The Association between EHRs and Care Coordination Varies by Team Cohesion

A growing number of Americans are living with chronic medical conditions and often require medical care that bridges multiple delivery sites, such as hospitals and primary care clinics (Partnership for Solutions 2004; Bodenheimer, Chen, and Bennett 2009; Schoen et al. 2009; Anderson 2010; Thorpe, Ogden, and Galactionova 2010). Effective coordination is necessary to ensure high-quality care for these patients. In part to promote greater care coordination, the American Recovery and Reinvestment Act (ARRA) of 2009 allocated $27 billion to encourage adoption and meaningful use of electronic health records (EHRs) in the United States (Blumenthal 2010b; Blumenthal and Tavenner 2010). Communication of clinical information for coordination of care across delivery sites is an explicit requirement for “meaningful use” payments under ARRA (Blumenthal 2010a). Other health care innovations such as bundled payments, accountable care organizations, and patient centered medical homes aim to improve care quality in part through facilitating care coordination and a greater reliance on team-based care (Rittenhouse and Shortell 2009; Blumenthal and Tavenner 2010; Shortell, Casalino, and Fisher 2010). Given the ongoing reforms targeting the organization and financing of health care, and sizable federal investment in EHRs, it is important to understand how the organizational environment can influence the EHR effect on various outcomes, including care coordination. The shared use of an EHR across hospitals, specialist and primary care practices, and other provider organizations offers great potential to improve coordination by enabling access to comprehensive, current patient information each time a patient is seen by clinicians. EHRs also provide tools to monitor a patient’s health status and intervene promptly when necessary. However, effective use of the information and tools made available by an EHR requires active communication and teamwork between clinicians. In other words, having the basic infrastructure of an integrated delivery system or shared EHR may be insufficient to improve the delivery of care if clinicians do not make full use of the information or fail to use it when working with other clinicians. There is limited research on the effects of EHR use on care coordination (Graetz et al. 2009; O’Malley et al. 2009) and no evidence on how organizational factors may change this effect. For this study, we focus on the coordination of care across delivery sites, such as when patients leave hospitals and re-enter primary care. These transitions represent a timely area of policy and clinical interest, during which prior studies have found high rates of errors (Coleman et al. 2006). We examined the combined effect of an integrated outpatient–inpatient certified EHR and team cohesion on clinician ratings of care coordination across delivery sites in a prepaid IDS. We used survey data from primary care clinicians collected in three different years (2005, 2006, and 2008), during the staggered implementation of a commercially available, integrated EHR system (2005–2010). We hypothesized that the use of the integrated EHR would result in improvements in all reported measures of care coordination and that the magnitude of the association would be greater for clinicians working in primary care teams with higher cohesion.