Ann S. O'Malley

Are Electronic Medical Records Helpful for Care Coordination? Experiences of Physician Practices

BACKGROUNDPolicies promoting widespread adoption of electronic medical records (EMRs) are premised on the hope that they can improve the coordination of care. Yet little is known about whether and how physician practices use current EMRs to facilitate coordination.OBJECTIVESWe examine whether and how practices use commercial EMRs to support coordination tasks and identify work-arounds practices have created to address new coordination challenges.DESIGN, SETTINGSemi-structured telephone interviews in 12 randomly selected communities.PARTICIPANTSSixty respondents, including 52 physicians or staff from 26 practices with commercial ambulatory care EMRs in place for at least 2 years, chief medical officers at four EMR vendors, and four national thought leaders.RESULTSSix major themes emerged: (1) EMRs facilitate within-office care coordination, chiefly by providing access to data during patient encounters and through electronic messaging; (2) EMRs are less able to support coordination between clinicians and settings, in part due to their design and a lack of standardization of key data elements required for information exchange; (3) managing information overflow from EMRs is a challenge for clinicians; (4) clinicians believe current EMRs cannot adequately capture the medical decision-making process and future care plans to support coordination; (5) realizing EMRs’ potential for facilitating coordination requires evolution of practice operational processes; (6) current fee-for-service reimbursement encourages EMR use for documentation of billable events (office visits, procedures) and not of care coordination (which is not a billable activity).CONCLUSIONSThere is a gap between policy-makers’ expectation of, and clinical practitioners’ experience with, current electronic medical records’ ability to support coordination of care. Policymakers could expand current health information technology policies to support assessment of how well the technology facilitates tasks necessary for coordination. By reforming payment policy to include care coordination, policymakers could encourage the evolution of EMR technology to include capabilities that support coordination, for example, allowing for inter-practice data exchange and multi-provider clinical decision support.

Adherence of Low-income Women to Cancer Screening Recommendations

BACKGROUND: African-American and low-income women have lower rates of cancer screening and higher rates of late-stage disease than do their counterparts. OBJECTIVE: To examine the effects of primary care, health insurance, and HMO participation on adherence to regular breast, cervical, and colorectal cancer screening. DESIGN: Random-digit-dial and targeted household telephone survey of a population-based sample. SETTING: Washington, D.C. census tracts with ≥30% of households below 200% of federal poverty threshold. PARTICIPANTS: Included in the survey were 1,205 women over age 40, 82% of whom were African American. MAIN OUTCOME MEASURES: Adherence was defined as reported receipt of the last 2 screening tests within recommended intervals for age. RESULTS: The survey completion rate was 85%. Overall, 75% of respondents were adherent to regular Pap smears, 66% to clinical breast exams, 65% to mammography, and 29% to fecal occult blood test recommendations. Continuity with a single primary care practitioner, comprehensive service delivery, and higher patient satisfaction with the relationships with primary care practitioners were associated with higher adherence across the 4 screening tests, after considering other factors. Coordination of care also was associated with screening adherence for women age 65 and over, but not for the younger women. Compared with counterparts in non-HMO plans, women enrolled in health maintenance organizations were also more likely to be adherent to regular screening (e.g., Pap, odds ratio [OR] 1.89, 95% confidence interval [CI] 1.11 to 3.17; clinical breast exam, OR 2.04, 95% CI 1.21 to 3.44; mammogram, OR 1.95, 95% CI 1.15 to 3.31; fecal occult blood test, OR 1.70, 95% CI 1.01 to 2.83.) CONCLUSIONS: Organizing healthcare services to promote continuity with a specific primary care clinician, a comprehensive array of services available at the primary care delivery site, coordination among providers, and better patient-practitioner relationships are likely to improve inner-city, low-income women’s adherence to cancer screening recommendations.

Beyond the Examination Room: Primary Care Performance and the Patient-physician Relationship for Low-income Women

OBJECTIVE: To assess whether primary care performance of low-income women’s primary care delivery sites is associated with the strength of their relationships with their physicians. DESIGN: Random-digit-dial and targeted household telephone survey of a population-based sample. SETTING: Washington, D.C. census tracts with ≥30% of households below 200% of federal poverty threshold. PARTICIPANTS: Women over age 40 (N=1,205), 82% of whom were African American. MEASUREMENTS AND MAIN RESULTS: The response rate was 85%. Primary care performance was assessed using women’s ratings of their systems’ accessibility (organizational, geographic, and financial), continuity, comprehensiveness, and coordination. Respondents’ ratings of trust in their physicians, communication with their physicians, and compassion shown by their physicians were used to operationalize the patient-physician relationship. Controlling for population and insurance characteristics, 4 primary care features were positively associated with women’s trust in and communication with their physicians: continuity with a single clinician, organizational accessibility of the practice, comprehensive care, and coordination of specialty care services. Better organizational access, but not geographic or financial access, was associated with greater levels of trust, compassion, and communication (odds ratios [ORs], 3.2, 7.4, and 6.9, respectively; P≤.01). Women who rated highest their doctor’s ability to take care of all of their health care needs (highest level of comprehensiveness) had 11 times the odds of trusting their physician (P≤.01) and 6 times the odds of finding their physicians compassionate and communicative (P≤.01), compared to those with the lowest level of comprehensiveness. CONCLUSIONS: Primary care delivery sites organized to be more accessible, to link patients with the same clinician for their visits, to provide for all of a woman’s health care needs, and to coordinate specialty care services are associated with stronger relationships between low-income women and their physicians. Primary care systems that fail to emphasize these features of primary care may jeopardize the clinician-patient relationship and indirectly the quality of care and health outcomes.

Continuity of care and delivery of ambulatory services to children in Community Health Clinics

This study assesses how continuity of care influences receipt of preventive care and overall levels of ambulatory care among children and adolescents in community health clinics (CHCs). It is a secondary data analysis of the 1988 Child Health Supplement to the National Health Interview Survey. Of 17, 110 children in the sample population, the 1465 who identified CHCs as their routine source of care formed the study population. Continuity of site was defined as identification of a CHC as a source of both routine and sick care, and continuity with a clinician was defined as identification of a specific clinician for sick visits. In bivariate analyses both continuity with the CHC and with a specific clinician were associated with increased levels of preventive care and overall ambulatory care. In logistic regression models, continuity of care was associated with nearly a two-fold increase in the odds of receiving age-appropriate preventive care. Alternatively, insurance status was a better predictor of receipt of overall levels of ambulatory care. We conclude that expanding financial access alone is unlikely to sufficiendy improve low-income childrens access to Community Health Clinics. Additional emphasis on localizing the delivery of both routine and sick care services in a single site or with a specific clinician may be needed to achieve higher levels of both preventive care and overall ambulatory care.This study assesses how continuity of care influences receipt of preventive care and overall levels of ambulatory care among children and adolescents in community health clinics (CHCs). It is a secondary data analysis of the 1988 Child Health Supplement to the National Health Interview Survey. Of 17, 110 children in the sample population, the 1465 who identified CHCs as their routine source of care formed the study population. Continuity of site was defined as identification of a CHC as a source of both routine and sick care, and continuity with a clinician was defined as identification of a specific clinician for sick visits. In bivariate analyses both continuity with the CHC and with a specific clinician were associated with increased levels of preventive care and overall ambulatory care. In logistic regression models, continuity of care was associated with nearly a two-fold increase in the odds of receiving age-appropriate preventive care. Alternatively, insurance status was a better predictor of receipt of overall levels of ambulatory care. We conclude that expanding financial access alone is unlikely to sufficiendy improve low-income childrens access to Community Health Clinics. Additional emphasis on localizing the delivery of both routine and sick care services in a single site or with a specific clinician may be needed to achieve higher levels of both preventive care and overall ambulatory care.

Feasibility of mobile cancer screening and prevention.

Many areas have high cancer mortality rates and medically underserved populations. This study describes the feasibility (acceptability and costs) of an urban multiphasic (multiple cancers) screening van. Feasibility was evaluated by literature review and informant interviews. Costs were estimated by resource use from urban mobile screening units; decision analysis estimated the costs per cancer detected for breast, cervix, colorectal, and prostate cancer screening. Acceptability of a multiphasic van varied by the informants perspective. Feasibility and costs were most sensitive to four parameters: age, prior screening history, risk factors, and volume of simultaneous examinations. Subsidized mobile screening facilities may have the potential to reduce cancer morbidity and mortality if they target hard-to-reach underscreened groups, maintain high volume, coordinate with primary care providers, and build on an infrastructure that provides diagnostic and treatment services regardless of ability to pay. It is unclear whether the investment required will translate into a reasonable cost per year of life saved.