Care Coordination - Enabled by Health IT

The AAFP NRN, in collaboration with the National Committee for Quality Assurance (NCQA), is conducting a research study better understand the feasibility and perceived value of electronic health record (EHR) system functions that support care coordination.

Study Description and Methods

The deployment of health information technology (IT) promises to eliminate the fragmentation of information that leads to delays and redundancies in care and to support new team-based models of care. The proposed objectives for Meaningful Use (MU) Stage 3 of the Centers for Medicare and Medicaid Services (CMS) EHR Incentive Program provide a blueprint for sharing information to allow more coordinated, patient-centered care. However, our work to date has identified numerous barriers to implementation of these objectives and achieving health IT-enabled care coordination.

This project will test the feasibility of using EHR technology to support and assess the performance of selected care coordination activities in actual clinical settings, and to identify ways to overcome existing barriers to its successful implementation. We will use the results of this project to provide clear guidance to the federal government on feasibility of proposed MU objectives and how to measure their achievement by providers in ambulatory care settings. At the end of this 12-month project, we will have developed and disseminated 1) recommendations for any revisions to definition of the target MU objectives and to the proposed measures, 2) recommendations for changes in EHR certification criteria, and 3) example of successful workflows and information on barriers to implementation.

Specific Aims and Objectives

  1. To what extent are the EHR functionality and clinical workflows envisioned by stage 3 Meaningful Use objectives for care coordination feasible in diverse settings today?
  2. What factors are associated with implementation of EHR functionality and clinical workflows for care coordination?
  3. How can each of these objectives be measured and reported?
  4. What potential outcomes related to care coordination could be linked using a health IT platform?


This study will be conducted from October 2013 through June 2014.


We are currently recruiting practices for site visits who have at least one clinician who has achieved Meaningful Use stage 1 objectives.

Ideal practices would have a high interest in, and the capacity to use, EHRs and Heath IT for Care Coordination activities, such as electronic data sharing and active tracking of referrals, may participate in the site visits.

Site visits include:

  • Allowing two research team members to visit your practice and observe the workflow and clinical process at the practice.
  • Provide the research study team with aggregate data reports from your EHR data related to proposed Stage 3 Meaningful Use care coordination objects.
  • Participate in one pre-visit phone call to prepare for the visit and one post-visit follow up call to answer any outstanding questions and to conduct a formal interview with the lead physician.

Site visits will be conducted through April 2014. Selected practices will be compensated $1,250 for participation in all project activities.

To participate please contact Mindy Spano or 800-274-2237 ext. 3178.

Contact Information

For additional information about this study, please contact:

Kim Kimminau, PhD
Research Director
AAFP National Research Network
1-800-274-2237, x3184

Mindy Spano
Project Coordinator for AAFP NRN activities
AAFP National Research Network
1-800-274-2237, x3178

Key Findings and Publications

Please check back soon for research results and key findings.

*This study was funded by the Agency for Healthcare Quality and Research (AHRQ)