Health IT-Enabled Care Coordination: A National Survey of Patient-Centered Medical Home Clinicians.

PURPOSE: Health information technology (IT) offers promising tools for improving care coordination. We assessed the feasibility and acceptability of 6 proposed care coordination objectives for stage 3 of the Centers for Medicare and Medicaid Services electronic health record incentive program (Meaningful Use) related to referrals, notification of care from other facilities, patient clinical summaries, and patient dashboards. METHODS: We surveyed physician-owned and hospital/health system-affiliated primary care practices that achieved patient-centered medical home recognition and participated in the Meaningful Use program, and community health clinics with patient-centered medical home recognition (most with certified electronic health record systems). The response rate was 35.1%. We ascertained whether practices had implemented proposed objectives and perceptions of their importance. We analyzed the association of organizational and contextual factors with self-reported use of health IT to support care coordination activities. RESULTS: Although 78% of the 350 respondents viewed timely notification of hospital discharges as very important, only 48.7% used health IT systems to accomplish this task. The activity most frequently supported by health IT was providing clinical summaries to patients, in 76.6% of practices; however, merely 47.7% considered this activity very important. Greater use of health IT to support care coordination activities was positively associated with the presence of a nonclinician responsible for care coordination and the practice's capacity for systematic change. CONCLUSIONS: Even among practices having a strong commitment to the medical home model, the use of health IT to support care coordination objectives is not consistent. Health IT capabilities are not currently aligned with clinicians' priorities. Many practices will need financial and technical assistance for health IT to enhance care coordination.

Patient-centered medical home and quality measurement in small practices.

OBJECTIVES: To assess performance on quality measures among small primary care practices that recently adopted an electronic health record (EHR), and how performance differs between practices that have achieved patient-centered medical home (PCMH) recognition and those that have not. STUDY DESIGN: Retrospective cohort study. METHODS: Comparison of practice characteristics and performance on quality measures across 150 independent practices from 2009 to 2011 by recognition status for Physician Practice Connections-PCMH. RESULTS: PCMH-recognized practices performed significantly better than nonrecognized practices on 5 out of 7 clinical quality measures at baseline, and the differences were maintained over the 2-year study period. Both groups improved on all clinical quality measures. Though the magnitude of differences was small, PCMHrecognized practices had a higher number of patients diagnosed with hypertension and proportionally more black patients. A significant difference in PCMH-recognized practices is that they received, on average, 4 additional quality improvement visits compared with nonrecognized practices. CONCLUSIONS: Among small practices that have adopted EHRs, practices with PCMH recognition consistently outperformed practices without recognition on most clinical quality measures. With adequate assistance, small, resource-strapped practices can continue to have higher performance on clinical quality measures.

Does it get easier to use an EHR? Report from an urban regional extension center.

BACKGROUND: Little is known about whether more experience with an electronic health record (EHR) makes it easier for providers to meaningfully use EHRs. OBJECTIVE: To assess whether the length of time that small practice providers have been using the EHR is associated with greater ease in performing meaningful use-related tasks and fewer EHR-related concerns. DESIGN/PARTICIPANTS: We administered a web-based survey to 400 small practice providers in medically underserved communities in New York City participating in an EHR implementation and technical assistance project. We used logistic regression to estimate the association between the length of time a provider had been using the EHR (i.e., "live") and the ease of performing meaningful use-related tasks and EHR-related concerns, controlling for provider and practice characteristics. KEY RESULTS: Compared to providers who had been live 6 to 12 months, providers who had been live 2 years or longer had 2.02 times greater odds of reporting it was easy to e-prescribe new prescriptions (p < 0.05), 2.12 times greater odds of reporting it was easy to e-prescribe renewal prescriptions (p < 0.05), 2.02 times greater odds of reporting that quality measures were easy to report (p < 0.05), 2.64 times greater odds of reporting it was easy to incorporate lab results as structured data (p < 0.001), and 2.00 times greater odds of reporting it was easy to generate patient lists by condition (p < 0.05). Providers who had been live 2 years or longer had 0.40 times lower odds of reporting financial costs were a concern (p < 0.001), 0.46 times lower odds of reporting that productivity loss was a concern (p < 0.05), 0.54 times lower odds of reporting that EHR unreliability was a concern (p < 0.05), and 0.50 times lower odds of reporting that privacy/security was a concern (p < 0.05). CONCLUSIONS: Providers can successfully adjust to the EHR and over time are better able to meaningfully use the EHR.

Patient-centered medical home among small urban practices serving low-income and disadvantaged patients.

PURPOSE: Research on the patient-centered medical home (PCMH) model and practice redesign has not focused on the unique challenges and strengths of very small primary care practices serving disadvantaged patient populations. We analyzed the practice characteristics, prior experiences, and dimensions of the PCMH model that exist in such practices participating in the Primary Care Information Project (PCIP) of the New York City Department of Mental Health and Hygiene. METHODS: We obtained descriptive data, focusing on PCMH, for 94 primary care practices with 5 or fewer clinicians serving high volumes of Medicaid and minority patient populations in New York City. Data included information extracted from PCIP administrative data and survey data collected specifically for this study. RESULTS: Survey results indicated substantial implementation of key aspects of the PCMH among small practices serving disadvantaged patient populations, despite considerable potential challenges to achieving PCMH implementation. Practices tended to use few formal mechanisms, such as formal care teams and designated care or case managers, but there was considerable evidence of use of informal team-based care and care coordination nonetheless. It appears that many of these practices achieved the spirit, if not the letter, of the law in terms of key dimensions of PCMH. CONCLUSIONS: Small practices can achieve important aspects of the PCMH model of primary care, often with informal rather than formal mechanisms and strategies. The use of flexible, less formal strategies is important to keep in mind when considering implementation and assessment of PCMH-like initiatives in small practices.

Small practices' experience with EHR, quality measurement, and incentives.

OBJECTIVES: To assess clinician attitudes and experiences in Health eHearts, a quality recognition and financial incentive program using health information technology. STUDY DESIGN: Survey of physicians. METHODS: A survey was administered to 140 lead clinicians at each participating practice. Survey domains included clinicians' experiences and attitudes toward the selected clinical quality measures focused on cardiovascular care, use of electronic health records (EHRs), technical assistance visits, quality measurement reports, and incentive payments. Responses were compared across groups of practices receiving financial incentives with those in the control (no financial rewards). RESULTS: Survey response rate was 74%. The majority of respondents reported receiving and reviewing the quality reports (89%), agreed with the prioritization of measures (89%), and understood the information given in the quality reports (95%). Over half of the respondents had a quality improvement visit (56%), with incentive clinicians more likely to have had a visit compared with the control group (68% vs 43%, P = .01). The incentive group respondents (92%) were more likely to report using clinical decision support system alerts than control group respondents (82%, P = .11). CONCLUSIONS: Clinicians in both incentive and control groups reported positive experiences with the program. No differences were detected between groups regarding agreement with selected clinical measures or their relevance to the patient population. However, clinicians in the incentive group were more likely to review quarterly performance reports and access quality improvement visits. Incentives may be used to further engage clinicians operating in small independently owned practices to participate in quality improvement activities.