Care Coordination - Enabled by Health IT

The AAFP NRN, in collaboration with the National Committee for Quality Assurance (NCQA), conducted 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 tested 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 was conducted from October 2013 through June 2014.


This study is closed.

Key Findings and Publications

Even among practices having a strong commitment to the medical home model, the use of health IT to support care coordination objectives is not consistent. Health IT capabilities are not currently aligned with clinicians’ priorities. Many practices will need financial and technical assistance for health IT to enhance care coordination.

Access the complete manuscript(s):

Health IT–Enabled Care Coordination: A National Survey of Patient-Centered Medical Home Clinicians(250 page PDF). Morton S, Shih SC, Winther CH, Tinoco A, Kessler RS, Scholle, SH. AnnFamMed. 2015 May;13(3):250-6.

Access AHRQ Sponsored Webinar:

Drs. Sarah Scholle (NCQA) and Kim Kimminau (AAFP NRN) discuss the results from the “Care Coordination Enabled by Health IT: What Will It Take?” study. This AHRQ recorded webinar presents research findings on the feasibility of select Centers for Medicare and Medicaid Services (CMS) proposed Meaningful Use Stage III objectives related to clinical decision support, care coordination, and the use of EHRs in pediatric primary care settings.

Webinar Slides (carecoordination_ahrqpbrnwebinar_finalslides.pdf(83 page PDF))

Watch the fully recorded webinar on the AHRQ PBRN YouTube channel.(

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
Research Communications Manager
AAFP National Research Network
1-800-274-2237, x3178

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