Promises and pitfalls of electronic health record analysis

Routinely collected electronic health records (EHRs) are increasingly used for research. With their use comes the opportunity for large-scale, high-quality studies that can address questions not easily answered by randomised clinical trials or classical cohort studies involving bespoke data collection. However, the use of EHRs generates challenges in terms of ensuring methodological rigour, a potential problem when studying complex chronic diseases such as diabetes. This review describes the promises and potential of EHRs in the context of diabetes research and outlines key areas for caution with examples. We consider the difficulties in identifying and classifying diabetes patients, in distinguishing between prevalent and incident cases and in dealing with the complexities of diabetes progression and treatment. We also discuss the dangers of introducing time-related biases and describe the problems of inconsistent data recording, missing data and confounding. Throughout, we provide practical recommendations for good practice in conducting EHR studies and interpreting their results.