A pilot study finds better disease management when EHRs are used in the context of a patient-centered medical home.
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An electronic health record (EHR) system can help improve the care of patients with multiple chronic diseases by enabling better coordination of care between healthcare providers, insurers, and patients themselves, a new study shows.
The study, sponsored by a multi-stakeholder group that included eHealth Initiative, the pharmaceutical company Sanofi-Aventis and Health & Technology Vector, a small, Hartford, Conn.-based health IT and care redesign firm, found many process improvements in the care of patients with both Type 2 diabetes and a cardiac-related condition when an EHR was used in the context of a patient-centered medical home.
"With use of a care plan enabled by the EHR, we were able to streamline the care process for these patients and more efficiently track their progress," Dr. Victor Villagra, founder and president of Health & Technology Vector, said in a statement. "For example, at one site, six separate cardiology referral forms were used before the project began. Following the intervention, a single form was developed and formatted within the EHR," he added.
The study included 119 patients, about half at Taconic Independent Practice Association in New York state and the rest at Community Health Center in Connecticut. The latter is a safety-net provider serving mostly Medicaid and uninsured patients.
Researchers studied each site for six months, analyzing patient records at the start and conclusion of the demonstration. Community Health Center scored well on its baseline measures because it already had had "mature medical-home processes in place," according to the report, and advanced technology such as medication reconciliation. The sponsors assigned a care coordinator to each organization.
"In spite of this high level of functioning they were able to improve their processes for the [organization's] three clinics, including adopting a common referral form for cardiology and raising the percent of referrals that included specific requests from the cardiologists," the report said. Such changes led to more information being transmitted to patients during each clinic visit, more frequent setting of goals, and more complete summaries being transmitted from primary care physicians to cardiologists.
Taconic was somewhat behind from the start, but showed measurable improvements in setting care goals, reconciling medications with orders, convincing patients and providers to sign off on goals, and providing relevant information to patients.
"Overall, the project demonstrated improvements in six months in care planning, content of manual communications, intra-office coordination, more advanced use of EHRs, patient coaching, substantive referral requests to specialists, enlarged nursing role, and information for patients," the report said. But the EHR fell short in supporting some functions thought to be essential to "inter-practice care coordination." This was especially evident in the lack of electronic communications between primary care physicians and specialists.
"Where the project did not substantially move the needle was in cardiologists' use of new tools and electronic communication between practices. The latter process was not ready: The communities did not have the tools for electronic data exchange, and the providers did not have compatible EHR systems," the report said. The researchers also reported that some cardiologists were interested in expanded exchange of electronic clinical data.
"We knew going into this project that interaction between caregivers and patients was important, but our observations at the two test sites drove home the fact that care coordination requires ongoing and explicit three-way communication between patient, primary care physician, and specialist in order to be successful and sustainable," said Jennifer Covich Bordenick , CEO of the eHealth Initiative.
Another success factor was reimbursement. "A business model with economic incentives that support visit volume rather than coordination of care can hinder care coordination efforts," according to the report. "Stratification of the most complex patients into nursing care coordination may make it financially sustainable by providing reductions in total patient costs and therefore attracting reimbursement from payers."
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