1. Meaningful Use Workgroup Report on Care Coordination Hearing David W. Bates, MD, MSc

2. Panels Current HIT support of care coordination Transitions and care coordination Care coordination in the ambulatory environment

3. Overall Assessment of Current Status EHRs of today do not support many of the key needs of practices especially those focusing on enabling team care Tremendous evolution underway today in how these processes are being managed Leaders did report some best practices Many minor issues with EHRs of today which can be addressed soon –But is an area in which additional change will occur

4. Key Functions of EHRs for Care Coordination Reconciling medications Tracking laboratory tests Communicating across settings Mediating care plans between disciplines O’Malley et al, Center for Studying Health System Change

5. Key Domains of EHRs for Enabling Care Coordination Medication-based care Problem lists Progress of patient over time Population-oriented tools O’Malley et al, Center for Studying Health System Change

6. Other Key Activities in Care Coordination Referrals Consultations Care transitions

7. Overarching Recommendations (I) Include the ability to support an interactive and longitudinal care plan Track who is on a care team—and share the information with the patient –Display and record for all patients who is the PCP and share with the patient –Aggregate data or messages and send it to all who need it

8. Overarching Recommendations (II) Support medication reconciliation including at least 4 functions –Importing medication data from other sources –Displaying and comparing medication lists –Ordering medications –Documenting that information Transfer Summary Document--ensure that 9-11 elements from the Care Transitions Performance Set are included in transition recommendations (at least for discharges) –Not only provide summary but include ability to confirm receipt –Include advanced care directives

9. Specific Recommendations Support longitudinal views, for issues like admissions including discharge diagnosis Support the ability of multiple providers on a team to write notes and document simultaneously Support the ability to designate who ordered the medication and who is allowed to refill it Ensure that referrals include the question to the consultant Make problems list sortable and searchable Make the medication list sortable by organ system

10. Conclusions EHRs today do not support needed care coordination activities well –But enormous variation in processes among practices Doing well in this area broadly will be central to improving efficiency, safety, quality Are a number of specific items that can be targeted for 2013 but evolution will be needed Important area for further research