Talk given at RSSDI 2012 held at Chennai.

1. Role of Electronic Medical Records
& Computer Gadgets in Diabetes
Dr. Santosh Malpani MD

3. Changing Medical Records…..

4. Changing Medical Records…..
The only thing which is permanent in this world is CHANGE.
And the exception is MEDICAL RECORDs !

5. Strengths of Paper Record
• Paper records are familiar to users who consequently
do not need to acquire new skills or behaviors to use
them.
• Paper records are portable and can be carried to the
point of care.
• Once in hand, paper records do not experience
downtime as computer systems do.
• Paper records allow flexibility in recording data and
are able to record "soft" (i.e., subjective) data easily.
• No new technology to be learnt for keeping data on
papers.

6. Weakness of Paper Record
• Find the record: Lost, being used elsewhere
• Find data within the record: Poorly
organized, missing, fragmented
• Read data: Language and Legibility
• Research: Difficult to search across patients
• Passive: No decision support

7. MCI Recommendations
• Keep Records for of 3 years from the date
of commencement of the treatment
• If demanded issue in 72 hrs
• Maintain a Register of Medical Certificates
giving full details of certificates issued.
• Efforts shall be made to computerize
medical records for quick retrieval.
MCI-Professional Conduct, Etiquette and Ethics Regulations, 2002

8. ADA recommendations
IX. STRATEGIES FOR IMPROVING DIABETES CARE
Changes that have been shown to increase quality
of diabetes care include
1. Basing care on evidence based guidelines
2. Implementing electronic health record tools
ADA- Standards of Medical Care in Diabetes 2012

9. • Physiology is 'the logic of life‟
• Pathology is „the logic of disease‟
• Health informatics is „the logic of healthcare‟
– Electronic Medical Records are not
WORD files stored with patients identity.

10. Definition of EHR
– It is a longitudinal collection of electronic
health information for and about persons
– With Immediate electronic access to
person and population level information
by authorized users;
– With provision of knowledge and
decision-support systems that enhances
the quality, safety, and efficiency of
patient care and
– Provides Support for efficient processes
for health care delivery.”
Institute of Medicine 2003 Patient Safety Report

11. Advantages of EMR in Diabetes
Storage Space
• Diabetes being a chronic disease, patients visits
OPDs, does the reports, gets admitted more
times as compared to any other diseases.
• Each activity creates one record leading to a
great quantum records.EMR requires virtually
negligible space.
• EMR allows for a complete set of backup
records at little or no cost reducing the number
of lost records

12. Back up of records

13. Advantages of EMR
Quality Assurance
• With EMR we an assure quality of medical
care to the patients as it can be
“measured” via analysis of records.
• Practitioners using EMR are giving better
quality of medical care as compared to
practitioners using paper record provided
they use it in “meaningful” way.

14. Author/ Title Sample/ Method Outcome
journal/ yr
Randal et al EHR and 2007 to 2009 EHR sites were associated
NEJM/2011 Quality of 27,207 records in with significantly higher
Diabetes 47 practices achievement of quality care
Care and outcome standards
DAVIS BU- Benefits of Computer model Use of EHR improved the
Diabetes IT- Enabled creation to health of patients with
Care 2007 DM Mgt project IT impact diabetes and reduced
on health
health care expenditures.
expenditures
VICTOR M. The Impact 16 primary care Planned care was associated
MONTORI of Planned sites, 200 pt from with improvements in
Diabetes Care and a each, measurement of HbA1c, HDL
Care 2002 DEMR on comparison of cholesterol and
Community baseline and microalbuminuria as well as
DM Care after the provision of tobacco advice
implementation
data

15. Author/ Title Sample/ Method Outcome
journal/ yr
DAVID IT Systems to 109 articles, Use of EMR improved Guideline
DORR et Promote 112 system adherence, visit frequency,
al Improved Care description, documentation, treatment
J Am Med for Chronic DM (42.9%)of adherence, referral rate,
appropriate screening/testing,
Inform Illness: A reviewed articles),
and cost. Most Studies reported
Assoc. Literature heart disease and positive and few studies
2007 Review mental illness . reported neutral results.
Jesse C. EMR and DM Cross sectional Diabetes care quality in all
Crosson Quality of Care: analysis of practices showed room for
Annals Of Results From a baseline data from improvement however, after
Family Sample of 50 practice sites adjustment, patient care in the
Medicine Family 37 practices not using an EMR
2007 Medicine was more likely to meet
Practices guidelines for process.
Meaningful use of EMR
recommended.

16. Inference
• These studies indicate that “meaningful”
use of EMR can be beneficial in improving
Quality of care in Diabetes management.

17. What information
Do you want my
master ?

18. Analysis of Practice Patterns
and Research Activities
• Demographic studies, prevalence studies
can be done.
• For clinical research specific sub-set of
patients who can meet the qualifying
criterion for a proposed trial can be easily
extracted.
• EMR output can be integrated in research
software.

20. Use of a Large Diabetes EMR System in India:
Clinical and Research Applications
V.Mohan Journal of Diabetes Science and Technology May 2011
Prevalence rates
Parameter T1 DM T2 DM
Neuropathy 13.0 % 33.1 %
Microalbuminuria 20 % 25 %
CAD 9.2 % 17.5 %
PVD 2.8 % 3.9 %
Retinopathy 35.7 % 37.9 %
Prevalence of microvascular and macrovascular
complications of diabetes increased with increasing glycated
hemoglobin levels (p for trend < .001) and increasing diabetes
duration (p for trend < .001)
The DEMR helps track diabetes care and is a valuable tool for
research.

21. Speed the Retrieval of Data

22. Advantages of EMR
• Expedite the transfer of data between
facilities, regardless of geographic
separation
• Opinion from a colleague, discussion of
the case possible.
• Are a proven long-term cost reducer,
practice enhancers and a public relations
tool.

24. Legible Record

25. Problems of wrong medication,
wrong dose, wrong directions

26. Drugs from same group

27. Same drug again

28. Special Precautions for drug

29. Allergy Alert

30. Patient Education Material

31. Multilingual Facility

32. Multilingual Facility

33. Decision Support Model
JoAnn M. Sperl-Hillen - Diabetes Spectrum Volume 23, Number 3, 2010

34. Advantages of EMR
• In professional liability suits against health
care providers the medical record is “The
witness that never dies.” A well
documented, complete, and unambiguous
medical record means a case that is
infinitely easier to defend.

35. Finance

36. Improvement in Practice Pattern

37. Problems associated with EMR
• High initial cost, Large training investment
• Hardware crashes and breakdowns, power
failures, software glitches, viruses, Trojan horses
• Loss of eye contact with patient, Physicians
don‟t feel free as with paper prescriptions.
• Reluctance of physicians to use the tightly
controlled format for notes.

38. Problems associated with EMR
• Coding language is not fixed. Variable at
each place.
• Don‟t accept „loose terms‟ as program is
„structured‟.
• Delay between investment & benefit.

39. Using EMR is like riding a horse.
New rider is afraid,
Learner falls many times,
Experienced enjoys the ride and remains
ahead in the race !
Thank you !

40. Thank You !
“Experience is a hard teacher because she
gives the test first, the lessons afterwards.”
-Vernon Law

41. •Presentation ends
here. All other
slides after this are
not included.

42. Perceived barriers and related
possible interventions
Finance
• Provide documentation on return on
investment.
• Show profitable examples from other EMR
implementations.
• Provide financial compensation.
• Government/ Association incentives.

43. Paper Record Versus EMR
• Physicians spend up to 38% of their time writing up
patient charts.
• Nurses spend up to 50% of their time writing up charts.
• Medical records are misplaced or missing in 30% of
patient visits.
• The average patient visit generates 13 pieces of paper.
• The average office spends $10 per visit to track and file
paper records
• The average patient record weighs 1.5 lbs.
Source: Committee on Improving the Patient Record, Institute of Medicine

44. Perceived barriers and related
possible interventions
Technical
• Educate physicians and support ongoing training.
• Adapt the system to existing practices.
• Implement EMR on a module-by-module basis.
• Link EMR with existing systems.
• Promote and communicate reliability and availability
of the system.
• Acquire third party for support during
implementation.

45. Perceived barriers and related
possible interventions
Time
• Provide support during implementation
phase to convert records and assist.
• Provide training sessions to familiarize
users.
• Implement a user friendly help function
and help desk.
• Redesign workflow to achieve a time gain

46. Perceived barriers and related
possible interventions
Psychological
• Discuss usefulness of the EMR
• Include trial period.
• Demonstrate ease of use.
• Start with voluntary use.
• Let fellow physicians demonstrate the
system.
• Adapt system to current medical practice.

47. Perceived barriers and related
possible interventions
Social
• Discuss advantages and disadvantages
for doctors and patients.
• Information and support from physicians
who are already users.
• Ensure support, leadership, and
communication from management.

48. Perceived barriers and related
possible interventions
Legal
• Develop requirements on safety and
security in cooperation with physicians and
patients.
• Ensure EMR system meets these
requirements before implementation.
• Communicate on safety and security of
issues.

49. Perceived barriers and related
possible interventions
Organization
• Redesign workflow to realize a better
organizational fit.
• Adapt EMR to organization type.
• Adapt EMR to type of medical practice

50. Perceived barriers and related
possible interventions
Change process
• Select a project champion, preferably an
experienced physician.
• Let physicians (or representatives) participate
during the implementation process.
• Communicate the advantages for physicians.
Use incentives.
• Ensure support, leadership, and communication
from management.

52. Methods and Dimensions of EHR Data Quality
Assessment: Enabling Reuse for Clinical Research
Weiskopf NG, Weng C. J Am Med Inform Assoc (2012). doi:10.1136/amiajnl-2011-000681
• There is currently little consistency or
potential generalizability in the methods
used to assess EHR data quality. If the
reuse of EHR data for clinical research is
to become accepted, researchers should
adopt validated, systematic methods of
EHR data quality.

53. EMR in Diabetes Management
• Diabetes mellitus is a chronic illness that requires
continuing medical care and ongoing patient self-
management education and support to prevent acute
complications and to reduce the risk of long-term
complications.
• Diabetes care is complex and requires that many issues,
beyond glycemic control, be addressed.
• A large body of evidence exists that supports a range of
interventions to improve diabetes outcomes.
• To achieve this keeping health record which can be
easily assessed, read and interpreted is required.

54. EMR in Diagnosing Diabetes
• Current criteria can be incorporated and
changed as per recommendations
• Protocols of tests can be incorporated in EMR
for specific population e.g. Symptomatic patient
protocol, Asymptomatic patient protocol,
Pregnancy with diabetes protocol.
• This improves the “value” and meaningfulness”
of test.

55. EMR in Glucose Monitoring
• Data of SMBG, CGMS, Lab Reports can
be incorporated in EMR.
• Visualizing these reports graphs, bar
diagrams on time line improves
assessment of variability in glucose value.
• This helps in monitoring diabetes,
detecting both hypo and hyperglycemia in
a better way.

56. EMR in Goals

57. Can Electronic Clinical Documentation Help
Prevent Diagnostic Errors ?
Gordon D. NEJM March 25, 2010
• Providing access to information
• Recording and sharing assessments
• Maintaining dynamic patient history
• Maintaining problem lists
• Tracking medications Record
• Tracking tests
• Ensuring coordination and continuity
• Enabling follow-up
• Providing feedback
• Providing placeholder for resumption of work
• Providing access to information sources
• Offering second opinion or consultation
• Increasing efficiency

58. Evidence for handheld electronic medical records
in improving care: a systematic review
Robert C Wu- BMC Medical Informatics and Decision Making 2006
• Handheld electronic medical records may
improve documentation, but as yet, the
number of studies is small and the data is
restricted to one group of patients and a
small group of practitioners. Further study
is required to determine the benefits with
handheld electronic medical records
especially in assessing clinical outcomes.

59. Impact of electronic medical record on physician
practice in office settings: a systematic review
• We examined six areas: prescribing support, disease management, clinical
documentation, work practice, preventive care, and patient-physician
interaction.
• Overall, 22/43 studies (51.2%) and 50/109 individual measures (45.9%)
showed positive impacts, 18.6% studies and 18.3% measures had negative
impacts, while the remaining had no effect.
• Forty-eight distinct factors were identified that influenced EMR success.
Several lessons learned were repeated across studies
(a) having robust EMR features that support clinical use;
(b) redesigning EMR-supported work practices for optimal fit;
(c) demonstrating value for money;
(d) having realistic expectations on implementation; and
(e) engaging patients in the process.
• Conclusions: Currently there is limited positive EMR impact in the physician
office. To improve EMR success one needs to draw on the lessons from
previous studies such as those in this review..

60. The Use of EMRs: Communication Patterns in
Outpatient Encounters
GREGORY MAKOULJ Am Med Inform Assoc. 2001;8:610–615.
• Compared with the control physicians, EMR physicians adopted a more
active role in clarifying information, encouraging questions, and ensuring
completeness at the end of a visit.
• A trend suggested that EMR physicians might be less active than control
physicians in three somewhat more patient-centered areas (outlining the
patient‟s agenda, exploring psychosocial/
• emotional issues, discussing how health problems affect a patient‟s life).
• The relatively fixed position of the computer limited the extent to which EMR
physicians could physically orient themselves toward the patient.
• Initial visits with EMR physicians took an average of 37.5 percent longer
than those with control physicians.
• An EMR system may enhance the ability of physicians to complete
information intensive tasks but can make it more difficult to focus attention
on other aspects of patient communication. Further study involving a
controlled, pre-/post-intervention design is justified.

61. Electronic Discovery and EMRs: Does the Threat of
Litigation affect Firm Decisions to Adopt Technology?
Amalia R. Miller- April 27, 2009- Economics Department, University of Virginia, Charlottesville, VA
• We ask how the threat of litigation affects decisions to adopt
technologies that leave more of an electronic trail, like EMR .
• On the one hand, firms may embrace a technology that allows
them to easily document that their actions were appropriate if they
have to defend them in court.
• On the other hand, firms may fear that the ease of „electronic
discovery‟ may increase their exposure to potentially costly
litigation.
• EMRs allow hospitals to document electronically both patient
symptoms and the health providers‟ reactions to those symptoms.
• We find evidence that hospitals are 33 percent less likely to adopt
electronic medical records if there are state laws that facilitate the
use of electronic records in court.

62. Primary care physicians‟ experiences
with electronic medical records
Dave Ludwick Can Fam Physician 2010;56:40-7
• In order to understand how remuneration and care setting
affected evaluation, selection, implementation, and adoption
of EMRs, family physicians who practiced in urban, hospital,
and academic settings and who were paid through
alternatives to fee-for-service payment models were
interviewed.
• Findings were compared with the finding of previous
interviews with community based family physicians.
• This study suggests that stronger physician professional
networks, more complete training, and in-house technical
support might be more influential than remuneration approach
in facilitating the adoption EMRs.

63. Web-Based Collaborative Care for T2DM
JAMES D. RALSTON- Diabetes Care 32:234–239, 2009
• Trial of 83 adults with type 2 diabetes randomized to receive usual
care plus Web-based care management or usual care alone
• Intervention patients received 12 months of Web-based care
management. The Web-based program included patient access to
electronic medical records, secure e-mail with providers, feedback
on blood glucose readings, an educational Web site, and an
interactive online diary for entering information about exercise, diet,
and medication.
• GHb levels declined by 0.7% (95% CI 0.21.3) on average among
intervention patients compared with usual-care patients. Systolic
blood pressure, diastolic blood pressure, total cholesterol levels, and
use of in-person health care services did not differ between the two
groups

64. Improving Outcomes for High-Risk Diabetics Using
Information Systems
A. John Orzano (J Am Board Fam Med 2007;20:245–251.)
• Use of relatively simple systems to identify and track patient
information can improve diabetic care outcomes. Practices making
investments in an EHR must recognize that this technology alone is
not sufficient for achieving desirable clinical outcomes. Researchers
must explore the interrelationships of organizational factors
necessary for successful information use.

65. How to Promote Meaningful Use of
EMR
• EMR Training Academy
• Incentives
• Web Based EMR
• Fixing the Fields and terminologies
• Coding parameters
• Promote Evidence-based Practice
• Workshops on EMR

66. • 1.3 Maintenance of medical records:
• 1.3.1 Every physician shall maintain the
medical records pertaining to his / her
indoor patients for a period of 3 years from
the date of commencement of the
treatment in a standard proforma laid
down by the Medical Council of India and
attached as Appendix 3.

67. MCI-Professional Conduct, Etiquette
and Ethics Regulations, 2002
• 1.3.2. If any request is made for medical
records either by the patients / authorised
attendant or legal authorities involved, the
same may be duly acknowledged and
documents shall be issued within the
period of 72 hours

68. MCI-Professional Conduct, Etiquette
and Ethics Regulations, 2002
• 1.3.3 A Registered medical practitioner shall
maintain a Register of Medical Certificates giving
full details of certificates issued. When issuing a
medical certificate he / she shall always enter
the identification marks of the patient and keep a
copy of the certificate. He / She shall not omit to
record the signature and/or thumb mark,
address and at least one identification mark of
the patient on the medical certificates or report.
The medical certificate shall be prepared as in
Appendix 2.

69. MCI-Professional Conduct, Etiquette
and Ethics Regulations, 2002
• 1.3.4 Efforts shall be made to computerize
medical records for quick retrieval.

70. Changing Medical Records….. ?

71. Definition
The Institute of Medicine 2003 Patient Safety Report
describes an EMR as encompassing:
– “a longitudinal collection of electronic health
information for and about persons
– Immediate electronic access to person- and
population-level information by authorized users;
– Provision of knowledge and decision-support systems
that enhance the quality, safety, and efficiency of
patient care and
– Support for efficient processes for health care
delivery.”

72. EMR Usage at Present…..
• The total penetration of IT in the Indian
healthcare industry is still very low as compared
to other industries like financial institutions.
• Majority of the physicians (75.8%) are familiar
with EMR function and benefits and only 24.2 %
said that they are unfamiliar with EMR function
and benefits.
• Gender, age, years of experience and
qualification has no association with familiarity of
doctors with EMR function and benefits.
To Analyze The Scope And Acceptance Of Electronic Medical Records Among Doctors In India A Project Of Summer Training
Fozia Afreen Institute Of Management Studies LAL QUAN, GHAZIABAD Batch: 2009-11

73. EMR Usage at Present…..
• Area of practice has a moderately good
association with familiarity of doctors with EMR.
• Majority of physician (95.7%) agree with the
statement that EMR will increase practice
productivity, but on the other hand the majority
(55.3%) disagree with the statement that EMR
usage should be mandated.
• Clinical functions of EMR diagnosis ,medication,
clinical notes and reports were given higher
rating.
To Analyze The Scope And Acceptance Of Electronic Medical Records Among Doctors In India A Project Of Summer Training
Fozia Afreen Institute Of Management Studies LAL QUAN, GHAZIABAD Batch: 2009-11

74. Why we are not changing?
Barriers of EMR Adoption
• Physicians resistance, Too much change involved
• Lack of funding, No reasonable return on investment
• Difficulty in evaluating EMRs
• Lack of staff support, Lack of trained staff
• Concern about amount of self-training needed
• Data/chart conversion
• EMRs do not meet needs
• Lack of IT people to develop EMR
• Security – System break downs, failures

75. EMR Usage at Present…..
• Still very low as compared to other industries like
financial institutions
• Majority of the physicians (75.8%) are familiar with
EMR function and benefits
• Area of practice has a moderately good
association
• Majority (95.7%) agree that EMR will increase
practice productivity
• Majority (55.3%) disagree with the statement that
EMR usage should be mandated.
To Analyze The Scope And Acceptance Of Electronic Medical Records Among Doctors In India A Project Of Summer Training
Fozia Afreen Institute Of Management Studies LAL QUAN, GHAZIABAD Batch: 2009-11

76. Doctors„ Use of EMR Systems in Hospitals:
Cross Sectional Survey
Hallvard Lærum-BMJ 2001;323:1344–8
• Conclusions : Doctors used electronic
medical records systems for far fewer
tasks than the systems supported.

77. EHR and Quality of Diabetes Care
Randall D. et all-NEJM 2011
• From July 2009 through June 2010, data were reported for
27,207 adults with diabetes seen at 46 practices
• After adjustment for covariates, achievement of composite
standards for diabetes care was 35.1 percentage and
composite standards for outcomes was 15.2 percentage
points higher. EHR sites were associated with higher
achievement on eight of nine component standards.
• Across all insurance types, EHR sites were associated with
significantly higher achievement of care and outcome
standards and greater improvement in diabetes care.

78. Benefits of IT- Enabled Diabetes Mgt.
DAVIS BU-Diabetes Care 30:1137–1142, 2007
• All forms of IT-enabled disease management improved the
health of patients with diabetes and reduced health care
expenditures.
• Over 10 years, diabetes registries saved $14.5 billion,
computerized decision support saved $10.7 billion, payer-
centered technologies saved $7.10 billion, remote monitoring
saved $326 million, self-management saved $285 million and
integrated provider-patient systems saved $16.9 billion.
• IT-enabled diabetes management has the potential to improve
care processes, delay diabetes complications, and save
health care dollars.
• These benefits must be weighed against the implementation
costs.

79. The Impact of Planned Care and a
Diabetes Electronic Management System
on Community-Based Diabetes Care
The Mayo Health System Diabetes Translation Project
• Planned care was associated with improvements in
measurement of HbA1c, HDL cholesterol and
microalbuminuria as well as the provision of tobacco advice
• DEMS use was associated with improvements in all
indicators, including microalbuminuria, retinal examination,
foot examinations, and self-management support
• Although planned care was associated with improvements in
metabolic control, we observed no additional metabolic
benefit when providers used DEMS
VICTOR M. MONTORIDiabetes Care 25:1952–1957, 2002

80. Informatics Systems to Promote Improved
Care for Chronic Illness: A Literature Review
DAVID DORR-J Am Med Inform Assoc. 2007;14:156 –163
• 109 articles were reviewed involving 112 information system
descriptions. Chronic diseases targeted included diabetes (42.9% of
reviewed articles), heart disease (36.6%), and mental illness
(23.2%).
• Studies assessed impact of informatics systems on process of care
variables including guideline adherence, visit frequency,
documentation, treatment adherence, referral rate, appropriate
screening/testing, and cost; studies reported mostly positive and
some neutral results.
• The majority of published studies revealed a positive impact of
specific health information technology components on chronic
illness care. Implications for future research and system designs are
discussed.

81. EMR and Diabetes Quality of Care: Results From
a Sample of Family Medicine Practices
Jesse C. Crosson Annals Of Family Medicine May/June 2007
• Diabetes care quality in all practices showed room for
improvement however, after adjustment, patient care in the 37
practices not using an EMR was more likely to meet
guidelines for process (odds ratio [OR], 2.25; 95% confidence
interval [CI], 1.42-3.57) treatment (OR, 1.67; 95% CI, 1.07-
2.60), and intermediate outcomes (OR, 2.68; 95% CI, 1.49-
4.82) than in the 13 practices using an EMR
• The use of an EMR in primary care practices is insufficient for
insuring high-quality diabetes care.
• Efforts to expand EMR use should focus not only on
improving technology but also on developing methods for
implementing and integrating this technology into practice
reality.

82. Typical EHR Use in Primary Care Practices
and the Quality of Diabetes Care
Jesse C. Crosson Ann Fam Med 2012;10:221-227. doi:10.1370/afm.1370.
• EHR use was not associated with better adherence to care guidelines
or a more rapid improvement in adherence. In fact, patients in
practices that did not use an EHR were more likely than those in
practices that used an EHR to meet all of 3 intermediate outcomes
targets for hemoglobin A1c, low density lipoprotein cholesterol, and
blood pressure at the 2-year follow-up (odds ratio = 1.67; 95% CI,
1.12-2.51). Although the quality of care improved across all practices,
rates of improvement did not differ between the 2 groups.
• Consistent use of an EHR over 3 years does not ensure successful
use for improving the quality of diabetes care. Ongoing efforts to
encourage adoption and meaningful use of EHRs in primary care
should focus on ensuring that use succeeds in improving care. These
efforts will need to include provision of assistance to longer-term EHR
users. NOT INCLUDED IN CHART

83. OPD- EHR-Based Diabetes CDS That Works: Lessons
Learned From Implementing Diabetes Wizard
JoAnn M. Sperl-Hillen - Diabetes Spectrum Volume 23, Number 3, 2010
• EHR-based diabetes CDS can lead to measurable
improvement in intermediate outcomes of diabetes care, with
high PCP satisfaction and use beyond an initial period in
which incentives were provided.
• Carefully planned steps are required to maximize use of EHR-
based CDS systems, including communication and
collaboration with leadership and providers, tracking of
utilization rates, and providing feedback and possibly financial
compensation or other incentives for use.
• Significant programming time is required to integrate CDS into
existing EHR systems. Resources are also required for
clinical experts to monitor and update clinical content and for
programmers to implement updates when needed.

84. Impact of EHR Clinical Decision Support on
Diabetes Care: A Randomized Trial
Patrick J. O‟Connor ANNALS OF FAMILY MEDICINE JANUARY/FEBRUARY 2011
• The intervention group diabetes patients had significantly
better hemoglobin A1c (intervention effect –0.26%; 95%
confidence interval, –0.06% to –0.47%; P = .01), and better
maintenance of systolic blood pressure control (80.2% vs
75.1%, P = .03) and borderline better maintenance of diastolic
blood pressure control (85.6% vs 81.7%, P = .07), but not
improved LDL levels (P = .62) than patients of physicians
randomized to the control arm of the study.
• Among intervention group physicians, 94% were satisfied or
very satisfied with the intervention
• EHR-based diabetes clinical decision support significantly
improved glucose control and some aspects of blood pressure
control in adults with type 2 diabetes.

85. Advantages of EMR
• EMR will not permit prescriptions or orders
for drugs for which the patient has a
known allergy.
• The system will alert both provider and
pharmacist of potentially harmful drug–
drug interactions or incompatibilities with
the patient‟s physical or laboratory
findings.

87. Advantages of EMR
• EMR systems automatically generate
patient educational materials tailored to
the patient‟s diagnosis and treatment.
• In professional liability suits against health
care providers the medical record is “The
witness that never dies.” A well
documented, complete, and unambiguous
medical record means a case that is
infinitely easier to defend.

88. Advantages of EMR
• From a legal standpoint, an electronic record
system will produce a legible record.
• The problems of wrong medication, wrong dose,
wrong directions, and wrong procedure caused
by illegible and misinterpreted records will be
eliminated.
• EMRs can be used as a tool for Medical
Education.

89. Advantages of EMR
Source: Partners Health Care experience based on 2500 patients and providers. “Cost and
Benefit Analysis for electronic medical records in primary care.” The American Journal of
Medicine 2003;114:397-403

90. Advantages of EMR
• Properly planned medical record system can
incorporate practice guidelines that are
automatically triggered by a diagnosis or
symptom syndrome.
• Adherence to practice guidelines has been an
effective defense in many malpractice actions.
• Guidelines have also been championed as the
most effective method of eliminating
unnecessary and costly defensive medicine
practices.

91. Hurdles in changing
• Lack of user training.
• Poor initial design of software
• Systems difficult to use or complex
• Dependence on one individual „champion‟.
• Lack of involvement of local staff in design and testing.
• Lack of perceived benefit.
• Lack of back-up systems in the event of computer loss.
• Poor system security leading to viruses and spyware.
• Unstable power supplies and lack of battery back-up.
• Lack of regular technical support
Electronic Medical Records: A Review Comparing the Challenges in Developed and Developing Countries
Sanjay P. Sood- Proceedings of the 41st Hawaii International Conference on System Sciences - 2008

92. Who is entering data?

93. Advantages of EMR
• EMR system can track ordered laboratory,
diagnostic, or imaging tests, alert the
provider of abnormal tests, and even notify
the patient needed
• EMR automatically confirm the date and
times of all entries and keep a dated and
timed log of all individuals who have
accessed the record providing protection
against fraud and abuse.

94. Use of a Large Diabetes EMR System in India:
Clinical and Research Applications
V.Mohan Journal of Diabetes Science and Technology May 2011
• Patients with T2DM had higher prevalence rates of
neuropathy (33.1% vs 13.0%), microalbuminuria (25.5%
vs 20.0%,),coronary artery disease (17.5% vs 9.2%,)
and peripheral vascular disease (3.9% vs 2.8%)
compared with T1DM patients, while prevalence of
diabetic retinopathy was similar (37.9% vs 35.7%).
• .
• The DEMR helps track diabetes care and is a valuable
tool for research.