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Electronic medical record (EMR)

EMR Use is Not Associated with Better Diabetes Care Patrick J O’Connor, MD, MPH Stephen E Asche, MA A Lauren Crain, PhD Leif I Solberg, MD William A Rush, PhD Robin R Whitebird, PhD, MSW. Electronic medical record (EMR).

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Electronic medical record (EMR)

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  1. EMR Use is Not Associated with Better Diabetes CarePatrick J O’Connor, MD, MPHStephen E Asche, MAA Lauren Crain, PhDLeif I Solberg, MD William A Rush, PhDRobin R Whitebird, PhD, MSW

  2. 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

  3. 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

  4. 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?

  5. 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)

  6. 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)

  7. 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

  8. 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

  9. Diabetes patients at clinics with and without an EMR * p < .05

  10. Diabetes patients at clinics with and without an EMR Year 2002 clinical values. Bivariate analysis.

  11. 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

  12. Multilevel analysis: HbA1c and change in HbA1c Patient and provider covariates included Time by treatment analysis: LR test p=.14

  13. Multilevel analysis: LDL and change in LDL Patient and provider covariates included Time by treatment analysis: LR test p=.37

  14. Multilevel analysis: SBP and change in SBP Patient and provider covariates included Time by treatment analysis: LR test p=.90

  15. Conclusions • EMR use not associated with better glucose, BP, or lipid control in adults with diabetes

  16. 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

  17. 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

  18. 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

  19. 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

  20. Questions or comments? Patrick O’Connor MD MPH HealthPartners Research Foundation Patrick.J.Oconnor@HealthPartners. Com

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