Keep pace with the changes

Editor's note: Michael Kuehne is senior research strategist at Stamford, Conn., research firm FocusVision.

The time is now for the hospital and health systems industry to move toward a coordinated care model. The way internal medicine is delivered to patients is changing at an unprecedented pace due to a shift in policy and the move toward consumerism. To prepare for these changes hospital and health systems must change the way they think about research, which has tended to be slow (mail surveys), usually quantitative and lacking a humanistic element. When combined with quantitative techniques, asynchronous qualitative coordinated care research prepares the industry to maintain patient panels and adapt to changes.

Beginning in 2017, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) policy will begin to affect the health care industry. As Deloitte (2016) has stated: “MACRA is expected to drive care delivery and payment reform across the U.S. health care system for the foreseeable future. Congress intended MACRA to be a transformative law that constructs a new, fast-speed highway to transport the health care system from its traditional fee-for-service payment model to new risk-bearing, coordinated care models. It has the potential to be a game-changer at all levels of our health care system.”

Despite the impending legislative changes, awareness among providers whose practices would be affected by MACRA is dangerously low. The Deloitte Center for Health Solutions 2016 Survey of U.S. Physicians found that: 50 percent of non-pediatric physicians surveyed have never heard of MACRA; 32 percent only recognize the name; and 21 percent of self-employed physicians and those in independently-owned medical practices report they are somewhat familiar with MACRA, versus 9 percent of employed physicians surveyed.

Significant revenue is at stake in the new risk-bearing coordinated care model. To adapt to the changes, a consolidation of the market will likely occur. Smaller private practices less-equipped to bear the level of risk needed to maintain their business will join larger networks. For large and complex organizations, coordinating care will require investment in information technology to support collaboration within the affiliated network of providers. By improving care coordination, hospital and health systems will be able to maintain or grow their patient panels (market share) and showcase how they treat patients more like consumers.

Level of continuity

Care coordination activities that will soon become best practices for performance measurement include helping with transitions of care, assessing patient needs and goals, creating proactive care plans, linking community resources, monitoring and follow-up (including responding to changes in patient needs). These activities increase the quality of care in addition to providing a level of continuity to patients during their treatment journey.

Care coordination is valuable to patients because it provides them with a continuous treatment experience from admittance through to rehabilitation. For example, a patient in a coordinated care model will have access to a connected network of providers for treatments such as: cardiology; geriatrics; orthopedics; primary care; diabetes and endocrinology; gastroenterology; infectious diseases; obstetrics and gynecology; and pulmonary and sleep.

In complex hospital and health systems, many patient concerns often arise, including those related to provider intra-communication and records-sharing. Take the example of medication lists, which are not always reconciled across provider networks (i.e., when an oncologist prescribes a medication whose drug interactions a dentist treating the same patient is unaware of). Similarly, when a patient sees multiple specialists they often need to explain their medical history to each one. The lack of coordinated care can leave patients discouraged and frustrated, increasing the likelihood of noncompliance and ultimately causing them to leave the network.

Change the way they work

Implementing care coordination will be challenging, as it will require that health services staff change the way they work. Chief among this, primary care providers, nursing and administrative staff will need to learn how to use electronic health records (EHR). As part of EHR adoption, hospitals and provider offices will install in-office computers to gain immediate access to medical information and history. While in-office computers allow providers to deliver a higher level of continuity to the patient, they require primary care providers and nursing staff to juggle the amount of attention they give to computers versus patients. However, by having access to EHRs via in-office computers, providers and staff can ensure that both informational and management continuity is being delivered to patients.

Informational continuity means that providers and patients have all the information they need or request. Management continuity means that multiple providers are in agreement about a patient’s care and the patient understands the next steps (Haggerty et al. 2003). Delivering both informational and management continuity requires active communication and teamwork among primary care providers, as well as the related nursing and administrative staff.

A research study conducted by Graetz et al. (2014), explored the association between electronic health records and care coordination. Specifically, the study recognized the need to understand and measure organizational factors and the effects team cohesion can have on successfully delivering care coordination in practices that have instituted electronic medical records.

This multi-year study quantitatively surveyed primary care clinicians in large, integrated health care systems that were, during the time of the study, deploying electronic heath records in their practices. Clinicians completed three surveys between 2005 and 2008. Over 1,500 survey responses were collected during this period.

Care coordination was measured in three dimensions closely correlated with informational and management continuity: access to timely and complete information, treatment agreement and responsibility agreement.

To better understand how organizational factors may change the effects of EHR on care coordination, the researchers employed quantitative team cohesion measures. Team cohesion questions were developed using published validated instruments (Ohman-Strickland et al. 2007). Using a five-point Likert agreement response scale, each clinician was asked:

1. “When there is conflict on this team, the people involved usually talk it out and resolve the problem successfully.”

2. “Our team members have constructive work relationships.”

3. “There is often tension among people on this team.” (reverse scored)

4. “The team members operate as a real team.”

The method used by Graetz et al. provided a good illustration of the impact team cohesion can have on coordinated care. However, this approach can be taken a step further to capture even deeper insights.

Qualitative asynchronous techniques

Coordinated care is asynchronous, and engaging practice staff using in-the-moment qualitative asynchronous techniques is a complementary tool to understand the delivery of informational and management continuity. Taking Graetz et al.’s approach further requires the blending of mobile qualitative data collection techniques together with the quantitative measurements used by the Graetz team. As a result, researchers will be able to interject a much-needed human element to the quantitative data.

The added qualitative component can draw upon a new laddering technique proposed by Moradin et al. (cited by Takhar-Lail and Ghorbani 2015), which lends itself to the asynchronous nature of both coordinated care and qualitative mobile online communities. Employing this approach would enable researchers to measure team cohesion across various levels of hospital and health system staff. The technique focuses on creating cognitive schemas consisting of declarative knowledge units (motives). Connecting these motives is procedural knowledge.

The new laddering can be best described as: “First, respondents list their personal reasons for choosing a focal goal (e.g., health care system coordinated care). After listing all of their reasons, respondents return to each reason they gave and justify why each reason was important to them.” (Takhar-Lail and Ghorbani 2015).

Using this technique, primary care providers, nurses and practice administrators could participate in online mobile research communities and complete laddering activities on their own terms. This may include a variety of video testimonials, journal exercises, journey maps and projective techniques. The data collected would be idiosyncratic and the raw data then segmented into response categories, which would be further broken down into goal categories (e.g., reduced length of patient visit and installation of in-office computers), and treated with semantic analysis.

Provide a humanistic element

As organizations work to deliver coordinated care, the inclusion of qualitative research will provide a humanistic element that can better prepare them for a risk-bearing, consumer-centric health care world. Hospitals and health systems are businesses and brands deeply rooted in human interactions. Very few industries have this level of consumer connection, which is why understanding the entire ecosystem responsible for delivering coordinated patient care is imperative. Providing best-in-class coordinated care experiences to patients will ensure that hospitals and health systems are truly poised for the future of internal medicine. 


Deloitte (2016) MACRA: Disrupting the health care system at every level (

Weinberg, D.B., Gittell, J.H., Lusenhop, R.W., Kautz, C.M. and Wright, J. (2007), “Beyond our walls: Impact of patient and provider coordination across the continuum on outcomes for surgical patients.” Health Services Research, 42: 7–24. doi:10.1111/j.1475-6773.2006.00653.x

Haggerty, J.L., Reid, R.J., Freeman, G.K., Starfield, B.H., Adair, C.E., and McKendry, R. (2003). “Continuity of care: a multidisciplinary review.” British Medical Journal, 327(7425), 1219-1221.

Graetz, I., Reed, M., Rundall, T.G., Bellows, J., Brand, R., and Hsu, J. (2009, November). “Care coordination and electronic health records: connecting clinicians.” In American Medical Informatics Association.

Graetz, I., Reed, M., Shortell, S.M., Rundall, T.G., Bellows, J. and Hsu, J. (2014), “The association between EHRs and care coordination varies by team cohesion.” Health Services Research, 49: 438–452.

O’Malley, A.S., Grossman, J.M., Cohen, G.R., Kemper, N.M., and Pham, H.H. (2010). “Are electronic medical records helpful for care coordination? Experiences of physician practices.” Journal of General Internal Medicine, 25 (3), 177-185.

Ohman-Strickland, P.A., John Orzano, A., Nutting, P.A., Perry Dickinson, W., Scott-Cawiezell, J., Hahn, K., and Crabtree, B.F. (2007). “Measuring organizational attributes of primary care practices: Development of a new instrument.” Health Services Research, 42(3p1), 1257-1273.

Takhar-Lail, A., and Ghorbani, A. (2015). Market Research Methodologies: Multi-Method and Qualitative.

Lafata, J.E., Shay, L.A., Brown, R. and Street, R.L. (2016), “Office-based tools and primary care visit communication, length and preventive service delivery.” Health Services Research, 51: 728–745. doi:10.1111/1475-6773.12348.

Harrison, A., and Verhoef, M. (2002), “Understanding coordination of care from the consumer’s perspective in a regional health system.” Health Services Research, 37: 1031–1054. doi:10.1034/j.1600-0560.2002.64.x