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Using Health IT for Care Coordination: Insights from Six Medicare Accountable Care Organizations


This evaluation provides insights into how select Medicare Accountable Care Organizations (ACOs) have used health information technology (health IT) tools to better coordinate care for their patients. Health IT has significantly enhanced providers' opportunities to coordinate patient care across health care settings. Care coordination helps ensure that patients' needs for health services are met across multiple encounters and settings. CMS has identified care coordination as integral to achieving better care, improved health, and lower costs.


We purposively selected six ACOs on the basis of their performance on a quality measure focused on care coordination and patient safety, a minimum of 3 years of experience as a Medicare ACO, geographic variation, and recommendations from CMS and ONC. We interviewed administrative staff and providers onsite at each of the six ACOs. Our discussions covered how ACOs use health IT to coordinate care for their patients and the challenges they face in doing so.


Overall, health IT tools have enabled the six ACOs we visited to better coordinate patient care. ACOs that used a single electronic health record (EHR) system across their provider networks were able to share data in real time. A small number of ACOs had access to robust health information exchanges (HIEs), which gave ACOs access to patient data even when patients saw providers outside the ACOs' networks. Most of the ACOs we visited use data analytics to inform their care coordination by identifying and grouping patients according to the potential severity and cost of their health conditions. However, the ACOs we visited still face challenges in these areas. ACOs using multiple EHR systems had to rely on other means to share data between providers, such as phone calls and faxes. ACOs also faced challenges from physician burnout due to the workload of managing EHRs. Most of the ACOs had access to HIEs with little or incomplete data, making it difficult to coordinate care when patients saw providers outside the ACOs' networks. Few of the ACOs use analytics to customize care to an individual patient's needs.


The ACOs we visited have used health IT to aid in care coordination in a variety of ways. However, the full potential of health IT has not been realized. ACOs vary in the extent to which they can rely on health IT tools. The Department of Health and Human Services has promoted the use of these tools for the promise they hold to help patients achieve better outcomes at lower costs. This work showcases some of the advances ACOs have made as well as challenges that remain for fulfilling that promise.