Barriers to healthcare coordination in market-based and decentralized public health systems: a qualitative study in healthcare networks of Colombia and Brazil
BACKGROUND Care coordination is essential to effective chronic care, but knowledge of processes by which health care professionals coordinate their activities when caring for chronically ill patients is limited. Electronic health records (EHRs) are expected to facilitate coordination of care, but whether they do so completely-and under what conditions-is not well understood. OBJECTIVES To identify processes by which providers worked together to provide care using an EHR and to examine factors supporting coordination of care. DESIGN Qualitative multiple case study in 4 sites with diverse care delivery models, using semi-structured in-person interviews with 46 physicians and staff and telephone interviews with 65 adult patients with diabetes. SETTING Four Kaiser Permanente medical centers. RESULTS Across all care models, physicians and staff acted sequentially as loosely coupled links in a chain, relying on EHR-enabled informational continuity to coordinate care. Of providers, 94% were highly satisfied with the availability of patient information, and 89% of patients were satisfied or very satisfied with the coordination of their care. However, 6 of 65 patients described experiences of uncoordinated care, and 5 of 12 primary care providers identified coordination issues. These pertained to unreconciled differences of opinion, conflicting role expectations, and discipline-specific views of patient needs. CONCLUSIONS Diabetes care can be coordinated across providers, but some coordination issues persist despite the informational continuity provided by an EHR. Multidisciplinary care teams should be alert to potential coordination challenges, and possible solutions should be explored, including longitudinal care planning with structured communications at key points in care.