Online Program

Challenges, pitfalls and successes of using electronic health records to measure population outcomes of and clinical processes in care coordination in primary care

Monday, November 2, 2015 : 9:30 a.m. - 9:50 a.m.

Ianita Zlateva, MPH, Weitzman Institute, Community Health Center, Inc., Middletown, CT
Mary Blankson, DNP, APRN, Community Health Center, Inc., Middletown, CT
Kathleen Thies, PhD, Weitzman Institute, Community Health Center, Inc., Middletown, CT
Daren Anderson, MD, Weitzman Institute, Community Health Center, Inc., Middletown, CT
Deb Ward, RN, Weitzman Institute, Community Health Center, Inc., Middletown, CT
Khushbu Khatri, BS, Weitzman Institute, Community Health Center, Inc., Middletown, CT
Nicholas Ciaburri, BS, Business Intelligence, Community Health Center, Inc., Middletown, CT
Care coordination in primary care has proven difficult to measure (National Quality Forum, 2014; Schultz et al, 2013). Electronic health records (EHRs) initially were designed to document care of individual patients and for billing insurers for reimbursement of services, and not for measuring population data or clinical processes.  Measurement based on EHR documentation is contingent on: 1) clear and standardized definitions of the structured fields in the EHR from which population data is mined; and 2) ease and consistency of use of these fields by individual clinicians. The definition of the fields and what kind of information they record should be predetermined based on a data model, which also determines how data will be stored and accessed. However, existing fields may not suit a data model for measuring the population outcomes and clinical processes of care coordination.  Some fields are redundant, or use different wording to measure the same thing.  Altering fields has consequences for how related fields are populated and accessed, and may interrupt data collection already under way.  Building new fields requires re-training clinicians. We will discuss the challenges and successes, and present lessons learned, of designing the following evidence-based health information technology tools for the EHR to measure care coordination at Community Health Center, Inc. (CHCI), a large multi-site Federally Qualified Health Center and Patient Centered Medical Home: 1) an operable nursing dashboard based on an algorithm of standardized definitions that identifies high risk patients who would benefit from care coordination; 2) a template based on Coleman’s (2004) pillars to document the care of patients transitioning from hospital to home; and 3) a scorecard that indicates performance on selected care coordination measures for primary care nurses and providers.

Learning Areas:

Chronic disease management and prevention
Conduct evaluation related to programs, research, and other areas of practice
Implementation of health education strategies, interventions and programs

Learning Objectives:
Discuss the complexity of structuring electronic health records to measure care coordination in primary care.

Keyword(s): Chronic Disease Management and Care, Community Health Centers

Presenting author's disclosure statement:

Qualified on the content I am responsible for because: Ianita Zlateva serves as the Director of Research and Evaluation. In this role she is responsible for managing a wide range of research activities and supporting the overall growth in primary care research that is relevant to the CHC’s mission to provide quality healthcare services to all. Ianita is involved in all aspects of the research process, including development and design of research proposals, implementation of research agendas and dissemination of findings.
Any relevant financial relationships? No

I agree to comply with the American Public Health Association Conflict of Interest and Commercial Support Guidelines, and to disclose to the participants any off-label or experimental uses of a commercial product or service discussed in my presentation.