BACKGROUND: Policies 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. OBJECTIVES:We 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, SETTING:Semi-structured telephone interviews in 12 randomly selected communities.PARTICIPANTS: Sixty 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. RESULTS:Six 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). CONCLUSIONS:There 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.KEY WORDS: electronic medical record; coordination of care; primary health care; quality; medical home; health information technology; data standards.

ObjectiveA core feature of e-prescribing is the electronic exchange of prescription data between physician practices and pharmacies, which can potentially improve the efficiency of the prescribing process and reduce medication errors. Barriers to implementing this feature exist, but they are not well understood. This study's objectives were to explore recent physician practice and pharmacy experiences with electronic transmission of new prescriptions and renewals, and identify facilitators of and barriers to effective electronic transmission and pharmacy e-prescription processing.DesignQualitative analysis of 114 telephone interviews conducted with representatives from 97 organizations between February and September 2010, including 24 physician practices, 48 community pharmacies, and three mail-order pharmacies actively transmitting or receiving e-prescriptions via Surescripts.ResultsPractices and pharmacies generally were satisfied with electronic transmission of new prescriptions but reported that the electronic renewal process was used inconsistently, resulting in inefficient workarounds for both parties. Practice communications with mail-order pharmacies were less likely to be electronic than with community pharmacies because of underlying transmission network and computer system limitations. While e-prescribing reduced manual prescription entry, pharmacy staff frequently had to complete or edit certain fields, particularly drug name and patient instructions.ConclusionsElectronic transmission of new prescriptions has matured. Changes in technical standards and system design and more targeted physician and pharmacy training may be needed to address barriers to e-renewals, mail-order pharmacy connectivity, and pharmacy processing of e-prescriptions.

Public and private efforts are under way to promote electronic prescribing to improve health care safety, quality, and efficiency. Findings from this qualitative study of physician practices suggest that substantial gaps may exist between advocates' vision of e-prescribing and how physicians use commercial e-prescribing systems today. While physicians were positive about the most basic e-prescribing features, they reported major barriers to maintaining complete patient medication lists, using clinical decision support, obtaining formulary data, and electronically transmitting prescriptions to pharmacies. Three factors help explain the gaps: product limitations, external implementation challenges, and physicians' preferences about using specific product features.

We interviewed hospitalist and nonhospitalist respondents as part of the Community Tracking Study site visits to examine how the growing use of hospitalists has affected care delivery systems. The growth of hospitalist programs contributes to a loss of physicians' participation on hospital medical staffs, which increases the burden of coordination and blurs accountability for the quality of postdischarge care. Arrangements where companies and multispecialty medical groups employ hospitalists are more likely than others to establish routines for ensuring coordinated transitions upon hospital admission and discharge. Policymakers could support the development of guiding principles for care coordination, greater reliance on nonphysicians, and reintegration of inpatient and outpatient providers.