Are Electronic Medical Records Helpful for Care Coordination? Experiences of Physician Practices
- 2.8k Downloads
Policies promoting widespread adoption of electronic medical records (EMRs) are premised on the hope that they can improve the coordination of care. Yet little is known about whether and how physician practices use current EMRs to facilitate coordination.
We examine whether and how practices use commercial EMRs to support coordination tasks and identify work-arounds practices have created to address new coordination challenges.
Semi-structured telephone interviews in 12 randomly selected communities.
Sixty respondents, including 52 physicians or staff from 26 practices with commercial ambulatory care EMRs in place for at least 2 years, chief medical officers at four EMR vendors, and four national thought leaders.
Six major themes emerged: (1) EMRs facilitate within-office care coordination, chiefly by providing access to data during patient encounters and through electronic messaging; (2) EMRs are less able to support coordination between clinicians and settings, in part due to their design and a lack of standardization of key data elements required for information exchange; (3) managing information overflow from EMRs is a challenge for clinicians; (4) clinicians believe current EMRs cannot adequately capture the medical decision-making process and future care plans to support coordination; (5) realizing EMRs’ potential for facilitating coordination requires evolution of practice operational processes; (6) current fee-for-service reimbursement encourages EMR use for documentation of billable events (office visits, procedures) and not of care coordination (which is not a billable activity).
There is a gap between policy-makers’ expectation of, and clinical practitioners’ experience with, current electronic medical records’ ability to support coordination of care. Policymakers could expand current health information technology policies to support assessment of how well the technology facilitates tasks necessary for coordination. By reforming payment policy to include care coordination, policymakers could encourage the evolution of EMR technology to include capabilities that support coordination, for example, allowing for inter-practice data exchange and multi-provider clinical decision support.
KEY WORDSelectronic medical record coordination of care primary health care quality medical home health information technology data standards
This study was supported by The Commonwealth Fund (grant 20070618). We are grateful to the numerous respondents who generously gave their time for interviews. We also thank the state and local physicians’ societies, the Massachusetts Medical Society and chapters of the American College of Physicians (ACP), the American Academy of Family Physicians (AAFP), the American Society of Clinical Oncologists (ASCO) and the American College of Cardiology (ACC) in the 12 communities for assistance in identifying practices with EMRs. Their input was invaluable. We also thank James E. Ward, Alwyn Cassil, Richard Baron and Peter Basch for their comments on an earlier version of this manuscript, as well as the anonymous reviewers.
Ann O’Malley had full access to all of the data in the study and takes responsibility for the integrity of the data and the accuracy of the data analysis.
Conflicts of interest
- 1.Audet AM, Davis K, Schoenbaum SC. Adoption of patient-centered care practices by physicians. Arch Intern Med. 2006;(166):754–9.Google Scholar
- 2.Smith PC, Araya-Guerra R, Bublitz C, et al. Missing clinical information during primary care visits. JAMA. 2005;(293):565–71.Google Scholar
- 3.Kripalani S, LeFevre F, Phillips CO, Williams MV, Basaviah P, Baker DW. Deficits in communication and information transfer between hospital-based and primary care physicians: implications for patient safety and continuity of care. JAMA. 2007;(297):831–41.Google Scholar
- 4.Cummins RO, Smith RW, Inui TS. Communication failure in primary care: failure of consultants to provide follow-up information, JAMA. 1980;(243):1650–2.Google Scholar
- 7.MedPAC. Care coordination in fee-for-service medicare. Chapter 2 of the report to the congress: increasing the value of medicare, June 2006.Google Scholar
- 8.Health Information Technology for Economic and Clinical Health Act, part of the American Recovery and Reinvestment Act (ARRA) of 2009.Google Scholar
- 9.Shekelle PG, Morton SC, Keeler EB. Costs and Benefits of Health Information Technology. Evidence Report/Technology Assessment No. 132. Prepared by the Southern California Evidence-based Practice Center under Contract No. 290-02-0003. AHRQ Publication No. 06-E006. Rockville, MD: Agency for Healthcare Research and Quality; 2006.Google Scholar
- 10.Glodzweig CL, Towfigh A, Maglione M, Shekelle PG. Costs and benefits of health information technology: new trends from the literature. Health Affairs. 2009; w282–93.Google Scholar
- 11.Hing E, Burt CW. Office-Based Medical Practices: Methods and Estimates from the National Ambulatory Medical Care Survey, Advance Data from Vital and Health Statistics No. 383. Hyattsville, Md: National Center for Health Statistics (NCHS); 2007.Google Scholar
- 12.Starfield B. Primary Care: Balancing Health Needs, Services and Technology. New York: Oxford University Press; 1998.Google Scholar
- 13.McDonald KM, Sundaram V, Bravata DM, et al. Care Coordination. In: Shojania KG, McDonald KM, Wachter RM, Owens DK, eds. Closing the Quality Gap: A Critical Analysis of Quality Improvement Strategies. Technical review No. 9 (Prepared by the Stanford University-UCSF Evidence-based Practice Center under contract 290-02-0017). AHRQ Publication No. 04(07)-0051-7, vol. 7. Rockville, MD: Agency for Healthcare Research and Quality; 2007.Google Scholar
- 14.Stille CJ, Jerant A, Bell D, Meltzer D, Elmore JG. Coordinating care across diseases, settings and clinicians: a key role for generalist in practice. Ann Intern Med. 2005;(142):700–8.Google Scholar
- 16.Miles MB, Huberman AM. Qualitative Data Analysis: An Expanded Sourcebook, 2nd ed. Sage Publications, Inc.;1994 338 pages.Google Scholar
- 17.Strauss AL, Corbin J. Basics of Qualitative Research: Grounded Theory Procedures and Techniques. Newbury Park, CA: Sage; 1990.Google Scholar
- 19.Park T, Basch P. Wedding health information technology to care delivery innovation and provider payment reform. Center for American Progress. Available at, http://www.americanprogress.org/issues/2009/05/pdf/health_it.pdf. Last accessed November 9, 2009.
- 20.Medicare-Medicaid Advanced Primary Care Demonstration Initiative. Description available at http://www.healthreform.gov/newsroom/factsheet/medicalhomes.html. The original Medicare Medical Home Demonstration project description is available at: Center for Medicare and Medicaid, Medical Home Demonstration Project. Available at: http://www.cms.hhs.gov/DemoProjectsEvalRpts/MD/itemdetail.asp?itemID=CMS1199247. Additional information on medical homes is available at http://pcpcc.net/content/pcmh-demonstration-guidelines. Last accessed October 27, 2009.
- 22.Phillips, RL, Klinkman M, Green LA. “Conference Report: Harmonizing Primary Care Clinical Classification and Data Standards.” Washington, DC. (Oct 10–11, 2007).Google Scholar
- 23.CCHIT Certification Commission for Healthcare Information Technology, 2009-1010 Final Criteria for ambulatory care EMRs. May 29, 2009. Available at: http://www.cchit.org/files/certification/09/Ambulatory/CCHITCriteriaAMBULATORY2009-2010Final.pdf.
- 24.Basch P. Electronic health records and the national health information network: affordable, adoptable, and ready for prime time? Ann Intern Med. 2005;(143):227–8.Google Scholar
- 25.Miller RH, West C, Brown TM, Sim I, Ganchoff C. The value of electronic health records in solo or small group practices. Health Aff (Millwood). 2005;(5):1127–37.Google Scholar
- 27.Markle Foundation. “Achieving the Health IT Objectives of the American Recovery and Reinvestment Act: A Framework for ‘Meaningful Use’ and ‘Certified or Qualified’ EHR. Available at: http://www.markle.org/downloadable_assets/20090430_meaningful_use.pdf. Last accessed November 9, 2009.
- 28.Commonwealth Fund Grant #2009-0102 to the Johns Hopkins University, NCQA and Park Nicollet Institute, The development and testing of EHR-based care coordination performance measures in ambulatory care.Google Scholar
- 29.Institute for Healthcare Improvement. “Create and Implement Service Agreements Between Primary Care and Specialty Care, and with Diagnostic Entities.” Available at: http://www.ihi.org/IHI/Topics/OfficePractices/Access/Changes/IndividualChanges/CreateandImplementServiceAgreementsBetweenPrimaryCareandSpecialtyCareandwithDiagnosticEntities.htm. Last accessed November 9, 2009.
- 30.O’Malley AS, Tynan A, Cohen GR, Kemper N, Davis MM. “Coordination of Care by Primary Care Practices: Strategies, Lessons and Implications.” Center for Studying Health System Change Research Brief, No. 12, April 2009. Available at http://www.hschange.org/CONTENT/1058/. Last accessed November 9, 2009.
- 31.Walker J, Pan E, Johnston D, Adler-Milstein J, Bates DW, Middleton B. The value of health care information exchange and interoperability. Health Aff (Millwood). 2005 Jan-Jun; Suppl Web Exclusives:W5-10-W5-18.Google Scholar
- 32.Baron RJ, Fabens EL, Schiffman M, Wolf E. Electronic health records: just around the corner? Or over the cliff? Ann Intern Med. 2005;(143):222–6.Google Scholar
- 33.Health Information Technology Extension Program. Description available at http://healthit.hhs.gov/portal/server.pt?open=512&objID=1335&mode=2&cached=true, last accessed November 9, 2009.
- 34.Joint Principles of the Patient-Centered Medical Home. Available at: http://www.medicalhomeinfo.org/joint%20Statement.pdf. Last accessed November 9, 2009.
- 35.National Committee for Quality Assurance (NCQA), Physician Practice Connections-Patient Centered Medical Home (PPC-PCMH), 2008, http://www.ncqa.org/tabid/631/Default.aspx. Last accessed November 9, 2009.
- 36.Moore G. Five Provocative Points about Bringing the Benefits of Information Technology to Health Care. A Discussion Paper. November 22, 2005. Available at http://www.rwjf.org/files/research/gtmooreinfotech112005.pdf. Last Accessed June 9, 2009.