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EHRs continue to improve in diabetes care

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January 27, 2019

Since their introduction, electronic health records have been shown to enhance disease management and quality of care for adults with diabetes, according to findings published in the Journal of Diabetes Science and Technology. However, improvements can still be made.

“Diabetes is not a static condition. It must be monitored and medications modified in accordance with changes,” Stephanie E. Lessing, MS, of the department of public policy and public affairs at the University of Massachusetts Boston, told Endocrine Today. “Since complex body systems are involved in diabetes progression, patients with diabetes benefit from reminder features that are available in EHR systems. These reminder tools increase the likelihood of providers executing often-neglected but simple practices like foot checks, for example. These small reminders can make a big difference in preventing adverse outcomes and keeping comprehensive records.”

To assess the effectiveness of EHRs and identify opportunities for their improvement, Lessing and colleagues conducted a systematic literature review of 14 studies published from March 2003 to November 2017. All studies were based on randomized or controlled trials or systematic reviews focused on EHR outcomes. Participants in the studies were aged at least 18 years and had a diabetes diagnosis or a prescription for diabetes medication within the previous year. Study outcomes included HbA1c, blood pressure and LDL cholesterol levels.

Quality of care

Of the 14 studies that were reviewed, several were concerned with improving quality of care for people with diabetes. Multivariate regression analysis in one study of 927 patient charts from practices in Pennsylvania and New Jersey from 2003 to 2004 showed that paper-based practices better adhered to treatment guidelines and improved intermediate outcomes better than EHR systems.

“Adoption of new technology is disruptive to standard procedures because it requires office staff and clinicians to alter their routines. There is evidence that these changes in routine caused inefficiencies when practices were first adopting EHR systems,” Lessing said. “To overcome these issues, it’s important that roles be assigned not just in clinical processes, but also in the use of EHR systems. Collaboration must be actively maintained so not to fall into an overreliance upon technology rather than the education, intuition and experience of practitioners.”

Results of more recent studies were more positive for EHR processes. A cross-sectional multivariate regression analysis of 27,207 random charts from 46 diverse clinics in Cleveland from 2007 to 2010 showed that more than 50% of adults treated at sites using an EHR system met four predetermined care standards for tests, prescriptions, examinations and vaccines compared with 6.6% of sites that used paper-based methods. Outcome standards for BP, cholesterol level, statin prescriptions, BMI and smoking status were also met more frequently at EHR sites (43.7%) vs. paper-based sites (15.7%).

Additionally, a 5-year longitudinal study of two Minnesota clinics showed that LDL cholesterol and HbA1c levels were improved at similar rates for people treated in the clinic using an EHR system vs. the paper-based practices, but there was greater improvement in the EHR group’s LDL cholesterol in the long term. Testing was also more common in EHR practice, but Lessing said one study showed that meeting successful thresholds for BMI and other measurements were more likely in EHR vs. paper-based practices.

“One might not think that BMI levels would improve just because a clinician was entering this information into an EHR system, but the reminders to input this information may have sparked conversations about weight, diet and exercise that may lead to plans to reduce BMI,” Lessing said. “This could be seen as a residual effect of the implementation of EHR. It was not necessarily a goal of the system, but a biproduct of having to take these measurements and incorporate it into the discussion at each office visit.”

In a follow-up randomized trial of 11 clinics with 41 primary care providers, the researchers found that when available, a decision support tool was used in 62% of office visits, and 94% of physicians were satisfied with the intervention. In addition, HbA1c levels and BP improved in the group using the tool vs. control.

Diagnoses, decisions and digital integration

Lessing and colleagues also sought to determine how effective EHRs can be as preventive and diagnostic tools. They found that a signal detection analysis of diabetes medications (sulfonylurea, metformin, rosiglitazone [Avandia, GlaxoSmithKline] and pioglitazone) that identified myocardial infarction risk within 18 months was improved by using EHR features in all four medications. In addition, an algorithm integrated in EHR systems properly identified cases 98% of the time in a masked manual review of 150 patient charts.

“Decision/clinical support tools offer recommendations for prescriptions based on how far patients are from their goals while also alerting prescribers of potential drug interactions. This is particularly beneficial for patients with diabetes because many are on multiple medications,” Lessing said, adding that these are not fool-proof systems. “Some studies still stress the importance of providers using their own expertise alongside these support tools. Small flaws in the algorithms can result in ineffective or unsafe treatment recommendations.”

EHR methods can also be integrated in a web-based component, which was evaluated in a sample of studies examined by Lessing and colleagues. One such study tested a live diabetes support program and found that patients were more active in their care and empowered in decision-making when they had access to such a program. Another randomized trial provided evidence that using a web-based diabetes tracker and message center led to improvements in primary and secondary outcomes and also increased diabetes management optimism and trust between patients and their physicians.

“This is critical for patients with diabetes who often have many specialists to address body systems affected by diabetes, such as their eyes, feet and kidneys,” Lessing said. “This communication increases continuity of care, allowing all physicians and clinicians to be up-to-date on all changes.” – by Phil Neuffer

Disclosures: The authors report no relevant financial disclosures.

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