EMR use is not associated with better diabetes care
Patrick J. O’Connor, MD, MPH, A. Lauren
Crain, PhD, Leif I. Solberg, MD, Stephen E.
Asche, MA, William A. Rush, PhD, Robin R.
Whitebird, PhD, MSW

Electronic medical record (EMR)

$10+ billion spent on EMR in last 5 years
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300 EMR vendors (EMR Institute)
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Office EMRs now used by > 35% of physicians
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Typical features of an EMR:

High expectations that EMRs will improve care quality since 1980; IOM reports 1992

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, and clinic factors related to quality of care for adults with diabetes or heart disease

Funded by Agency for Healthcare Research and Quality (AHRQ)

Project Quest Diabetes
Sample
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Diabetes patients in 1998 (based on ICD-9 and pharmacy codes)
HealthPartners insurance in 1998
19+ yrs old in 1998
Returned patient survey
Self-report confirmed having diabetes
Consented to chart audit
Linked to a clinic in which a clinic medical director completed a survey
N=1,491 DM patients from N=60 clinics

Data Sources

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Administrative data
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Diabetes determination (based on diagnosis & pharmacy codes), limited demographic information
Patient survey (2000)
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Socio-demographic information
Clinic medical director survey (2000)

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Report on use of EMR
Other clinic variables
Chart audit (1999, 2000, 2001)

HbA1c, LDL, SBP (last in each year)

EMR item

“Does your clinic use computerized medical record systems that include provider entry of data”

Asked of 60 clinic medical directors

14 / 60 (23.3%) replied “yes”

Diabetes patients at clinics with and without an EMR
Age (mean)*
EMR
(n=441)
64.2
Non-EMR
(n=1050)
60.7
Female (%)*
Duration DM
(mean)*
Charlson
(mean)
* p < .05
51.5
11.5
1.6
43.8
10.3
1.4

Diabetes patients at clinics with and without an EMR
EMR Non-EMR
A1c
(mean, sd)
LDL
(mean, sd)
SBP
(mean, sd)
7.3 (1.21)
(n=359)
101.4 (30.1)
(n=246)
132.5 (17.6)
(n=397)
7.3 (1.34)
(n=877)
101.8 (30.0)
(n=680)
130.8 (17.3)
(n=934)
Year 2001 clinical values. Bivariate analysis. * p < .05

Multilevel analysis


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Uses clinical values in all 3 years
Models clinical value pooled across all 3 years, and change in clinical values over time
Models time within person within provider within clinic (“clean” hierarchy)
Used MLWin
Patient covariates: age, sex, education, duration of DM, Charlson score, CHD disease,
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
Change over time 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
Change over time 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
Change over time analysis: LR test p=.90

Strengths of Study
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Large number of patients with diabetes
Multiple data sources (patient, provider, clinic medical director)
Use of hierarchical analytic models to accommodate nested data
Uniform data collection procedures and standards at all clinics

Potential Limitations
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Study only involved 60 clinics in one state, generalizability to other regions or patient populations is uncertain
Observational study precludes causal inference
Clinic systems already in place
Didn’t examine process measures as dependent variables
(e.g., test rates)
Clinic EMR use examined in isolation (no other clinic variables considered in same analysis)
We don’t have information on 1) features / functionality of the EMR, 2) extent to which EMR is used, 3) extent to which practitioners are trained to use the EMR
Some patients may link to multiple doctors, who link to multiple clinics, but we have simplified the hierarchy

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

Compare to Other Studies

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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

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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.J.Oconnor@
HealthPartners.com

Appendix slides

Diabetes identification
Diabetes identified using a method with estimated sensitively of 0.91 and positive predictive value of
0.94. Data on A1c and CHD were obtained from a medial record review.
See paper draft for detail

Recruitment rates, sampling
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QUEST successfully recruited:
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19 of 22 eligible medical groups
85 of 86 eligible clinics within those medical groups
See paper draft for details on sampling: 19 MG, all clinics in these MG, minimum of 10 pts per clinic (DM and CHD sample)

Survey response rates
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Survey response rates of medical groups (100%), clinics (98%), providers (55%) and chart audit consent rate of patients responding to surveys (about
80%) exceeded levels needed to power the analysis.

Patient Factors Analyzed
*Age
*Educational Level
*Duration of Diabetes
*Comorbidity
*Gender
*BMI

Physician Factors
Analyzed
Years Experience (Post-
Residency)
Gender
Specialty (FP, IM)

Measures of Clinic Systems in Clinic Surveys
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Expanded Roles for Nurses/Teams
Registries
Electronic Medical Records
Monitoring of Clinical Status
Prioritization based on Risk, RTC
Active Interventions:

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Visit Planning
Active Outreach
Patient Activation

Where is the Variance?
--80-90% of variance at
Patient/Time level
--5% of variance at Physician level
--5% of variance at Clinic level
--2-4% of variance at Medical
Group level