New Research Finds EHRs Improve the Quality of Diabetes Care

Two years ago in an address to Congress, President Obama declared his commitment to invest in electronic health records (EHRs), saying he thought it was perhaps the best way to quickly improve the quality of American health care. Just two years later, that hunch is proving true in Cleveland, Ohio.

New EHR Research Findings:

Today, the New England Journal of Medicine released research authored by my colleagues and me at Better Health Greater Cleveland showing that physician practices that use electronic health records had significantly higher achievement and improvement in meeting standards of care and outcomes in diabetes than practices using paper records.

Though most of us assumed EHRs would have some effect on patient care, we were delighted by what’s proving to be the reality in greater Cleveland. Just consider:

Care is better: Nearly 51% of patients in EHR practices received care that met all of the endorsed standards.

  • Only 7% of patients at paper-based practices received this same level of care– a difference of 44%.
  • After accounting for differences in patient characteristics between EHR and paper-based practices, EHR patients still received 35% more of the care standards.
  • Just fewer than 16% of patients at paper-based practices had comparable results.
  • After accounting for patient differences, the adjusted gap remained 15% higher for EHR practices.

Outcomes are better: Nearly 44 % of patients in EHR practices met at least four of five outcome standards for diabetes.

Improvement is faster: EHR practices had annual improvements in care that were 10% greater and improvements in outcomes that were 4% greater than those of paper-based practices.

Everyone benefits: Patients in EHR practices showed better results regardless of their insurance status, whether privately insured, uninsured, or covered by Medicare or Medicaid. Thus, all payers benefited too.

EHR Research Participants:

The research involved more than 27,000 adults with diabetes who received care in 46 practices across the Cleveland metro area.

The work was fueled by being selected one of the Robert Wood Johnson Foundation’s Aligning Forces for Quality communities. All 16 committed to public reporting and improving care for their patients with chronic medical conditions.

In the Cleveland area, the improvements we report would not have been possible without the more than 500 courageous doctors who stepped up and made the commitment to work directly with Better Health Greater Cleveland to share best practices in care and publicly report their achievement.

Most inspiring were the contributions of the region’s Federally Qualified Health Centers – who care for some of the most vulnerable people in the area and who have committed to compete head-to-head with health care organizations with substantially more advantaged patients.

Not surprisingly, all of our paper-based safety net practices have capitalized on federal funds and resources to acquire EHRs and to leverage involvement with Better Health to accelerate their quality-related improvements. We look forward to helping out.

Positive Outcomes:

EHRs aren’t the end-all-be-all solution for all the gaps in quality facing American health care, and they require significant commitment and teamwork from health care providers to implement them – not to mention encouragement and support from the government.

But results from our study provide optimism that the President’s faith is well-placed. Here in Cleveland, we’re working to make our region a healthier place to live and a better place to do business.


  1. Sherry Reynolds @cascadia says:

    What is especially interesting is that even though patients who’s providers had an EHR received the standard of care 35% of the time more often the outcomes didn’t differ.. This shows how critically important it is to partner with patients outside of their providers office to bring about actual change in outcomes.

  2. william hyman says:

    It is a leap to say that the EHR was the cause of the better care as distinguished from the practices simply better (perhaps) as evidenced in part by their adoption of the EHR.

  3. Donald W. Simborg, MD says:

    It is interesting how prominently Dr. Mostashari touts this study’s conclusions compared to the many studies with negative implications for EHRs. It is the same uncritical bias that may be present in the study itself. Although the results of this study suggest the hypothesis that EHRs lead to better quality care, it certainly does not prove that point. As with all uncontrolled retrospective analytical studies, the results here could very well be unrelated to the independent variable being studied. The result may simply be related to the fact that other variables which lead to good quality care may also have resulted in a practice choosing to implement an EHR.

  4. Lawrence Gordon, MD says:

    The Cebul article provides solid support for the benefits to quality of care when using EHR. Both academic studies and reporting initiatives are hampered by inconsistently applied standard for patient inclusion in denominator populations. The diabetic patient population is not consistently defined not applied in Clinical Quality Measures submitted to CMS, P4P or clinical study designs. Because of this, we are not able to replicate or compare studies. Similarly performance data is less meaningful between sites and between information systems that use different standards and therefore more prone to “gaming” to change the results. The Cebul study is similarly limited in not providing a clear and replicable definition of what specifically defines the population of diabetic patients for inclusion in the study. Is it the provider labeling a patient as a diabetic, a single ICD-9 diagnosis on a claim or EHR note, elevated fasting blood glucose lab value(s), the treatment of the patient with insulin or an oral anti-diabetic medication, or some combination of the above? Whatever the inclusion metric, it should not have influenced the outcome if consistently applied to the EHR and paper-based patient population. Data that is extremely difficult and time-consuming for paper-based records is trivial to obtain from electronic health records. The results of EHR studies will be more MEANINGFUL when we have consistently applied national standards for inclusion in the denominator population. ONC should take the lead to promote consistent patient population standards.

  5. Scot Silverstein, MD says:

    This article is fine; its findings are well known to me as former CMIO at the largest hospital in Mr. Biden’s home state. We had similar results in a pilot study using EMR data there – circa 1997. When health IT is done well, it can perform well.

    The problem is, there is massive, perhaps wicked complexity behind those simple two words “done well.”

    I am concerned about 2 other issues:

    1. The methodological limitations noted in the study may make the P.R. the article is getting a bit excessive.

    2. As in “Tensions and Paradoxes in Electronic Patient Record Research: A Systematic Literature Review Using the Meta-narrative Method” by Greenhalgh, Potts, Wong, Bark and Swinglehurst at University College London appeared in the Dec. 2009 Milbank Quarterly:

    “… This review has also identified some areas where more research does not appear to be needed… [including] simplified experimental studies based on functionalist and determinist assumptions of the general format “what is the impact of technology X on outcome Y?” or variations thereof … the circumstances in which they add value are more limited than is often assumed.”

    It seems this study is of that type.

    Greenhalgh et al. also wrote:

    “… as a cross-cutting theme in all the above areas, the realpolitik of EPR projects within and between organizations and interest groups should be more explicitly explored … Orlikowski and Yates have called for more research on the “messy, dynamic, contested, contingent, negotiated, improvised, heterogeneous, and multi-level character of ICTs [information & communications technologies – ed.] in organizations. We suggest that sponsors and publishers eschew sanitized accounts of successful projects and instead invite studies of the EPR in organizations that “tell it like it is” – perhaps using the critical fiction technique to ensure anonymity.”

    There’s no trace of that in the new NEJM article. Where health IT is concerned, that’s where the money is (no pun intended) in learning how to “do health IT well.”

  6. John Lynn says:

    I think we have to be careful to draw such wide ranging conclusions from a very focused study. Plus, I’m not sure that all the benefits found in the study were really attributable to the EHR software as opposed to other factors.

    It’s nice to see research talk about the benefits of EHR, but let’s not over-exaggerate the actual conclusions of the study.

  7. Bobby Lee says:

    My main question is whether the compliance to standard protocol is the real driver to outcomes difference rather than whether was EHR or not.

    EHR –> helps with getting on standard protocol –> better outcome, NOT
    EHR = better outcome.

    I would of like to see stats on two groups; both using EHR, but compliancy to the protocol being the variance to see how the outcomes measure up.

  8. Janeen Smith, MSN, RN-BC says:

    Article seemed to lead to more questions than answers. WHY is EHR better? Is it due to the built-in checklists to jog the healthcare provider’s memory? Is it because the checklist will not be content till a response is provided? Does it teach the provider how to assess/diagnose/treat more effectively? As a nurse educator I would love to know what is so magical about data being provided electronically. Isn’t it still dependent upon input which is dependent upon critical thinking?

  9. Monika Bell says:

    It’s nice to see some hard numbers supporting use of EHR, not that they should be needed. Working with paper records is a nightmare – you can easily spend 75% of your day looking for records or waiting for paper reports to be filed. Half the time, hand-written notes can’t be deciphered, leaving much room for error and there are no good ways of gathering data on treatment outcomes and physician performance from paper records. Anyone with some common sense can see how having a patient’s chart at your fingertips at any time contributes greatly to faster, better and safer service. In my experience, it’s been the technologically disadvantaged providers and staff who opposed EHR implementation for fear of change or fear of lacking necessary skills. There is also a myth that electronics make patient care less personal or caring. It’s up to providers and staff to use the technology and still add a personal touch. Healthcare is about people and using efficient tools helps us spend more hours caring for patients rather than looking for their records.

  10. Medical Records Scanning says:

    It’s no surprise that making a doctor’s practice more productive with information technology equates to better patient care. I think there may be a learning curve and some resistance to change for some, but I have to believe most doctors are achieving similar results.

  11. Symptoms of diabetes says:

    Good to know! Thank you!

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