Linking the pieces together: Predictors of care coordination

Background. Health care innovations such as bundled payments and accountable care organizations seek to improve care in part through better coordination. Even in such environments, tools to communicate better and shared values among clinical teams could result in greater coordination.

Objective. To examine the impact of an integrated electronic health record (EHR) and team orientation on care coordination in a prepaid, integrated delivery system (IDS).

Methods. Surveys of all IDS primary care clinicians were collected over three years during the staggered implementation of an EHR. Response rates were 48.1% (N=565) in 2005, 61.5% (N=678) in 2006, and 60.8% (N=626) in 2008. Using multivariate logistic regression to adjust for clinician characteristics, medical center, and time, we examined the impact of EHR use and team orientation on changes over time in three dimensions of care coordination across delivery sites: access to complete and timely information; treatment goal agreement; and role/responsibility agreement. We calculated team orientation by using standardized mean values of three aspects of team climate: stress, team unity, and participative decision-making. Clinicians needed to work in facilities where both the inpatient and outpatient EHR components were implemented to qualify as having an integrated EHR.

Results. Reported access to complete and timely clinical information was substantially greater with EHR use (52% vs. 34% pre-EHR); similarly, agreement on treatment goals (62% vs. 49% pre-EHR) and on clinician roles and responsibilities were greater with EHR use (64% vs. 51% pre-EHR, all comparisons p<0.001). After adjustments, clinicians working in medical centers with the EHR were significantly more likely to report access to complete and timely information than those without EHR (OR=2.41, 95%CI: 1.05-5.53). Clinicians working in teams with a high level of team unity were significantly more likely to report agreement on treatment goals (OR=1.25, 95% CI: 1.04-1.50) and agreement on roles and responsibilities (OR=1.31, 95%CI: 1.09-1.56). Team participative decision making was associated with reports of access to complete and timely information for care transferred across delivery sites (OR=1.30, 95%CI: 1.04-1.63).

Discussion. Creating conductive payment and delivery systems represents only one step toward well coordinated care. Both effective information management and a team orientation also appeared to be useful for improving clinician perceptions of well coordinated care across delivery sites. As expected, EHR use was associated with improvements in information sharing, but not with the other dimensions of coordination. In contrast, team unity and participative decision-making were associated with other aspects of care coordination.