Chen C et al. 2009 "The Kaiser Permanente Electronic Health Record: transforming and streamlining modalities of care."

Chen C, Garrido T, Chock D, et al. The Kaiser Permanente electronic health record: transforming and streamlining modalities of care. Health Aff 2009;28(2):323-333.
"We examined the impact of implementing a comprehensive electronic health record (EHR) system on ambulatory care use in an integrated health care delivery system with more than 225,000 members. Between 2004 and 2007, the annual age/sex-adjusted total office visit rate decreased 26.2 percent, the adjusted primary care office visit rate decreased 25.3 percent, and the adjusted specialty care office visit rate decreased 21.5 percent. Scheduled telephone visits increased more than eightfold, and secure e-mail messaging, which began in late 2005, increased nearly sixfold by 2007. Introducing an EHR creates operational efficiencies by offering nontraditional, patient-centered ways of providing care."
To examine the impact of EHR implementation "on several types of ambulatory care patient contacts: outpatient, urgent care, and emergency department (ED) visits; external referrals; scheduled telephone visits; and secure patient-physician e-mail messaging."
Type Clinic
Primary care and specialty care
Urban, suburban, and rural
Other Information
Kaiser Permanente's Hawaii region has 250,000 patient members.
Type of Health IT
Electronic health records (EHR)
Type of Health IT Functions
"The program is a comprehensive health information system with numerous functionalities, including (1) an EHR with comprehensive documentation across care settings -- inpatient and outpatient -- clinical decision support, and complete, real-time connectivity to lab, pharmacy, radiology, and other ancillary systems;
(2) secure patient-provider messaging available through a member Web site that also provides personal health records; [and] (3) electronic inter-provider messaging about care that is automatically incorporated into patients' records."
Context or other IT in place
"At the time of [the] implementation, a third of care sites had had full...functionality [of another EHR] for just over two years; the rest had [had] read-only access."
Workflow-Related Findings
"Age/sex-adjusted total office visits per member decreased 26.2 percent between 2004 and 2007 (p < 0.001)."
"Total scheduled telephone visits per member increased nearly ninefold."
After the implementation of secure messaging, "in the remaining months of 2005, members initiated more than 3,000 secure e-mail messages, a rate of 0.03 secure messages per member. In 2006, members sent nearly 25,000 messages (0.11 per member). In 2007, they sent more than 51,000 messages (0.23 per member). The increase between 2005 and 2007 was statistically significant (p < 0.001)."
"In 2004, 78 percent of KP Hawaii members rated the level of interest and attention of their health care providers at 8 or above; in 2007, 79 percent did so."
"The 26.2 percent reduction in office visits indicates greater efficiency of care with an integrated EHR. With complete patient data available, unnecessary and marginally productive office visits are reduced or replaced with telephone visits and secure e-mail messaging supported by easy access to patients' medical records. For example, doctors reported that the EHR enabled them to resolve patients' health issues in the first contact or with fewer contacts."
Study Design
Only postintervention (no control group)
Study Participants
All clinics in the Kaiser Permanente Hawaii region participated.