Care Coordination and Electronic Health Records

AcademyHealth Annual Research Meeting June 9, 2008

Connecting the Medical Home with the Rest of the Village

Study Team

Ilana GraetzMary Reed, DrPHJie Huang, PhDRichard Brand, PhDThomas Rundall, PhDJohn Hsu, MD, MBA, MSCE

Kaiser Permanente - Center for Health Policy Studies and the Division of ResearchUniversity of California, Berkeley, CAUniversity of California, San Francisco, CA

Funding Support: Agency for Health Care Research and QualityNo other relevant financial relationships to disclose

Background

• The number of patients with complex care needs is large and growing– Require coordination between multiple clinicians – High risk for problems during transitions– Primary care clinicians coordinate care

• Use of an Electronic Health Records (EHR) system could provide a mechanism to share information and coordinate care

Objective

To examine the impact of EHR use on 3 key elements of care coordination:

• Timely and complete information transfer • Agreement on treatment goals and plans • Agreement on roles and responsibilities

Methods: Survey Design

• Data collected in 2005 and 2006• Setting

– Kaiser Permanente-Northern California

– Large, prepaid integrated delivery system (IDS)

– 18 Medical Centers & 110 Primary Care Teams

• Population: Adult Primary Care Clinicians • Response rates

– 48.1% (N=565) in 2005 – 61.5% (N=678) in 2006

Study Timeline

2005 2006

Pre-EHR• Four separate Health IT applications • Paper medical charts

Survey #1

Pre-EHR: 92.9%

Post EHR < 6 months: 5.5% ≥ 6 months: 1.6%

Survey #2

Pre-EHR: 38.1%

Post EHR < 6 months: 29.7% ≥ 6 months: 32.3%

Post-EHR• 3-year staggered implementation by medical center and team• Commercially available, integrated EHR• EHR replaces paper-medical charts

Med

ical C

ente

rs (1

-18)

& P

rimar

y Ca

re T

eam

s (1

-110

)

Survey items: Coordination of Care

• How often do the following occur when care is transferred across clinicians (e.g. from a specialist to the primary care team): – All relevant medical information is available when

care is transferred across clinicians – The information transfer is timely, i.e. available when

it is needed for care transferred across clinicians – All clinicians agree on the treatment goals and plans

when care is transferred across clinicians – All clinicians agree on roles and responsibilities of

each party when care is transferred across clinicians

• Response categories: [never, rarely, sometimes] & [usually and always]

Analysis

• Model: Generalized estimating equation (GEE)• Dependent variable:

– Timely and complete information transfer– Agreement on treatment goals and plans– Agreement on roles and responsibilities

• Independent variable: – EHR-Status: based on ≥ 80% of visits by team done with EHR

• Covariates:– Systematic Health IT use: use of Health IT for charting, data-

review, and communication for ≥ 80% of visits – PCP panel size, self-reported hours worked per week– Age, gender, race/ethnicity, job title– Year survey collected (2005 vs. 2006)– Medical center dummies

  (N=847)Age: < 40 39.8%

41-50 31.3%51+ 28.9%

Gender: Female 53.3%Male 46.8%

Race/Ethnicity: White 54.4% Non-white 45.5%Job Title: MD/DO 88.1%

NP/PA 11.9%Panel Size: ≤ 1000 20.3%

1001-1500 25.3%1501-2000 30.0%> 2000 22.8%

Hours worked per week: < 40 hrs 38.8%40 hrs and over 45.8%

Respondent characteristics

847 individual clinicians completed the survey in either year of data collection; of those 396 completed the survey in both 2005 & 2006; total of 1,243 surveys completed. For clinicians who completed the survey in both years, 2006 responses used for this table. Percentage of missing responses omitted from the table.

Unadjusted clinician reported coordination of care by EHR-status

Figure displays the percentage of respondents who reported that the coordination outcome always or usually occurs when patient care is transferred across clinicians. Error bars represent 95% confidence interval. Excludes missing (<5%).

67%

72%

62%

55%

61%

55%

41%

57%

49%

0% 25% 50% 75% 100%

All clinicians agreeon roles &

responsibilities

All clinicians agreeon treatmentgoals & plans

Timely & completeinformation

transfer

Percent of Respondents

Pre-EHR

<6 months post-EHR

≥6 months post-EHR

Multivariate results

Model used: GEE model, adjusted for clinician age, race, gender, job title, panel size, survey year, level of Health IT use, and includes medical center fixed effects.

Coordination of Care and EHR (Pre- EHR: comparison group)

1.3

2.7

1.1

1.9

1.01.2

0

1

2

3

4

5

< 6 months ≥ 6 months < 6 months ≥ 6 months < 6 months ≥ 6 months

Timely & complete informationtransfer

Agreement on treatment goals &plans

Agreement on roles &responsibilities

Post-EHR

Od

ds

Rat

io

Limitations

• All data collected from a single, integrated delivery system

• Self-reported outcome data

• Modest response rates

Conclusion

• Clinicians who used the EHR for 6+ months were more likely report:

• Timely and complete information transfer• Agreement on treatment goals and plans

– No significant changes to agreement on roles and responsibilities

• Use of the EHR for < 6 months not associated with significant differences in any elements of care coordination

Implications

• EHR is important for coordinating care

• Improvements may continue to increase with time and widespread use

• Studies should examine whether improvement in coordination of care results in improved quality of care

Thank You

3 Elements of Care Coordination:

• Goal Agreement: all care activities aimed at achieving the patient’s goals

• Roles Agreement: each participant has adequate knowledge of their own and other’s roles and responsibilities

• Information exchange: Patient information such as consultation reports, progress notes, test results, and current medications are available to all team members caring for a patient at the point of care

Closing the Quality Gap: A Critical Analysis of Quality ImprovementStrategies: Volume 7- Care Coordination, June 2007