EMR Use is Not Associated with Better Diabetes Care

Patrick J O’Connor, MD, MPHStephen E Asche, MAA Lauren Crain, PhDLeif I Solberg, MD William A Rush, PhDRobin R Whitebird, PhD, MSW

Electronic medical record (EMR)

High expectations that EMRs will improve care quality since 1980; IOM reports 1992

$10+ billion spent in US in last 5 years 400 EMR vendors

Healthcare Information and Management Systems Society

Office EMRs now used by about 35% of physicians nationally

EMR Core Functions – IOM, 2003

health information and data

results management

order entry

decision support

electronic communication

patient support

administrative processes

reporting, population health mgmt

Research Question Do patients receiving care at clinics using

EMRs have better quality of diabetes care, compared to patients receiving care at clinics not using EMRs?

Project Quest Multi-site 3 year study involving 19

medical groups, 85 clinics, 700 providers and 7865 adult DM or CHD patients

Designed to identify patient, physician, clinic and group factors related to quality of care for adults with diabetes or heart disease

Funded by Agency for Healthcare Research and Quality (AHRQ)

Data Sources Administrative data

Diabetes determination (based on diagnosis & pharmacy codes), limited demographic information

Patient survey (2001) Socio-demographic information

Clinic medical director survey (2001) Report on use of EMR Other clinic variables

Chart audit (2000, 2001, 2002) HbA1c, LDL, SBP (last in each year)

Project Quest Diabetes Sample

Diabetes patients in 1999 (based on ICD-9 and pharmacy codes), N=4802

HealthPartners insurance, 19+ years old in 1999 Returned patient survey, N=2838 Self-report confirmed having diabetes, N=2754 Consented to chart audit, N=2019 Linked to a clinic in which a clinic medical director

completed a survey N=1491 DM patients from N=60 clinics

EMR item “Does your clinic use computerized medical

record systems that include provider entry of data” 60 clinic medical directors responded 14 (23.3%) replied “yes” n=441 patients in EMR clinics n=1050 patients in non-EMR clinics

Diabetes patients at clinics with and without an EMR

EMR (n=441) Non-EMR (n=1050)

Age (mean)* 64.2 60.7

Female (%)* 51.5 43.8

Duration DM (mean)*

11.5 10.3

Charlson (mean)

1.6 1.4

* p < .05

Diabetes patients at clinics with and without an EMR

EMR Non-EMR

A1c (mean, sd)

7.3 (1.21)(n=359)

7.3 (1.34)(n=877)

LDL (mean, sd)

101.4 (30.1)(n=246)

101.8 (30.0)(n=680)

SBP(mean, sd)

132.5 (17.6)(n=397)

130.8 (17.3)(n=934)

Year 2002 clinical values. Bivariate analysis.

Multilevel analysis Used MLwiN

adjusted treatment, and adjusted time by treatment analysis Used up to 3 clinical values per patient Nested yearly values within person within provider

within clinic (“clean” hierarchy) Predict clinical values, and change in clinical values

over time, as a function of EMR Patient covariates: age, sex, education, duration of DM,

Charlson score, CHD status, BMI Provider covariate: physician specialty

Multilevel analysis: HbA1c and change in HbA1c

Coeff SE p

Intercept 7.31 - -

EMR present

-0.07 .11 .56

Patient and provider covariates included

Time by treatment analysis: LR test p=.14

Multilevel analysis: LDL and change in LDL

Coeff SE p

Intercept 106.4 - -

EMR present

0.1 1.7 .95

Patient and provider covariates included

Time by treatment analysis: LR test p=.37

Multilevel analysis: SBP and change in SBP

Coeff SE p

Intercept 128.8 - -

EMR present

1.18 .82 .15

Patient and provider covariates included

Time by treatment analysis: LR test p=.90

Conclusions EMR use not associated with better

glucose, BP, or lipid control in adults with diabetes

Strengths of Study

Large number of patients with diabetes Multiple levels of data collection (patient,

provider, clinic medical director) Uniform data collection procedures and

standards at all clinics Use of hierarchical analytic models to

accommodate nested data

Potential Limitations Generalizability to other regions or patient populations is

uncertain; 60 clinics in one state Observational study precludes causal inference

Clinic systems already in place vs. pre-post design No information on 1) EMR features / functionality, 2) extent to

which EMR is used, 3) extent to which practitioners are trained to use the EMR

Clinic EMR examined in isolation (no other clinic variables considered in same analysis)

Some patients link to multiple providers and clinics, but we have simplified the hierarchy to link to one clinic

Compare to Other Studies Meigs ’02 at Mass General Clinics—EMR

increased A1c tests but did not improve A1c level

Montori ’02 at Mayo—EMR improved number of A1c tests but did not improve A1c or LDL level

O’Connor ’01 at HPMG—EMR use led to more A1c tests, but worse A1c levels

Crabtree ’06 at NJ clinics—EMR using clinics no better than non-EMR for DM care

Implications

Anticipated benefits of very expensive EMRs for improving diabetes (and other chronic disease) care have yet to be realized

Office systems not yet redesigned to take advantage of EMR potential

Physician training to use EMRs not standardized or optimized

More research needed if the potential of very expensive EMRs to support better care is to be realized

Questions or comments?

Patrick O’Connor MD MPHHealthPartners Research FoundationPatrick.J.Oconnor@HealthPartners.

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