Health care experts say care coordination is an important component of good patient care, and most family physicians would agree. But the ability to achieve meaningful levels of communication depends on a consistent flow of health information among physicians, patients and other health care professionals involved in a patient's care.
Electronic health records (EHRs) and other forms of health information technology would seem to be logical and efficient choices for passing along that information, but authors of an article(annfammed.org) titled "Health IT-Enabled Care Coordination: A National Survey of Patient-Centered Medical Home Clinicians" highlighted a gap between current health IT capabilities and clinicians' priorities.
The research was published in the May/June issue of Annals of Family Medicine.
Corresponding author Suzanne Morton, M.P.H., M.B.A., senior health care analyst for the National Committee for Quality Assurance (NCQA) told AAFP News that NCQA was keenly interested in learning more about care coordination and the use of health IT to support it.
Ditto for the Agency for Healthcare Research and Quality (AHRQ).
"Care coordination is a cornerstone of the patient-centered medical home (PCMH), for which NCQA has a recognition program," said Morton.
- New research published in the Annals of Family Medicine explores inconsistencies in the use of health information technology to facilitate care-coordination activities.
- Researchers found that care-coordination activities most commonly implemented by practices that participated in the survey were not the ones with the greatest degree of health IT support.
- Physicians ranked lack of time and money at the top of the list of barriers that impede their ability to coordinate patient care.
For its part, the AHRQ seeks to inform direction for the federal EHR incentive programs and specifically needs information about primary care practices' readiness for care-coordination objectives proposed for meaningful use stage three.
"So NCQA, in partnership with AAFP's National Research Network and the New York City Department of Health and Mental Hygiene, applied for and received a grant to do both quantitative and qualitative research about this topic. This paper covers the survey portion of our study," said Morton.
Research Project Design
From January to July 2014, researchers surveyed nearly 1,000 practices, including 275 community health centers (CHCs), 284 practices owned by health systems, 247 small physician-owned practices and 191 large physician-owned practices. Ultimately, 350 participated in the study.
Participants came from diverse geographic areas in 41 states, and most of their practices had achieved level-three PCMH recognition. According to the authors, about one-third of clinicians were very concerned about the financial health of their practices. More than 76 percent had received assistance to improve care coordination, and more than 58 percent employed a nonclinician to oversee care coordination.
"The care-coordination activities most routinely implemented were not the ones with greatest degree of health IT support," said the authors. For instance, they noted that practices' use of health IT to achieve individual care-coordination activities ranged from 38.8 percent for identifying patients who'd had an ER visit to 76.6 percent for providing clinical summaries to patients.
"Importantly, the use of computerized systems for supporting care coordination was not consistent with clinicians' priorities," said the authors. Clinicians gave the highest importance ratings to timely electronic notification of hospital discharges (77.5 percent) and patient deaths (77.3 percent), but these activities were least likely to be support electronically.
"Conversely, clinical summaries were frequently generated by a computerized system but not highly valued by clinicians," the authors noted.
Least-valued objectives included specialist acknowledgement of patient information (about 33 percent) and real-time patient dashboards (about 40 percent).
Barriers that impeded physicians' ability to coordinate patient care included time (nearly 40 percent rated the time element as a major barrier), money and other resources (about 35 percent), and health IT or EHR systems (about 32 percent).
Regarding routine performance of care-coordination activities and the routine use of health IT to conduct those activities:
- 81.4 percent of practices provided patients with clinical summaries of their visits; 76.6 percent routinely used health IT to do so;
- 92.3 percent sent referral requests to other clinicians; 68.6 percent used health IT;
- 69.4 percent provided a comprehensive medical summary for each site transition or referral; 45.4 percent used health IT;
- 90.0 percent responded to requests for additional information from a clinician receiving a referral; 54.0 percent used health IT;
- 74.3 percent provided reminders for guideline-based interventions or screening tests to clinicians at the point of care; 64.9 percent used health IT;
- 63.1 percent identified patients who'd been to the ER; 39.4 used health IT; and
- 75.4 percent identified patients admitted to or discharged from the hospital; 48. 9 used health IT.
Additional Author Comments
Corresponding author Morton provided further insight into the study findings in response to questions from AAFP News. Highlights of that discussion follow:
Q. Were you surprised by any of the research findings?
A. Even among more advanced PCMH practices, there was only moderate health IT support for many of the care-coordination activities such as tracking referrals and identifying hospital and emergency room discharges. We were also surprised that some of the activities for which clinicians considered it very important to have health IT support -- such as identifying hospital discharges and seeing reports that come back from specialists -- currently had the least health IT support. Conversely, providing clinical summaries for patients, which had high electronic support, was seen as less important to clinicians.
Q. Why should this research be of interest to family physicians?
A. The stage three meaningful use (MU) requirements for care coordination may be challenging for family physician practices to perform given the current state of health IT use in primary care practices. Many practices will need to make major changes to their workflows and EHR systems to meet these objectives. We are sharing this information with policymakers and other stakeholders to make it clear that practices need resources, time and technical assistance to put into place the workflows and staffing arrangements that are needed to achieve the MU program requirements.
Q. What's the most important takeaway in terms of practices using health IT to facilitate care coordination?
A. There is only moderate use of health IT for many types of care-coordination activities, especially those aspects requiring interaction among non-affiliated practices and facilities. Practices may need financial and/or technical support to increase the use of health IT for care coordination.
Q. What would you like to see policymakers do with this information?
A. In our study, time and money/other resources were the greatest barriers to coordinating patient care with other practices or facilities. Our companion site observation study of practices (2015 unpublished data) showed the fax as the most important tool for information-sharing. Technical and financial assistance should be offered to practices to facilitate interoperability and the uptake of health IT for care-coordination needs. Reimbursement approaches that support nonvisit-based care can assist practices in meeting these challenging care-coordination objectives. The new Medicare initiatives, such as reimbursement for chronic care management services and a value-based payment modifier, are a step in this direction, but more assistance will likely be needed.
Q. In what direction should future research go?
A. More research is needed into how/whether different types of financial and technical assistance programs can improve the use of health IT for care coordination. It would also be helpful to know the degree to which patients are informed of the results of care-coordination efforts (i.e., is the primary care provider having a conversation with the patient about the results of the specialist report or the hospital visit?).
Related AAFP News Coverage
Meaningful Use Stage Three
AAFP Demands Physician-Friendly MU Rules