It’s how care teams communicate in the EHR—not how often—that matters, one study shows.
In this interview, Marlon Mundt, a health economist and associate professor in the Department of Family Medicine and Community Health at the University of Wisconsin-Madison School of Medicine and Public Health, discusses how indirect communication among primary care team members using electronic health records (EHRs) can lead to more hospital visits and higher medical costs for patients with diabetes.
On the impetus for the research. Hospitals and health systems have invested millions in new EHR systems with the hope that they will improve patient care and lower costs, in part by providing a more efficient way for clinicians to communicate with one another. But research in this area has been limited.
Mundt and co-author Larissa Zakletskaia embarked on their own research to gain a better understanding of the impact of care team communication via the EHR on patient outcomes in primary care clinics. They were particularly interested in studying how the structure of communication networks—including how many people pass the patient care information in the EHR—might affect the quality of diabetes care as well as cost outcomes.
“Team communication in the EHR, where patient care information is being passed from person to person to person, becomes more variable versus one where the EHR messages are purposefully directed to the appropriate recipient,” Mundt says.
The researchers did not study the specific content of EHR messages among primary care professionals, but rather the count of messages and who was involved in the communication. To create the structure of team communication networks in the EHR, researchers extracted EHR communication logs that tracked who was communicating with whom, and how often, in the primary care teams. Researchers also reviewed healthcare utilization outcomes of patients with diabetes who were cared for by the primary care teams.
On the impact on patient care. Mundt and Zakletskaia studied EHR patient care information flow and healthcare utilization outcomes for patients with diabetes during three six-month periods and found that hospital visits, including hospital stays and emergency department (ED) visits, increased 13 percent for every increase in one percentage point in indirect team communication in the EHR. An example of indirect communication includes, but it is not limited to, EHR message forwarding among care team members, rather than a direct message to an appropriate primary care professional.
Mundt says the findings, which were published in a recent issue of The American Journal of Managed Care, suggest that the way teams communicate could have an impact on quality of diabetes care. “We know that team-based care is associated with better patient outcomes,” Mundt says. “It is possible that teams may not be collaborating effectively if the team members rely on EHR forwarding to reach the right recipient. Direct EHR communication also could be a marker for how well a primary care team coordinates its actions overall.”
Interestingly, the EHR communication patterns mattered more than the number of messages sent within the team. “One of the things that surprised me was that it wasn’t the volume of messaging through the EHR system that was associated with patient outcomes—it was the EHR communication network structure,” Mundt says. “Specifically, teams that streamlined their team EHR communication purposefully, with well-established EHR connections among fewer team members, had fewer hospital days in their diabetes patient panels.”
“It didn’t seem to matter how many messages were sent if they were flowing in a direct, deliberate way to the appropriate person,” he says. “It is possible that high-functioning teams have developed a better team capacity to process patient care information on the team level.”
On the impact on cost. The researchers also found that medical costs rose by $223 per patient with diabetes in the previous six months for every increase in one percentage point in indirect EHR communication. Based on this cost analysis, Mundt estimates that his health system, UW Health, could save $19.2 million annually by promoting more direct EHR communication about patients with diabetes among primary care team members. On a national level, the potential savings could reach nearly $10 billion, he says.
Advice for healthcare leaders. Mundt recommends leaders take a complex systems science approach to the way in which their clinical teams use their EHR to communicate about patients with diabetes. “I don’t think that looking at how an individual health professional uses the EHR system is as important as observing how care teams support EHR communication with face-to-face communication and how teams coordinate efforts to process patient care information on a team level. Overreliance on EHRs alone may not produce desired improvements in quality of diabetes care,” he says.
“Our research suggests that one benefit of implementing direct EHR communication patterns to improve diabetes care delivery is that it does not require significant investment, as EHR adoption is being carried out in primary care clinics nationwide,” Mundt says. “Exploring the ways in which teams use the EHR may help improve quality of care for patients with diabetes. By making changes in how health professionals communicate in the EHR, teams may significantly raise the quality of diabetes care.”
Interviewed for this article:
Marlon Mundt, PhD, is a health economist and associate professor in the Department of Family Medicine and Community Health, University of Wisconsin School of Medicine, Madison.