Electronic Health Record Use and Care Coordination

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.