EHR-Based Care Coordination Performance Measures in Ambulatory Care

November 18, 2011 | Volume 25

Authors: Kitty S. Chan, Ph.D., Jonathan P. Weiner, Dr.P.H., Sarah H. Scholle, Dr.P.H., Jinnet B. Fowles, Ph.D., Jessica Holzer, Lipika Samal, M.D., M.P.H., Phillip Renner, M.B.A.
Contact: Kitty S. Chan, Ph.D., Associate Professor Health Policy and Management, Johns Hopkins Bloomberg School of Public Health
Editor: Deborah Lorber


Good coordination of care in the ambulatory setting has the potential to reduce unnecessary or duplicative use of health services, prevent hospitalizations for ambulatory care–sensitive conditions, improve patient safety, and potentially reduce costs. Unfortunately, coordination failures are common across the health care system. Using performance measures can drive practice improvement, particularly if reimbursement aligns with measurement. However, there are few well-developed, standardized measures of care coordination. This study sought to develop electronic health record–based measures to assess the quality of coordination during the primary care physician-to-specialist referral process, one of the most common transitions across providers in health care. Using input from interviews with primary care physicians and experts, the authors developed a core set of five electronic measures for use in primary care and specialist settings. Through a preliminary evaluation, they determined that the measures are valid with practicing physicians and two are ready for implementation.


K. S. Chan, J. P. Weiner, S. H. Scholle et al., EHR-Based Care Coordination Performance Measures in Ambulatory Care, The Commonwealth Fund, November 2011.