From the Chair: Care Coordination and the Office-based EHR

We continue to hear more and more about organizing the delivery system around “Accountable Care Organizations” that aim to coordinate care across multiple sites of care.   Major strides are currently being made in development and implementation of interoperability standards which will support transport of information among providers’ electronic health records (EHRs).  Health Information Exchange Organizations all over the country are preparing to support exchange of hospital discharge summaries and clinical care summaries.

This type of information sharing among various types of providers using disparate EHRs is critical for true care coordination.   Also important, however, is the degree to which clinicians and EHRs in the ambulatory setting are prepared to actively provide more comprehensive integrated care as more robust data become available.   There are a number of basic functions that are common to most EHRs (i.e., recording patient demographics, drug/drug alerts, reminders, report generation, etc.).   There are also a number of integrated EHR functions that are key to the support of care coordination by practices.

Support team-based care

As you reassess your current EHR or look to a new one, there are a number of care coordination functions you should look for.  A good starting point would be to support team-based care through EHR use of:

• Intra-practice communications  through messaging, inclusion of verbal orders, and recording of telephone conversations
• Concurrent use of your EHR by multiple authorized individuals while maintaining information integrity when accessing care plans, guidelines, and protocols
• Clinical task assignment and routing
• Management of clinical documents and notes to include co-signers, corrections, support for both  notes in progress and  final notes, patient annotations, and free text in addition to structured data

Organize and assess

Once you have built an effective team with clear job descriptions and efficient workflows, and you have trained them well to use these enabling functions, you will want to assure that you have an EHR with the functionality necessary to organize and assess your electronic patient health information.   Some of the more important areas that you should look for are:

• Managing coded problem lists to include not just diagnoses, but dates of onset, resolution, chronicity, updates, linkage to orders, addition of free text, and different ways of viewing
• Managing medication lists to include ordering clinician, changes (when and who made them) explanatory free text, medication history, over the counter preparations, or  no medications when that  is the case
• Managing results — in addition to many of the steps noted above, you will want your EHR to be able to display results graphically and on flow sheets, be notified of new results, and forward results to others with notes and annotations
• Managing a patient history by including documents from external sources, recording both negative and positive findings, and updating clinical, family, and social histories

Consider patient engagement

Care coordination without patient engagement is an oxymoron.   You will want to know your EHR system at least supports:

• Generating and providing patient specific instructions through links to other sites or from embedded functionality
• Managing  consents and authorizations with the ability to print, sign, and store and possibly allow for electronic patient signature
• Managing  advanced directives by at least noting the type, that you’ve reviewed them with the patient, and where they might be found or who should be contacted as a health care proxy
• Identifying  all clinicians engaged in a specific encounter and the primary provider of care
• Scheduling of appointments and follow-ups, and the ability to view whether or not they were kept

If your system provides a patient portal or secure messaging with a patient, consider this an added but important bonus.

Incorporate data electronically

Lastly, until your capacity to incorporate data electronically from other sources expands, you will want your EHR to support some way of

• Capturing, storing, and indexing external clinical documents
• E-prescribing and communicating with pharmacies about medication requiring prior authorization or other administrative processes

Conclusion

In summary, you can review your EHR and processes now to assure that you are coordinating care for your patients using the information you currently have.   When access to more comprehensive patient data from outside of your office setting or healthcare system becomes available, they can be incorporated into the record and be included in your approach to the coordinated care that you already have in place.

Many of these desirable functions are already included in EHRs tested by our CCHIT Certified® 2011 program. This independently developed CCHIT certification program includes a more rigorous inspection of integrated EHR functionality than the Office of the National Coordinator (ONC) authorized program which is designed only to meet minimum government requirements qualifying providers for meaningful use incentives. Future CCHIT Certified development will continue to consider the evolving care coordination needs of office-based practices.

Karen M. Bell, MD, MMS
Chair, Certification Commission

Karen Bell, MD, MMS, is Chair of the Certification Commission for Health Information Technology (CCHIT®. Dr. Bell has wide and varied expertise in health information technology (HIT), quality assurance and clinical practice, in both the private and public sectors. Previously, she served as Senior Vice President, HIT Services, Masspro, the federally-contracted Quality Improvement Organization within Massachusetts, where she oversaw the development, implementation and distribution of products and services to support adoption of electronic health records (EHRs) within the health care system. Between 2005 and 2008, Dr. Bell was Director, Office of Health Information Technology Adoption, Office of the National Coordinator (ONC), U.S. Department of Health and Human Services (HHS), and, in 2006, served as Acting Deputy of ONC. She was ONC’s representative on CCHIT’s Board of Commissioners from 2006 to 2008.

Prior appointments held by Dr. Bell include Division Director, Quality Improvement Group/Office of Standards and Quality for the Centers for Medicare and Medicaid (CMS), and Medical Director of Blue Cross Blue Shield (BCBS) of Rhode Island and of Anthem BCBS of Maine.

She received her medical degree from Tufts University School of Medicine, Boston, and her master of medical science degree from Brown University, Providence, R.I. Dr. Bell has clinical experience as a board certified physician in internal medicine and also was an Associate Professor at the University of Rochester, and Clinical Instructor at Harvard University School of Medicine.