IMPACT OF AN ORGANIZATION WIDE ELECRONIC HEALTH RECORD SYSTEM ON CLINICALLY INTEGRATED PATIENT CARE

Finn, Amy

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IMPACT OF AN ORGANIZATION WIDE ELECRONIC HEALTH RECORD SYSTEM ON CLINICALLY INTEGRATED PATIENT CARE

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This research explored the impact of an organization-wide electronic health record system (EHR) on clinical integration through an affordance-actualization lens, focusing on Primary Care perspectives on communication, care coordination, and physician engagement. Clinical integration supports horizontal care delivery across entities and time. We constructed a 4-stage model based on the literature to create a conceptual framework of how integration evolved over time from vertical integration bringing different health care entities into the same organization to technical integration using the same organization-wide electronic health record (EHR) system across the disparate entities, for health care systems in the United States. Technical integration can encourage collaboration and communication to enable clinically integrated care across the care continuum, resulting in improved patient outcomes and cost savings. While technical integration facilitates clinical integration, it is likely not sufficient for achieving clinical integration that requires significant organization change. Few studies have examined the organizational dynamics by which clinical integration occurs. We carried out our research at a large health care system that had recently implemented the Epic EHR system organization-wide. Using an IRB-approved protocol, we interviewed 10 Primary Care Physicians (PCPs) in 2019-2020, with a second round of interviews conducted in 2022 with 7 of the same PCPs. Using grounded theory, we explored four research questions related to the impact of an organization-wide EHR on Primary Care, specifically examining: overall effects (RQ #1), inter-practice communication (RQ #2), coordination of care (RQ #3), and physician engagement (RQ #4). We also identified themes that broadly reflected PCPs’ experiences using the EHR, capturing enablers and challenges at environmental and individual levels. Our analysis identified that overall, PCPs interviewed believed the organization-wide EHR offered value and required thinking like a system. The EHR gave the PCPs a voice in proactively communicating care plans and rationale, and technical integration enabled by the EHR supported improved communication. The PCPs interviewed were enthusiastic about the use of Epic Secure Chat to directly address patient care issues requiring rapid response. They considered their role as the “Grand Coordinator” of care, supporting care teams with greater access to patient information as well as an ability to manage urgent patient needs. In terms of engagement, PCPs used EHR features to find new ways to facilitate care and appreciated the connectedness afforded through EHR use. Challenges identified by the PCPs included different practice cultures, information overload, varying clarity of communications, noise in the system from reminders, distribution of duplicate information, additional workload, and frustrations with EHR usability. Based on these findings and the literature, we used an affordance-actualization lens to investigate harnessing technical integration to accelerate clinical integration. We identified five affordances including (1) accessing and using patient data through a unified data source, (2) visualizing system requirements and patient needs, (3) facilitating provider-to-provider communication, (4) engaging Primary Care physicians throughout a health care system, and (5) coordinating care across providers and sites. We found that the actualization of the care coordination affordance (Affordance #5) most closely aligned with clinical integration and that improving care coordination depends on visualization (Affordance #2), communication (Affordance #3), and engagement (Affordance #4). We identified 8 drivers representing conditions or factors that enable or constrain actualization of care coordination, including for example, health care system decisions regarding resources and PCP concerns about workload. Drivers help to define effective actions that support affordance realization. We also applied three key performance indicators (KPIs), alignment, consistency and extent, to explore how individual level actions can facilitate or hinder organizational actualization of care coordination. This work contributes to the literature by introducing the engagement affordance and by presenting dependencies and drivers that enable actualization of clinical integration through care coordination. Another contribution from our analysis is practical insights that can inform the implementation of an organization-wide EHR to facilitate movement towards clinical integration.

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