Electronic Health Record Use and Care Coordination (California)

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Summary:

While electronic health record (EHR) systems have been consistently promoted as a policy priority for improving the quality and efficiency of the United States health care system, there is limited research evidence to inform policymakers about the effects of EHR use on care coordination. This study examined the association between EHR use and care coordination and clinical care quality for patients with diabetes, and how team working relationships modify these effects. This study was conducted in Kaiser Permanente Northern California (KPNC), a large, prepaid integrated delivery system providing comprehensive medical care for over three million members, including outpatient, inpatient, emergency department, pharmacy, and laboratory services.

For this AHRQ-funded dissertation project, Dr. Graetz examined the association between EHR use and care coordination, while adjusting for clinician characteristics and organizational factors and whether the association between EHR use and care coordination varies by team climate. Measures of care coordination and team climate were captured using existing self-administered survey responses collected from primary care clinicians in 2005, 2006, and 2008 during the staggered implementation of the EHR system. Quality and clinical outcome measures were captured using the health system’s automated databases. They included guideline-adherent prescription drug use and laboratory monitoring, and physiologic disease control for diabetes patients receiving care from multiple clinicians.

The specific aims of the project were to:

  • Examine the association between EHR use and care coordination among teams with positive and negative reports of team climate, while adjusting for patient, physician, team, and medical center characteristics.
  • Examine the association between care coordination and clinical care quality for patients receiving care from multiple clinicians.

Use of an outpatient and an integrated outpatient and inpatient EHR was associated with improvements in care coordination across clinicians and delivery sites respectively. Use of the outpatient EHR was associated with improvements in glycemic and lipid control for patients with diabetes. There was a statistically significant interaction effect between team cohesion and EHR use on clinical outcomes for patients with diabetes and care coordination. Patients cared for by clinicians working in primary care teams with high cohesion had substantially better patient outcomes with the EHR compared with patients care for by teams with low cohesion. Patients cared for by clinicians working in primary care teams with higher cohesion experienced a 0.11 percentage point decrease in hemoglobin A1c (HbA1c) and a 2.15 mg/dL reduction in low density lipoprotein cholesterol (LDL-C) with use of the EHR compared to a 0.08 percentage point decrease in HbA1c and 1.42 mg/dL reduction in LDL-C with the EHR for patients cared for by clinicians working in primary care teams with lower cohesion. The organizational context, in particular primary care team members’ working relationships, is critical to maximize potential gains from EHR use.

Electronic Health Record Use and Care Coordination - 2012

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    PAR: HS09-212: AHRQ Grants for Health Services Research Dissertation Program (R36)
  • Grant Number: 
    R36 HS 021082
  • Project Period: 
    September 2011 – December 2012
  • AHRQ Funding Amount: 
    $41,276
  • PDF Version: 
    (PDF, 189.92 KB)

Summary: While electronic health record (EHR) systems have been consistently promoted as a policy priority for improving the quality and efficiency of the United States health care system, there is limited research evidence to inform policymakers about the effects of EHR use on care coordination. This study examined the association between EHR use and care coordination and clinical care quality for patients with diabetes, and how team working relationships modify these effects. This study was conducted in Kaiser Permanente Northern California (KPNC), a large, prepaid integrated delivery system providing comprehensive medical care for more than three million members, including outpatient, inpatient, emergency department, pharmacy, and laboratory services.

Researchers examined the association between EHR use and care coordination, while adjusting for clinician characteristics and organizational factors and whether the association between EHR use and care coordination varies by team climate. Measures of care coordination and team climate were captured using existing self-administered survey responses collected from primary care clinicians in 2005, 2006, and 2008 during the staggered implementation of the EHR system. Quality and clinical outcome measures were captured using the health system’s automated databases. They included guideline-adherent prescription drug use and laboratory monitoring, and physiologic disease control for diabetes patients receiving care from multiple clinicians.

Specific Aims:

  • Examine the association between EHR use and care coordination among teams with positive and negative reports of team climate, while adjusting for patient, physician, team, and medical center characteristics. (Achieved)
  • Examine the association between care coordination and clinical care quality for patients receiving care from multiple clinicians. (Achieved)

2012 Activities: Dr. Graetz obtained and analyzed data for both aims and drafted and submitted manuscripts to her dissertation committee for review. Abstracts were submitted to the American Public Health Association conference, the American Medical Informatics Association annual symposium, and the AcademyHealth annual research meeting. She submitted a manuscript of her findings to the Health Services Research Journal. Dr. Graetz used a 4-month no-cost extension to conduct the final analysis and prepare a manuscript. The project ended in December 2012.

Impact and Findings: Use of an outpatient and an integrated outpatient and inpatient EHR was associated with improvements in care coordination across clinicians and delivery sites respectively. Use of the outpatient EHR was associated with improvements in glycemic and lipid control for patients with diabetes. There was a statistically significant interaction effect between team cohesion and EHR use on clinical outcomes for patients with diabetes and care coordination. Patients cared for by clinicians working in primary care teams with high cohesion had substantially better patient outcomes with the EHR compared with patients cared for by teams with low cohesion. Patients cared for by clinicians working in primary care teams with higher cohesion experienced a 0.11 percentage point decrease in hemoglobin A1c (HbA1c) and a 2.15 mg/dL reduction in low-density lipoprotein cholesterol (LDL-C) with use of the EHR, compared to a 0.08 percentage point decrease in HbA1c and 1.42 mg/dL reduction in LDL-C with the EHR for patients cared for by clinicians working in primary care teams with lower cohesion. The organizational context, in particular primary care team members’ working relationships, is critical to maximize potential gains from EHR use.

Target Population: Adults, Chronic Care*, Diabetes

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patient-centered care, the coordination of care across transitions and the electronic exchange of health information to improve quality of care.

Business Goal: Knowledge Creation

* This target population is one of AHRQ’s priority populations.

EHR Use and Care Coordination - 2011

Summary Highlights

  • Principal Investigator: 
  • Funding Mechanism: 
    PAR: HS09-212: AHRQ Grants for Health Services Research Dissertation Program (R36)
  • Grant Number: 
    R36 HS 021082
  • Project Period: 
    September 2011 - August 2012
  • AHRQ Funding Amount: 
    $41,276
  • PDF Version: 
    (PDF, 204.12 KB)

Summary: While electronic health record (EHR) systems have been consistently promoted as a policy priority for improving the quality and efficiency of the U.S. health care system, there is limited research evidence to inform policymakers about the effects of EHR use on care coordination. This study is using a quasi-experimental design with concurrent controls to evaluate the impact of outpatient physician use of a newly-implemented, certified EHR system at Kaiser Permanente Northern California (KPNC) on measures of care coordination and, in turn, the association between care coordination and care quality for patients receiving care from multiple clinicians. The study includes 110 primary care teams in 18 medical centers within the KPNC delivery system, which served more than 2 million adult patients 18-years-and-older between the years 2005 and 2008.

Researchers are examining the association between EHR use and care coordination, while adjusting for clinician characteristics and organizational factors. They are further examining whether the association between EHR use and care coordination varies by team climate. Measures of care coordination and team climate are being captured using existing self-administered survey responses collected from primary care clinicians in 2005, 2006, and 2008 during the staggered implementation of the EHR system. Quality and clinical outcome measures are captured using the health system's automated databases. They include guideline-adherent prescription drug use and laboratory monitoring, and physiologic disease control for diabetes patients receiving care from multiple clinicians.

This study uses existing data, including survey responses that capture detailed measures of clinician-reported care coordination and team climate at multiple points in time, as well as substantial data resources from the study setting. The staggered nature of the EHR implementation allows for adjustment of secular changes. The outcomes of this study will provide evidence of the impact of EHR use on care coordination and quality improvement. In the current clinical environment, where care provided to patients is increasingly fragmented and complex, effective care coordination is essential. The EHR offers new opportunities for improving overall quality of care, preventing medical errors, and reducing health care costs.

The principal investigator (PI) is researching the impact of EHR use on care coordination and clinical quality for patients with complex health care needs for her dissertation. For the last 7 years, she has been working with Kaiser Permanente on a long-term study to examine the impact of new health IT on clinical care. She completed preliminary analyses based upon the data sources used in this study and will build upon this work and her experience as a doctoral candidate in University of California Berkeley's Health Services.

Specific Aims:

  • Examine the association between EHR use and care coordination among teams with positive and negative reports of team climate, while adjusting for patient, physician, team, and medical center characteristics. (Ongoing)
  • Examine the association between care coordination and clinical care quality for patients receiving care from multiple clinicians. (Ongoing)

2011 Activities: The project focused on analysis of data sets obtained from Kaiser Permanente to examine the relation of EHR use and process and outcome measures such as test intervals and HgA1c levels respectively.

Preliminary Impact and Findings: This project has no findings to date.

Target Population: Adults, Diabetes*

Strategic Goal: Develop and disseminate health IT evidence and evidence-based tools to support patientcentered care, the coordination of care across transitions and the electronic exchange of health information to improve quality of care.

Business Goal: Knowledge Creation

* This target population is one of AHRQ's priority populations.

Electronic Health Record Use and Care Coordination - Final Report

Citation:
Graetz I. Electronic Health Record Use and Care Coordination - Final Report. (Prepared by the University of California, Berkeley under Grant No. R36 HS021082). Rockville, MD: Agency for Healthcare Research and Quality, 2012. (PDF, 126.73 KB)

The findings and conclusions in this document are those of the author(s), who are responsible for its content, and do not necessarily represent the views of AHRQ. No statement in this report should be construed as an official position of AHRQ or of the U.S. Department of Health and Human Services.
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Medical Condition: 
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