Care Coordination and Electronic Health Records

1. Care Coordination and Electronic Health Records Connecting the Medical Home with the Rest of the Village AcademyHealth Annual Research Meeting June 9, 2008

2. Study Team Ilana Graetz Mary Reed, DrPH Jie Huang, PhD Richard Brand, PhD Thomas Rundall, PhD John Hsu, MD, MBA, MSCE Kaiser Permanente - Center for Health Policy Studies and the Division of Research University of California, Berkeley, CA University of California, San Francisco, CA Funding Support: Agency for Health Care Research and Quality No other relevant financial relationships to disclose

3. 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

4. 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

5. 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

6. Study Timeline • Pre-EHR • Four separate Health IT applications • Paper medical charts Survey #1 Pre-EHR: 92.9% Survey #2 Pre-EHR: 38.1% • Post-EHR • 3-year staggered implementation • by medical center and team • Commercially available, integrated EHR • EHR replaces paper-medical charts Medical Centers (1-18) & Primary Care Teams (1-110) Post EHR < 6 months: 29.7% ≥ 6 months: 32.3% Post EHR < 6 months: 5.5% ≥ 6 months: 1.6%

7. 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 informationis 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]

8. 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

9. 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.

10. 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%).

11. 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.

12. Limitations • All data collected from a single, integrated delivery system • Self-reported outcome data • Modest response rates

13. 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

14. 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

15. Thank You

16. 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 Improvement Strategies: Volume 7- Care Coordination, June 2007