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H H S Department of Health and Human Services
U.S. Department of Health and Human Services
Health Information Technology and Quality
Improvement

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Introduction

Improving care coordination is the third health policy priority of the EHR Incentive Program (also called Meaningful Use).  Care coordination is the integration of patient care activities between two or more participants involved in a patient’s care to facilitate the appropriate delivery of health care.  As patients transition from one provider or facility to another, those involved in their care, their primary care providers, specialists, home care agencies, acute care hospitals, emergency departments, families, caregivers and others, must communicate with each other to share medical information.  The information that is shared will help providers to coordinate their patients’ care.  

The Meaningful Use objectives that address care coordination promote the exchange of medical information and the use of that information to manage patient care.  Improved coordination among providers reduces the potential for preventable errors and allows providers and patients to make more effective medical decisions and design more appropriate care plans.  EHR technologies can support your care coordination efforts by automating the transfer of patient medical information to other providers or care facilities.  Electronic exchange of information can also ease your administrative burden (e.g., writing referrals to a specialist) and reduce your administrative costs (e.g., printing and mailing summary reports).  

Care coordination is particularly important for patients with chronic conditions, as most receive care from multiple providers at multiple settings.  Chronic conditions are prevalent among the Medicaid and Medicare populations: among Medicare beneficiaries, approximately 65 percent have one or more chronic condition and 18 percent have 3 or more; among Medicaid beneficiaries, approximately 56 percent of non-disabled adult Medicaid beneficiaries have a chronic condition; and among those enrolled in both Medicare and Medicaid, over 75 percent have a chronic condition.  The more chronic conditions a patient has and the more complex the conditions are, the more intense the coordination needs to be.  

Although there is no consensus of what care coordination entails, below are tasks that are considered necessary for effective care coordination:

  • Maintaining patient continuity with the primary care provider/primary care team
  • Documenting and compiling patient information generated within and outside the primary care office
  • Using information to coordinate care for individual patients and for tracking different patient populations within the primary care office
  • Initiating, communicating, and tracing referrals and consultations
  • Sharing care with clinicians across practices and settings
  • Providing care and/or exchanging information for transitions and emergency care 

Despite the importance of coordinating care, poor care coordination among providers is common.  Examples of common coordination failures include patients who receive contradictory information from providers, specialists who receive no referral information from the referring provider, and referring providers who receive no feedback from the specialist.  Delays in receiving patient information are also widespread.  It may take weeks, for example, for consultation and emergency department reports to reach primary care providers.  

Those providers who strive to coordinate care face numerous challenges.  These challenges include the large number of providers that must be coordinated (a typical primary care physician with Medicare patients would need to interact with 229 other physicians working in 117 different practices); the substantial amount of time that coordination takes (a study of family physicians found that 13 percent of the workday was spent coordinating care); and the low quality of consultant and referral notes.  The difficulty of sharing paper-based medical records across practices is another barrier to care coordination.  

EHR systems can help you coordinate care.  They can document and compile your patients’ histories and other medical information, including medications and the start and stop dates necessary for medication reconciliation.  EHR systems can also help maintain patient continuity within a medical practice and facilitate information exchange across medical practices and settings.  As an example, the EHR system can allow you to send referral requests electronically and share relevant information from the patient’s medical record with providers of other practices.    

There are two core set and two menu set care coordination objectives for Stage 1 Meaningful Use, as shown in the table below.    

Health Policy Priority:  Improve care coordination

Stage 1 Objectives and Measures

Objective

 

Eligible Professional

Eligible Hospital

Measure

Core Set

Capability to exchange key clinical information (for example, problem list, medication list, medication allergies, diagnostic test results), among providers of care and patient authorized entities electronically

 

Capability to exchange key clinical information (for example, discharge summary, procedures, problem list, medication list, medication allergies, diagnostic test results), among providers of care and patient authorized entities electronically

 

Performed at least one test of certified EHR technology's capacity to electronically exchange key clinical information

 

Menu Set

Perform medication reconciliation upon receipt of a patient from another setting of care or provider of care or when an encounter is believed relevant

Perform medication reconciliation upon receipt of a patient from another setting of care or provider of care or when an encounter is believed relevant

 

Performed medication reconciliation for more than 50% of transitions of care

 

 

Provide summary of care records for patients who transition to another setting of care or provider of care or upon referral of patient to another provider of care

 

Provide summary of care records for patients who transition to another setting of care or provider of care or upon referral of patient to another provider of care

 

Provided summary of care record for more than 50% of transitions of care and referrals 

 

 

EHR technologies can facilitate the coordination and integration of care across providers and health care settings; promote quality and safety through the use of clinical decision support tools designed to reconcile medications; and provide records of care to support patients’ transition from one provider or facility to another.  This module explains how care coordination will benefit you and your patients and what you need to do to meet these objectives.  

This module poses questions on Meaningful Use and care coordination, then provides a response and suggests additional resources.  Only Stage 1 criteria for demonstrating Meaningful Use are addressed, as Stage 2 and Stage 3 criteria have not yet been finalized by CMS.  The terms “EHR Incentive Program” and “Meaningful Use” are used interchangeably throughout.

Related Resources:

EHR Incentive Program Final Rule – CMS’ rules and regulations for demonstrating Meaningful Use.  See pages 44360-44364 for more complete information on care coordination objectives.  
Meaningful Use of Electronic Health Records (Webcast) go to exit disclaimer– Webcast presentations by Dr. Neil Calman and Peter Cucchiara of the Institute for Family Health provide an overview of Meaningful Use and how providers can assess their readiness to participate.
EHRs and Care Coordination in the Ambulatory Setting go to exit disclaimer– Comments by the Medical Director of Health Information Management Systems at the Mayo Clinic on the successful use of EHRs to improve care coordination.
Care Coordination and Information Exchange go to exit disclaimer– PowerPoint presentation by Francia Ortiz & Donna Goldbloom of Open Door Family Medical Centers, on Open Door’s experience using health IT to promote patient engagement.  
Care Coordination and Electronic Health Records: Connecting Clinicians go to exit disclaimer– Study presented at the American Medical Informatics Association’s 2009 Annual symposium highlighting the problems in care quality and how they can be alleviated by use of an EHR.
Care Coordination: Breaking It Down go to exit disclaimer – PowerPoint presentation by Paul Kaye of Hudson River HealthCare, Inc. describes the principles of care coordination and the Hudson Information Technology for Community Health HEAL 10 Project.
Using HIT to Facilitate Coordination go to exit disclaimer– PowerPoint presentation by Wes Willett & Dan Calman, Institute for Family Health, discusses the use of health IT to facilitate care coordination processes.
Care Coordination and Information Exchange go to exit disclaimer– PowerPoint presentation by Luke Doles, NYCLIX, on the integration of Health Information Exchange with primary care provider’s work flow.

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