EHRs improve care coordination in medical homes

Using EHR-enabled care coordination resulted in numerous process improvements for patients with Type 2 diabetes and heart disease within a medical home, according to a new report from the eHealth Initiative (eHI).

Working with sanofi-aventis and Health & Technology Vector, eHI undertook a six-month exploratory project last year to understand how EHRs can be used to improve care coordination for complex patients. The study looked at use of EHRs with patients at three clinics of a community health center and with an independent practice association (IPA).

The community health center's central care coordinator implemented various changes to the use of the EHR and trained staff at the clinics to use them. Those changes included:

  • A common referral form developed for the project and accepted by all cardiologists; 
  • Drop-down boxes within the EHR that prompted providers to include additional relevant clinical information in referrals; 
  • A version of a care-plan summary built within the EHR.

With the IPA, the care coordinator worked with cardiologists to communicate patient information to the regional cardiology practice through updated individual care-plan summaries and spreadsheets of changed medications or lab results. These could be imported into the cardiology group's EHRs.

The project also identified areas where EHRs were unable to support tasks considered essential to interpractice care coordination--most notably electronic communications between primary care providers and cardiologists. Gaps in the EHR functions needed to support care coordination resulted in a "wish list" for future enhancements, the report said.

For more information:
- read the eHI report (free reg. req.)