcomes for Patients With Diabetes

Robert Lowes

Authors and Disclosures

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August 31, 2011 — Patients with diabetes were more likely to meet care standards, such as annual eye exams, and outcome standards, such as blood glucose control, if their physician used an electronic health record (EHR) instead of a paper chart, according to a study published today in the New England Journal of Medicine.

Such good news about EHR usage has been scarce, comments lead author Randall Cebul, MD, a professor of medicine, epidemiology and biostatistics at Case Western Reserve University, Cleveland, Ohio, and coauthors.

Government efforts to promote EHRs anticipate "a quality-related financial return," they write. However, "available studies have shown few quality-related advantages of [EHRs] over traditional paper records."

To put the question to the test, the authors studied how 46 medical practices in and around Cleveland cared for 27,207 adults with diabetes. The practices, 33 of which relied on EHRs, publicly report their clinical performance in managing chronic illnesses as members of a group called Better Health Greater Cleveland (Dr. Cebul serves as its president). All 13 of the paper-based practices were so-called safety-net providers that serve a high proportion of patients considered vulnerable on account of lower income, lower education, lack of insurance, and other factors. Thirteen of the 33 EHR-based practices also qualified as safety-net providers, although the risk factors for their patients were less pronounced than for those in the paper-based practices.

The different categories of practices were compared on the basis of 4 standards of care and 5 clinical outcomes. The 4 standards of care were:

• Receipt of a glycated hemoglobin value;
• Kidney management, defined as testing for urinary microalbumin or prescription of an angiotensin-converting enzyme inhibitor or an angiotension-receptor inhibitor;
• An eye exam to screen for diabetic retinopathy; and
• Administration of a pneumococcal vaccine.

For the 5 clinical outcomes, the authors chose:

• A glycated hemoglobin value below 8%;
• Blood pressure below 140/80 mm Hg;
• A low-density lipoprotein cholesterol value below 100 mg/dL or documented prescription for a statin medication;
• A body mass index below 30 kg/m²; and
• Nonsmoking status.

EHRs May Not Fully Account for Performance Gap

When the authors looked at composite results, patients in the EHR-based practices scored 35.1 percentage points higher on care standards and 15.2 percentage points higher on outcome standards after an adjustment for income, education, insurance status, ethnic group, and other factors. The digital practices were ahead of the paper ones 25 percentage points on eye exams and nearly 11 percentage points for blood glucose control.

When the paper-based practices were compared to safety-net counterparts equipped with EHRs, the latter still came out on top in terms of composite care and outcome scores, although by smaller margins than when all EHR-based practices were studied.

The authors cautioned that they could not conclude that EHRs were the sole explanation for the quality differences. Causal wildcards include "the participation of exceptional EHR-based organizations, a nonrepresentative sample of paper-based organizations and inadequate adjustment for patient characteristics." They also noted that their study would have provided more compelling evidence for an EHR edge if they had measured before-and-after performance for groups that had switched from hard copy to software.

All authors state that they are active participants in Better Health Greater Cleveland, a regional collaborative supported by the Robert Wood Johnson Foundation and other sources. Their disclosure forms are available with the full text of this article.

  N Engl J Med. 2011;365:825-833. Published online August 31, 2011.