title: Implementation of an outpatient electronic health record and emergency department visits, hospitalizations, and office visits among patients with diabetes.
abstract: OBJECTIVE
  The US federal government is spending billions of dollars in physician incentives to encourage the meaningful use of electronic health records (EHRs). Although the use of EHRs has potential to improve patient health outcomes, the existing evidence has been limited and inconsistent.
  
  
  OBJECTIVE
  To examine the association between implementing a commercially available outpatient EHR and emergency department (ED) visits, hospitalizations, and office visits for patients with diabetes mellitus.
  
  
  METHODS
  Staggered EHR implementation across outpatient clinics in an integrated delivery system (Kaiser Permanente Northern California) between 2005 and 2008 created an opportunity for studying changes associated with EHR use. Among a population-based sample of 169,711 patients with diabetes between 2004 and 2009, we analyzed 4,997,585 person-months before EHR implementation and 4,648,572 person-months after an EHR was being used by patients' physicians.
  
  
  METHODS
  We examined the association between EHR use and unfavorable clinical events (ED visits and hospitalizations) and office visit use among patients with diabetes, using multivariable regression with patient-level fixed-effect analyses and adjustment for trends over time.
  
  
  RESULTS
  In multivariable analyses, use of the EHR was associated with a statistically significantly decreased number of ED visits, 28.80 fewer visits per 1000 patients annually (95% CI, 20.28 to 37.32), from a mean of 519.12 visits per 1000 patients annually without using the EHR to 490.32 per 1000 patients when using the EHR. The EHR was also associated with 13.10 fewer hospitalizations per 1000 patients annually (95% CI, 7.37 to 18.82), from a mean of 251.60 hospitalizations per 1000 patients annually with no EHR to 238.50 per 1000 patients annually when using the EHR. There were similar statistically significant reductions in nonelective hospitalizations (10.92 fewer per 1000 patients annually) and hospitalizations for ambulatory care-sensitive conditions (7.08 fewer per 1000 patients annually). There was no statistically significant association between EHR use and office visit rates.
  
  
  CONCLUSIONS
  Among patients with diabetes, use of an outpatient EHR in an integrated delivery system was associated with modest reductions in ED visits and hospitalizations but not office visit rates. Further studies are needed to quantify the association of EHR use with changes in costs.
authors.affiliation: Division of Research, Kaiser Permanente Northern California, Oakland, California 94610, USA. mary.e.reed@kp.org
authors.forename: Mary
authors.initials: M
authors.lastname: Reed
authors.forename: Jie
authors.initials: J
authors.lastname: Huang
authors.forename: Richard
authors.initials: R
authors.lastname: Brand
authors.forename: Ilana
authors.initials: I
authors.lastname: Graetz
authors.forename: Romain
authors.initials: R
authors.lastname: Neugebauer
authors.forename: Bruce
authors.initials: B
authors.lastname: Fireman
authors.forename: Marc
authors.initials: M
authors.lastname: Jaffe
authors.forename: Dustin W
authors.initials: DW
authors.lastname: Ballard
authors.forename: John
authors.initials: J
authors.lastname: Hsu
mesh_terms: D000293:Adolescent; D000328:Adult; D000368:Aged; D000554:Ambulatory Care Facilities; D002140:California; D002648:Child; D002675:Child, Preschool; D015331:Cohort Studies; D019033:Delivery of Health Care, Integrated; D003920:Diabetes Mellitus / Q000628:therapy*; D057286:Electronic Health Records / Q000706:statistics & numerical data*; D004636:Emergency Service, Hospital / Q000706:statistics & numerical data*; D005260:Female; D006279:Health Maintenance Organizations; D006760:Hospitalization / Q000706:statistics & numerical data*; D006801:Humans; D007223:Infant; D008297:Male; D008875:Middle Aged; D015999:Multivariate Analysis; D009819:Office Visits / Q000706:statistics & numerical data*; D010045:Outpatients; D012042:Registries / Q000706:statistics & numerical data; D055815:Young Adult
references.citation: Arch Intern Med. 2011 May 23;171(10):897-903
references.pmid: 21263077
references.citation: Ann Fam Med. 2005 Jul-Aug;3(4):300-6
references.pmid: 16046561
references.citation: Health Care Manag Sci. 2002 Aug;5(3):211-9
references.pmid: 12363048
references.citation: Am J Manag Care. 2011 Dec;17(12 Spec No.):SP117-24
references.pmid: 22216770
references.citation: Arch Intern Med. 2007 Jul 9;167(13):1400-5
references.pmid: 17620534
references.citation: Health Aff (Millwood). 2005 Sep-Oct;24(5):1103-17
references.pmid: 16162551
references.citation: J Am Med Inform Assoc. 2012 May-Jun;19(3):423-38
references.pmid: 21984590
references.citation: Ann Intern Med. 2006 May 16;144(10):742-52
references.pmid: 16702590
references.citation: Health Serv Res. 2012 Aug;47(4):1522-40
references.pmid: 22250953
references.citation: Health Aff (Millwood). 2012 Jan;31(1):208-19
references.pmid: 22232112
references.citation: Health Aff (Millwood). 2010 Jul;29(7):1370-5
references.pmid: 20606190
references.citation: Ann Intern Med. 2012 Oct 2;157(7):482-9
references.pmid: 23027319
references.citation: Health Aff (Millwood). 2011 Mar;30(3):464-71
references.pmid: 21383365
references.citation: J Am Med Inform Assoc. 2009 Jul-Aug;16(4):457-64
references.pmid: 19390094
references.citation: Am J Public Health. 1992 May;82(5):703-10
references.pmid: 1566949
references.citation: Ann Fam Med. 2012 May-Jun;10(3):221-7
references.pmid: 22585886
references.citation: Health Aff (Millwood). 2012 May;31(5):1100-7
references.pmid: 22535501
references.citation: N Engl J Med. 2011 Sep 1;365(9):825-33
references.pmid: 21879900