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Original Investigation
September 11, 2013

Implementation of an Outpatient Electronic Health Record and Emergency Department Visits, Hospitalizations, and Office Visits Among Patients With Diabetes

Author Affiliations
  • 1Division of Research, Kaiser Permanente Northern California, Oakland, California
  • 2Department of Epidemiology and Biostatistics, University of California at San Francisco
  • 3Department of Medicine and Endocrinology, The Permanente Medical Group, South San Francisco, California
  • 4Department of Emergency Medicine, The Permanente Medical Group, San Rafael, California
  • 5Mongan Institute for Health Policy, Massachusetts General Hospital, Harvard Medical School, Boston
  • 6Department of Health Care Policy, Harvard Medical School, Boston, Massachusetts
JAMA. 2013;310(10):1060-1065. doi:10.1001/jama.2013.276733

Importance  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.

Design, Setting, and Population  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.

Main Outcomes and Measures  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 and Relevance  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.