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Aims: To describe physicians' acceptance of decision‐support electronic health record system and its impact on diabetes care goals among people with Type 2 diabetes. Methods: We analysed data from participants in the Centre for Cardiometabolic Risk Reduction in South Asia (CARRS) trial, who received the study intervention (care coordinators and use of a decision‐support electronic health record system; n=575) using generalized estimating equations to estimate the association between acceptance/rejection of decision‐support system prompts and outcomes (mean changes in HbA1c, blood pressure and LDL cholesterol) considering repeated measures across all time points available. We conducted in‐depth interviews with physicians to understand the benefits, challenges and value of the decision‐support electronic health record system and analysed physicians' interviews using Rogers' diffusion of innovation theory. Results: At end‐of‐trial, participants with diabetes for whom glycaemic, systolic blood pressure, diastolic blood pressure and LDL cholesterol decision‐support electronic health record prompts were accepted vs rejected, experienced no reduction in HbA1c [mean difference: –0.05 mmol/mol (95% CI –0.22, 0.13); P=0.599], but statistically significant improvements were observed for systolic blood pressure [mean difference: –11.6 mmHg (95% CI –13.9, –9.3); P ≤ 0.001], diastolic blood pressure [mean difference: –5.2 mmHg (95% CI –6.5, –3.8); P ≤ 0.001] and LDL cholesterol [mean difference: –0.7 mmol/l (95% CI –0.6, –0.8); P ≤0.001], respectively. The relative advantages and compatibility of the decision‐support electronic health record system with existing clinic set‐ups influenced physicians' acceptance of it. Software complexities and data entry challenges could be overcome by task‐sharing. Conclusion: Wider adherence to decision‐support electronic health record prompts could potentially improve diabetes goal achievement, particularly when accompanied by assistance from a non‐physician health worker. What's new?: This is the first study to quantify the impact of physicians' acceptance of decision‐support electronic health records (DS‐EHR) on diabetes care goals in South Asia using a mixed‐methods evaluation.The study shows that physicians' adherence to DS‐EHR prompts with regard to diabetes management was associated with significantly large improvements in blood pressure and LDL cholesterol levels and small reductions in HbA1c levels.The study results provide perspectives from busy healthcare providers in South Asia on the relative benefits, challenges and value of DS‐EHR, which has implications for wider adoption and scale‐up of this intervention. [ABSTRACT FROM AUTHOR]