Meaningful use care coordination criteria: Perceived barriers and benefits among primary care providers

Meaningful use care coordination criteria: Perceived barriers and benefits among primary care providers RECEIVED 10 June 2015 REVISED 18 August 2015 ACCEPTED 27 August 2015 PUBLISHED ONLINE FIRST 13 November 2015 Genna R Cohen 1 and Julia Adler-Milstein 2 ABSTRACT... Background Stage 2 and proposed Stage 3 meaningful use criteria ask providers to support patient care coordination by electronically generating, exchanging, and reconciling key information during patient care transitions. Methods A stratified random sample of primary care practices in Michigan (n ¼ 328) that had already met Stage 1 meaningful use criteria was surveyed, in order to identify the anticipated barriers to meeting these criteria as well as the expected impact on patient care coordination from doing so. Results The top three barriers, as identified by >65% of the primary care providers surveyed, were difficulty sending and receiving patient information electronically, a lack of provider and practice staff time, and the complex workflow changes required. Despite these barriers, primary care providers expressed strong agreement that meeting the proposed Stage 3 care coordination criteria would improve their patients treatment and ensure they know about their patients visits to other providers. Conclusion The survey results suggest the need to enhance policy approaches and organizational strategies to address the key barriers identified by providers and practices in order to realize important care coordination benefits.... Keywords: meaningful use, electronic health records, care coordination, primary care, health information exchange INTRODUCTION The 2009 Health Information Technology for Economic and Clinical Health (HITECH) Act provides financial incentives for healthcare providers to adopt electronic health records (EHRs) and use them in accordance with federally defined meaningful use criteria that are intended to facilitate improvements in healthcare quality and efficiency. 1 The initial stage of meaningful use is well underway; as of March 2015, over 150 000 eligible providers had attested to meeting Stage 1 meaningful use criteria. 2 Providers are now working towards achieving Stage 2 criteria and will move on to Stage 3, in which they are asked to use their EHRs in more advanced ways, in 2018. One of the most significant differences between Stage 1 criteria and subsequent criteria (Stage 2 and the proposed Stage 3 meaningful use criteria) is that providers are asked to exchange data electronically across healthcare delivery settings to facilitate patient care coordination. Currently, when patients move between delivery settings, whether their record follows them from setting to setting often depends on an inconsistent, error-prone process of transmitting that information via phone, fax, and mail. 3 As a result, providers often make clinical decisions for patients based on incomplete information, increasing the chances of misdiagnosis, preventable adverse drug events, and duplicative utilization. 4 6 When EHR adoption is coupled with electronic health information exchange (HIE), the key pieces of a patient s health record can be electronically shared and reconciled during referrals and care transitions. HIE is thus a key mechanism through which EHR use is expected to improve patient care coordination and overall healthcare quality. 7 Given the significant potential value of HIE, Stage 1 meaningful use criteria focused on providers initial adoption of EHRs and structured data capture, to support subsequent HIE. Stage 2 and proposed Stage 3 meaningful use criteria require that providers create and electronically transmit a summary of care record (SCR) during patients care transitions, and that the receiving provider reconcile a subset of patient information. 8 Between Stages 2 and 3 of meaningful use, the thresholds for these criteria increase. For example, SCRs must be transmitted electronically for at least 10% of patient care transitions under Stage 2 meaningful use criteria and for at least 50% of patient care transitions in the most recently proposed Stage 3 criteria. 9 Fulfilling the Stage 2 and proposed Stage 3 meaningful use care coordination criteria is likely to be particularly challenging for providers, because they require internal changes to practices as well as factors in the external environment that are not fully under practices control. This is particularly true for primary care practices, because they are at the center of care transitions: they regularly send patients to specialists for referrals and treat patients after specialist consults or hospital discharges. To fulfill Stage 2 and Stage 3 meaningful use criteria, primary care providers (PCPs) will need to learn to use their EHR to create referral-specific documentation for each patient and alter their workflow to ensure that this documentation is consistently generated. PCPs may find that current EHRs do not make this easy. Several recent studies point to shortcomings in the ability of EHRs to facilitate patient care coordination (eg, fragmenting patient information in distinct tabs that must be searched and creating long, disorganized, and sometimes inaccurate lists of patient information due to the limitations of generic templates). 10,11 Even if PCPs successfully tackle these challenges, they will face a second substantial obstacle: sending and receiving patient data electronically. Most providers have little experience exchanging or using electronically shared clinical data. 12 Correspondence to Genna R. Cohen, School of Public Health (Health Management and Policy), University of Michigan, 1415 Washington Heights, M3025 SPH II, Ann Arbor, Michigan 48109-2029; grcohen@umich.edu. For numbered affiliations see end of article. VC The Author 2015. Published by Oxford University Press on behalf of the American Medical Informatics Association. All rights reserved. For Permissions, please email: journals.permissions@oup.com e146

For many, the problem is a lack of HIE options, although others have multiple choices but no information on which will work best. 13 In addition, most HIE solutions are not seamlessly integrated with EHRs, requiring providers to introduce new steps into their workflows. Without evidence that speaks to the key challenges of meeting meaningful use criteria, policymakers, vendors, and stakeholders will struggle to anticipate and to make the changes required to ensure that the meaningful use program results in demonstrated improvements in care. We therefore undertook a study to answer the following research questions: 1) What are the perceived barriers to meeting the meaningful use care coordination criteria? and 2) To what extent do PCPs feel that meeting the meaningful use care coordination criteria will improve various dimensions of patient care coordination? We focused on the proposed Stage 3 meaningful use criteria, because they require providers to engage in higher thresholds of patient information exchange and reconciliation than Stage 2 criteria and, therefore, are likely to be a better indicator of the potential barriers to, as well as benefits from, moving to the ultimate goal of fully health information technology (HIT)-enabled patient care coordination. METHODS Setting and Data We conducted a statewide survey of primary care practices that had achieved Stage 1 meaningful use (as of September 1, 2013), with the support of the Michigan Center for Effective Information Technology Adoption, which is Michigan s Regional Extension Center. We selected a random sample of 328 practices, stratified by practice size, and collected data between October 2013 and March 2014. Study participants were offered multiple means of completing the survey: phone, online, or on paper via fax or mail. We made at least three attempts to follow-up with participants by phone to obtain a survey response. All respondents received a $50 incentive for completing the survey. Our survey instrument contained two parts. The first part asked the practice manager (PM) of each practice selected to report practice demographics, their practice s primary method(s) of sharing patient information with other providers (electronic or via paper/fax), and the extent to which specific factors were perceived to be barriers to meeting proposed Stage 3 meaningful use care coordination criteria. The second part asked a PCP within each practice about the same barriers, in addition to the extent to which the PCP perceived that proposed Stage 3 meaningful use criteria would improve various aspects of patient care coordination. (Please refer to the Supplementary Appendix for a copy of our survey.) All survey questions were piloted with a convenience sample of five practices, then refined to improve the clarity of the questions and to ensure that each part of the survey could be completed in <15 min. We received responses from 233 PMs (71% response rate) and 174 PCPs (53% response rate). We compared respondents to the population from which they were sampled and found no differences by practice size or by most EHR vendors. The only statistically significant differences were that respondents were less likely to use the EHR vendor AllScripts (v 2 ¼ 5.36, P <.05) and were more likely to use the EHR vendor eclinicalworks (v 2 ¼ 5.90, P < 0.05). At the time that we designed our survey, the proposed Stage 3 meaningful use care coordination criteria were as follows: 1. Send an SCR for at least 65% of patient care transitions or referrals, with at least 30% sent electronically. SCRs for referrals must include a concise narrative in support of care transitions, ie, free text that captures the patient s current care synopsis and expectations for the referral. 18 2. Be prepared to receive an EHR-generated acknowledgement from practices that received patient information from the focal practice (ie, a referral receipt, with at least 10% returned electronically) for at least 50% of referrals. 3. Reconcile patients medications for >50% of care transitions and reconcile patients medication allergies and health problems (eg, uncontrolled diabetes) for >10% of care transitions. In the March 2014 revised Stage 3 meaningful use criteria, a subset of the thresholds was changed (see Supplementary Appendix Table 2). Measures and Analysis We used the survey data to create four types of measures. First, we created measures of practice demographics to characterize our sample. Second, we created measures of the proportion of PMs and the proportion of PCPs who felt that each of the seven barriers listed on the survey was a moderate or substantial barrier to meeting the proposed Stage 3 meaningful use care coordination criteria. Third, we created eight measures to capture how practices shared information during a patient care transition, which describe whether or not practices reported using predominately electronic means to send and/or receive patient information with hospitals as well as ambulatory practices, both within and outside their networks. Fourth, we created measures of the proportion of PCPs who reported that they somewhat agreed or strongly agreed that each of five domains of patient care coordination would be improved by meeting the proposed Stage 3 meaningful use care coordination criteria. We calculated all measures using survey sampling weights based on our sampling strategy, in order to generalize results to the statewide population of primary care practices that had achieved Stage 1 meaningful use. To answer our research questions, we first generated descriptive statistics of barriers to meeting proposed Stage 3 meaningful use care coordination criteria, as reported by PMs as well as by PCPs. Because the ability to share patient information across settings was identified as a key barrier, we explored this barrier in more depth by reporting the patterns of information sharing during patient care transitions. We also assessed whether any practice characteristics were independently associated with practices that used primarily electronic methods of sharing patient information. To do this, we created an overall measure that captured whether or not practices used predominantly electronic means to both send patient information to and receive patient information from hospitals and ambulatory practices within and outside their networks. We then ran a logistic regression model with all practice demographic variables that were statistically significant (at the P <.1 level) in bivariate analyses as predictors. Finally, we generated descriptive statistics of the proportion of PCPs who felt that each domain of patient care coordination would be improved by meeting the proposed Stage 3 meaningful use criteria. RESULTS Demographic characteristics of our practice sample are reported in Table 1. Most practices in the sample had fewer than six practitioners (81%). Over half of the practices (56%) were independently owned and the majority (88%) were affiliated with a Physician Organization (PO). POs are structured entities designed to align the interests and activities of affiliated physicians and physician groups with one another, hospitals, and/or healthcare systems. In Michigan, POs take the form of independent practice associations, physician-hospital organizations, large multispecialty group practices, or other umbrella organizations that provide clinical leadership, administrative structure, e147

Table 1: Overview of Practice Sample Practice size (n 5 233) Small (2 or fewer) 45% Medium (2-5) 36% Large (6 or more) 19% Practice is independently owned (n 5 233) 59% Practice is affiliated with a physician 88% organization (n 5 228) Hospital physician organization affiliation (n 5 215) 32% Dominant payer (n 5 232) Medicare covers >50% Pts 11% Medicaid covers >50% Pts 5% Private covers >50% Pts 30% Average practitioner patient panel (n 5 196) a 55 26% 56 114 49% 115 25% EHR use (n 5 220) 1 2 years 32% 3 5 years 38% 6þ years 30% IT Support (n 5 232) No IT support 36% In-house only 18% External only 39% In-house and external 7% Practice participates in an ACO (n 5 226) 38% Practice meets one or more set of PCMH criteria (n 5 226) 81% ACO, Accountable Care Organization; EHR, electronic health record; IT, information technology, PCMH, Patient-Centered Medical Home. a Average number of patients seen at the practice per week/practice Full Time Equivalent Providers (FTEs). technical infrastructure, and other resources for physician practices. 14 The majority of practices in our sample (68%) had been using an EHR for >2 years at the time of the survey and had some form of IT support (64%). Barriers to Meeting Proposed Stage 3 Meaningful Use Care Coordination Criteria There were six barriers that more than half of both PMs and PCPs felt were substantial or moderate barriers to meeting the proposed Stage 3 meaningful use care coordination criteria. PMs and PCPs identified the same top three barriers: difficulty sending and receiving information electronically (81% of PMs and 74% of PCPs); a lack of provider and practice staff time (77% of PMs and 79% of PCPs); and complex required workflow changes (78% of PMs and 78% of PCPs) (Figure 1). When we assessed current patterns of information sharing among the survey sample, we found low rates of electronic information sharing overall and that practices were just as likely to send patient information electronically as they were to receive patient information electronically (23% for both measures). Similarly, practices did not differ on the extent to which they exchanged patient information electronically with hospitals or with ambulatory providers (22% vs 23%). However, practices were more likely to share patient information electronically within their network (40%) compared to outside their network (5%; P ¼.06). When we broke these relationships down further, we found that primary care practices were most likely to receive patient information electronically from in-network hospitals (43% of practices) and were least likely to receive patient information electronically from out-of-network ambulatory practices (2%) (Figure 2). In our multivariate logistic regression, we found that practice ownership and size were independently associated with whether or not practices used predominantly electronic methods to share patient information. Specifically, independent practices were less likely to use predominantly electronic means to share patient information (OR 0.34, P <.1), and both medium (OR 1.48, P <.1) and large (Odds Ratio (OR) 2.95, P <.001) practices were more likely than small practices to use predominantly electronic methods to share patient information. Expected Impact of Meeting Proposed Stage 3 Meaningful Use Care Coordination Criteria PCPs felt that meeting the proposed Stage 3 meaningful use criteria would have a positive effect on all dimensions of patient care coordination included in the survey. The largest proportion of PCPs felt that achieving the proposed Stage 3 criteria would improve their patients treatment (86% of respondents somewhat agreed or strongly agreed), help patients overall (85%), and ensure that doctors know about their patients visits to other doctors (85%). PCPs anticipated that meeting the proposed Stage 3 criteria would have the least effect on reducing hospitalizations (59%), reducing adverse drug events (72%), and improving specialist responsiveness (75%) (Figure 3). DISCUSSION Despite the increase in EHR adoption following the passage of the HITECH Act, key capabilities required for effective patient care coordination are not yet in place. Specific barriers to effective care coordination range from a lack of technical capabilities to time and resource constraints. Underlying many of these barriers is the fact that HIE is still often a manual process, relying on paper and fax. This is particularly true for connectivity among unaffiliated ambulatory practices, which often lack the resources of hospitals or practices affiliated with larger organizations to invest in interfaces. Although addressing these challenges will require substantial effort, our results suggest that doing so would be worthwhile PCPs felt that a broad array of patient care coordination dimensions would be improved by achieving the proposed Stage 3 meaningful use criteria. The meaningful use program is one of several, including the Patient-Centered Medical Home program and Accountable Care Organization demonstrations under the Affordable Care Act, currently offering incentives to primary care practices to engage in activities that target improved patient care coordination. 15 It is key to determine how to help practices overcome the barriers to meeting the meaningful use care coordination criteria. It will be critical to expand the options for how practices can effectively engage in HIE and to use the EHR Certification process to ensure that HIE systems work well once e148

Figure 1: Reported barriers to meeting proposed Stage 3 meaningful use care coordination criteria. 90% 80% 70% 60% 50% 40% 30% Practice Manager% 20% 10% 0% Difficulty sending and receiving information electronically Complexity of required workflow changes Lack of provider and practice staff time Direct financial costs EHR design and functions Competing priorities (e.g., becoming a medical home) Lack of trust in accuracy of information* Primary Care Physician% * Not asked of PM Figure 2: Percentage of practices using predominantly electronic means to share patient information with different healthcare partners. Within Network, Hospital: Receive Within Network, Hospital: Send Within Network, Ambulatory: Send Within Network, Ambulatory: Receive Outside Network, Ambulatory: Send Outside Network, Hospital: Receive Outside Network, Hospital: Send Outside Network, Ambulatory: Receive 0% 5% 10% 15% 20% 25% 30% 35% 40% 45% 50% they are deployed. More tailored efforts may be required to ensure that HIE systems support all required forms of connectivity in particular, among unaffiliated ambulatory practices, between which electronic exchange is dismally low. Expanding support from Regional Extension Centers is also likely to be beneficial in helping practices tackle the new workflows required to use EHRs to meet meaningful use care coordination criteria. LIMITATIONS Our study has several limitations. First, practices in our sample were relatively advanced, having already achieved Stage 1 meaningful use criteria. This characteristic is likely to decrease practices and providers perceived barriers to criteria achievement, suggesting that other practices may be less prepared to use EHRs to support patient care coordination. Second, our survey was conducted in a single state (Michigan), in which POs actively support member practices. 14,16,17 This is likely to further decrease providers and practices perceived barriers to achieving meaningful use criteria and, in particular, may mean that practices are less likely to consider direct financial costs and a lack of provider and practice staff time to be barriers to meaningful use criteria fulfillment. Finally, we conducted our survey prior to Stage 2 of meaningful use. Because proposed Stage 3 meaningful use e149

Figure 3: Anticipated impact of meeting Stage 3 meaningful use coordination criteria. Improve Treatment Help the Patient Overall Know about Visits to Other Doctors Send Specialists Patient History and Reason for Referral Improve Diagnosis Reduce Duplication Improve Specialist Clarity Talk to Patients about Specialist Results Improve Specialist Timeliness Improve Specialist Responsiveness Reduce Adverse Drug Events Reduce Hospitalizations 0% 10% 20% 30% 40% 50% 60% 70% 80% 90% 100% Percent of Primary Care Providers in Agreement criteria builds on Stage 2 s criteria, the ramp up to Stage 3 criteria may be less challenging than our results suggest, with better HIE options (eg, Direct) available and more time to make the changes required to meet the Stage 3 thresholds. CONCLUSION There are many barriers to primary care practices achieving the proposed Stage 3 meaningful use care coordination criteria. A key barrier is the lack of effective HIE capabilities and, in particular, practices ability to exchange data electronically with unaffiliated ambulatory care practices. Despite these barriers, there is widespread agreement among PCPs that meeting the proposed Stage 3 meaningful use criteria is likely to broadly improve patient care coordination. This suggests that we should continue to support and tailor policy efforts to enable practices to overcome barriers to achieving these criteria. CONTRIBUTORS Both authors conceived and designed the study, supervised and contributed to the data analysis, interpreted results, and drafted and revised the paper. FUNDING This work was supported by Agency for Healthcare Research and Quality grant R18 HS022674-01: Assessing Readiness, Achievement and Impact of Stage 3 Care Coordination Criteria. COMPETING INTERESTS None. ACKNOWLEDGEMENTS We are grateful to the practices who participated in this study and to Paige Nong, Brayton Statham, Emily Walton, Brandon Spiegel, and our colleagues at the Michigan Center for Effective Information Technology Adoption, for their help fielding the survey. SUPPLEMENTARY MATERIAL Supplementary material is available online at http://jamia.oxfordjournals.org/. REFERENCES 1. Blumenthal D. Launching HITECH. N Engl J Med. 2010;362(5):382 385. 2. Centers for Medicare & Medicaid Services. Medicare & Medicaid EHR Incentive Programs. In: HIT Policy Committee, editor; 2015. http:// www.healthit.gov/facas/sites/faca/files/hitpc_cms_presentation_2015-03-10.pptx. 3. Pham HH, Schrag D, O Malley AS, et al. Care patterns in medicare and their implications for pay for performance. New Engl J Med. 2007;356(11): 1130 1139. 4. Smith PC, Araya-Guerra R, Bublitz C, et al. MIssing clinical information during primary care visits. JAMA. 2005;293(5):565 571. 5. Brown RS, Peikes D, Peterson G, et al. Six features of Medicare coordinated care demonstration programs that cut hospital admissions of high-risk patients. Health Aff. 2012;31(6):1156 1166. 6. Craig C, Eby D, Whittington J. Care Coordination Model: Better Care at Lower Cost for People With Multiple Health And Social Needs. Institute for Healthcare Improvement; 2011. 7. Bodenheimer T. Coordinating care a perilous journey through the health care system. New Engl J Med. 2008;358(10):1064 1071. 8. Office of the National Coordinator (ONC). HIT Policy Committee: Request for Comment Regarding the Stage 3 Definition of Meaningful Use of Electronic Health Records (EHRs). In: Office of the National Coordinator for Health Information Technology DoHaHS, editor; 2012. 9. Department of Health and Human Services Centers for Medicare & Medicaid Services. Medicare and Medicaid Programs; Electronic Health Record Incentive Program-Stage 3. Federal Register; 2015. p. 16731 16804. 10. O Malley AS, Grossman JM, Cohen GR, et al. Are electronic medical records helpful for care coordination? experiences of physician practices. JGIM. 2010;25(3):177 185. e150

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