Electronic Health Records Can Improve Diabetes Care

The study looked at the impact of an electronic health record–based diabetes clinical decision support system on control of hemoglobin A1c, blood pressure, and low-density lipoprotein (LDL) cholesterol levels in adults with diabetes….

A clinic-randomized trial was conducted from October 2006 to May 2007 in Minnesota. Included were 11 clinics with 41 consenting primary care physicians and the physicians’ 2,556 patients with diabetes. Patients were randomized either to receive or not to receive an electronic health record (EHR)-based clinical decision support system designed to improve care for those patients whose hemoglobin A1c, blood pressure, or LDL cholesterol levels were higher than goal at any office visit. Analysis used general and generalized linear mixed models with repeated time measurements to accommodate the nested data structure.

The results showed that the intervention group physicians used the EHR-based decision support system at 62.6% of all office visits made by adults with diabetes. The intervention group diabetes patients had significantly better hemoglobin A1c (intervention effect –0.26%; 95% confidence interval, –0.06% to –0.47%; P=.01), and better maintenance of systolic blood pressure control (80.2% vs. 75.1%, P=.03) and borderline better maintenance of diastolic blood pressure control (85.6% vs. 81.7%, P =.07), but not improved low-density lipoprotein cholesterol levels (P = .62) than patients of physicians randomized to the control arm of the study. Among intervention group physicians, 94% were satisfied or very satisfied with the intervention, and moderate use of the support system persisted for more than 1 year after feedback and incentives to encourage its use were discontinued.

The data showed that an EHR-based clinical decision support system led to modest but significant improvements in glucose control and some aspects of blood pressure control. Primary care physicians reported high levels of satisfaction with the intervention and had high rates of use of the clinical decision support system during the intervention period and continued to use the technology for more a year after incentives and feedback were discontinued, although at a lower rate. Patients of intervention physicians who were and were not exposed directly to the clinical decision support system had comparable improvement in hemoglobin A1c levels and systolic blood pressure during the follow-up period. This finding suggests that physicians were able to transfer what they learned from using the clinical decision support system with some patients to the care of other patients — an important challenge and desirable finding in learning research.

The data provide proof-of-concept that an EHR-based clinical decision support system can improve key intermediate outcomes of diabetes care in primary care settings. The observed clinical impact, although modest, is comparable to that achieved by many disease management or patient education programs that are more expensive.

EHR-based clinical decision support is scalable and can be used in conjunction with additional care improvement strategies. In the coming era of personalized medicine, clinical decision support strategies capable of simultaneously standardizing and personalizing clinical care will likely become an essential tool in primary care, and investments to further enhance the effectiveness of this technology are urgently needed.

Annals of Family Medicine. 2011;9(1):12-21.