Using Electronic Health Records at Community Health Centers to Help Children Get Health Insurance and Access Health Care

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Abstracts

Public Abstract

Download this abstract: In English (pdf) | En Español (pdf)

What was the research about?

Children who do not have health insurance are less likely to get necessary care, such as regular checkups to identify health problems early and vaccines to prevent common diseases. Low-cost public health insurance (Medicaid) is available to many children whose families can’t get private insurance. But signing up for Medicaid and keeping it can be hard.

The research team wanted to see if using a health insurance enrollment tracking form could help families get and keep health insurance and access health care. They developed a tracking form that community health centers used with electronic health records. The form tracked the help given to families applying for Medicaid. This included providing updates on the status of insurance applications and next steps.

What were the results?

The community health centers that had the tracking form used it with only 15 percent of children who visited the community health centers.

When the tracking form was used in their health records, uninsured children were more likely to get and keep health insurance. They were also more likely to come back to the doctor within six months of when the centers started using the tracking form, get all their checkups in the first 15 months after birth, and get all their recommended shots on time.

Who was in the study?

The research team looked at the health records of 27,251 children who got health care at eight community health centers in Oregon. The children either had no insurance or they had Medicaid. The children were from low-income families of diverse racial and ethnic backgrounds. The four community health centers that had access to the tracking form used it with 2,240 children.

What did the research team do?

The research team looked at electronic health records from the eight community health centers. All eight centers used the same kind of electronic health record. Four centers added the tracking form to their electronic health records. The other four used electronic health records without the tracking form. The research team looked at differences in getting health insurance and health care between children at clinics with the tracking form and children at clinics without the tracking form. In the study, the community health centers that had the tracking forms did not end up using them with all the children. The research team also compared children who did and did not have the tracking forms used at the centers that had the forms.

What were the limits of the study?

All research studies have some limits. In this study, the research team couldn’t say for sure that the tracking form was the reason children got and kept health insurance and got health care. There may have been other reasons for these results. For example, the community health centers that used the form may have been different from the community health centers that did not use the form. Likewise, patients who had the tracking form used in their health records might have been different from patients at the same center who did not have the form. Also, there were changes being made to children’s insurance coverage at the time of this study. The center staff did not use the tracking form with all their patients as the research team had wanted. This may have changed the results of the study. Future studies could look at how to get health center staff to use the form with all patients. This would help the research team understand if the tracking form led to patients getting health insurance and better health care.

How can people use the results?

Community health centers may decide to use electronic health records with tracking forms to help more children get health insurance and health care.

Professional Abstract

Objective

To compare the effects of using electronic health records (EHRs) equipped with insurance enrollment tracking forms versus using nonautomated and nonstandardized tracking outside of EHRs on pediatric patients’ health insurance status, healthcare utilization, and receipt of recommended pediatric care in community health centers (CHCs).

Study Design

Design Elements	Description
Design	Retrospective cohort study
Population	Electronic health records of 27,251 pediatric patients receiving care at eight CHCs in Oregon
Interventions/ Comparators	EHRs equipped with a health insurance enrollment tracking form Nonautomated and nonstandardized tracking outside of EHRs
Outcomes	Obtaining and maintaining insurance coverage (primary), odds of return visit after uninsured visit, odds of being uninsured at return visits, rate of receiving recommended pediatric care
Timeframe	18 month follow-up for primary outcomes

The research team developed a health insurance enrollment tracking form (the “tracking form”) to be used with EHRs to help families obtain and maintain coverage. The tracking form enabled CHC staff to assist patients with health insurance enrollment. CHC staff used the form to track the status of patients’ insurance applications. The research team conducted an 18-month retrospective cohort study to evaluate the form’s use in intervention clinics.

The study included eight CHCs that used the same EHR system. During the study period, four CHCs used the tracking form to monitor patients’ insurance enrollment progress. Four control CHCs did not use the form. Researchers matched control CHCs to intervention CHCs based on the ratio of children to adults, the percentage of patients of Hispanic ethnicity, and the length of EHR experience. All CHCs in the study served patients from low-income and ethnically diverse backgrounds. They also served children who were either uninsured or on Medicaid.

The research team identified three cohorts of children who had one or more visits at a participating CHC during the study period:

Intervention patients: Children who visited intervention CHCs and for whom staff used the tracking form (n=2,240).
Within-clinic comparison patients: Children who visited intervention CHCs and for whom staff did not use the tracking form (n=12,784).
Control-clinic patients: Children who visited a control CHC where the tracking form was not implemented (n=12,227).

The research team reviewed EHR and Medicaid data to see if children for whom the tracking form was used were more or less likely to have insurance coverage at follow-up visits; return for a clinic visit in the first six months of the study; and receive recommended pediatric care.

Results

Use of the tracking form. Intervention CHCs only used the tracking form with 15 percent of all pediatric patients.

Insurance coverage. At the intervention CHCs, intervention patients had higher rates of continuous insurance coverage than within-clinic comparison patients. Fewer intervention patients had Medicaid coverage for less than half of the post-intervention period compared with the within-clinic comparison patients and control-clinic patients.

Intervention patients who were uninsured were more likely to gain Medicaid coverage than uninsured within-clinic comparison patients (adjusted odds ratio [aOR]=1.76; 95% confidence interval [95%CI] 1.60-1.93) or control-clinic patients (aOR=2.28; 95% CI 1.91-2.72). In addition, insured intervention patients were less likely to lose coverage than insured within-clinic comparison patients (aOR=0.71; 95% CI 0.53-0.94) or control-clinic patients (aOR=0.55; 95% CI 0.45-0.67).

Among patients who visited a CHC while uninsured and who returned for a subsequent visit, intervention patients were less likely to be uninsured than within-clinic comparison patients (aOR=0.46, 95% CI 0.24-0.88); but there was no difference between intervention and control-clinic patients.

Healthcare utilization. Intervention patients were more likely to return for at least one follow-up CHC visit compared to the within-clinic comparison patients (aOR=1.83, 95% CI 1.39-2.40); however, there was no difference between intervention and control-clinic patients.

Receiving recommended pediatric care. Intervention patients were more likely to receive recommended well-child visits and be up to date on immunizations than within-clinic comparison and control-clinic patients. More intervention patients (63%) received the recommended pediatric care in the first 15 months of life than within-clinic control patients (39%, p <0.001) and control-clinic patients (53%, p <0.002)). Intervention patients were significantly more likely to be up to date on immunizations than both comparison groups (p <0.05).

Limitations

This study captured correlations between the EHR tracking form and the outcomes described. It could not establish causality for several reasons. Because this was not a randomized study, differences between the clinics and the patient populations could be responsible for the results. The follow-up period may have been too short to adequately review form uptake and impact. Finally, the form was used with only 15 percent of eligible patients at the intervention CHCs. The research team attributed this to concurrent initiatives that also required CHC staff to submit different tracking data on insurance enrollment support and payment tracking, which may have overburdened staff. Likewise, Medicaid coverage end dates that had been built into the EHR system were no longer accurate after Oregon extended coverage end dates for those reapplying for Medicaid in response to the surge of applications and increased processing times resulting from Medicaid expansion.

Conclusions and Relevance

EHRs equipped with health insurance enrollment tracking forms may help increase insurance coverage, decrease the chance of losing coverage at the time of reenrollment, and increase the use of recommended care among pediatric patients in CHCs. However, drawing conclusions about causal relationships between the tracking form and the study outcomes would require CHC staff to use the tracking form with more patients.

Future Research Needs

Future research could continue to examine how EHR-based insurance enrollment tracking forms help patients obtain and maintain insurance coverage.

Project Details

Principal Investigator

Jennifer E. DeVoe, MD, DPhil

Project Status

Completed; Results posted

Project Title

Innovative Methods for Parents and Clinics to Create Tools (IMPACCT) for Kids Care

Project Start Date

December 2012

Project End Date

February 2017

Organization

Oregon Community Health Information Network

Year Awarded

2012

State

Oregon

Funding Announcement

Improving Healthcare Systems

Conditions

Other or Non-Disease Specific

Project Budget

$1,802,033

Study Registration Information

HSRP20142235

NCT02298361

Peer Review Summary

Peer review of PCORI-funded research helps make sure the report presents complete, balanced, and useful information about the research. It also confirms that the research has followed PCORI’s Methodology Standards. During peer review, experts who were not members of the research team read a draft report of the research. These experts may include a scientist focused on the research topic, a specialist in research methods, a patient or caregiver, and a healthcare professional. Reviewers do not have conflicts of interest with the study.

The peer reviewers point out where the draft report may need revision. For example, they may suggest ways to improve how the research team analyzed its results or reported its conclusions. Learn more about PCORI’s peer review process here.

In response to peer review, Dr. DeVoe made changes including:

Adding more description of the patient and stakeholder engagement process
Explaining more fully how the staff at the study sites used the intervention
Describing how the groups of study participants that did or didn’t receive the intervention were similar enough that they could be compared in this research

Conflict of Interest Disclosures

View the COI disclosure form

More on This Project

Published Articles on this Project

Likumahuwa-Ackman S, Angier H, Sumic A, et al., IMPACCT Kids' Care: a real-world example of stakeholder involvement in comparative effectiveness research. Journal of Comparative Effectiveness Research (August 2015).

DeVoe JE, Crawford C, Angier H, et al., The Association Between Medicaid Coverage for Children and Parents Persists: 2002-2010. Maternal and Child Health Journal (August 2015).

DeVoe JE, Tillotson CJ, Marino M, et al., Trends in Type of Health Insurance Coverage for US Children and Their Parents, 1998-2011. Academic Pediatrics (Agust 2015).

Angier H, Marino M, Sumic A, et al., Innovative Methods for Parents And Clinics to Create Tools for Kids' Care (IMPACCT Kids' Care) Study Protocol. Contemporary Clinical Trials (August 2015).

Gold R, Burdick T, Angier H, et al., Improve Synergy Between Health Information Exchange and Electronic Health Records to Increase Rates of Continuously Insured Patients. eGEMS (August 2015).

Heintzman J, Marino M, Hoopes M, et al., Supporting health insurance expansion: do electronic health records have valid insurance verification and enrollment data? Journal of the American Medical Informatics Association (July 2015).

DeVoe JE, Tillotson CJ, Angier H, et al., Predictors of children's health insurance coverage discontinuity in 1998 versus 2009: parental coverage continuity plays a major role. Maternal and Child Health Journal (April 2015).

Angier H, Hoopes M, et al., An Early Look at Rates of Uninsured Safety Net Clinic Visits After the Affordable Care Act. Annals of Family Medicine (January/February 2015).

Angier H, Gold R, Crawford C, et al., Linkage methods for connecting children with parents in electronic health record and state public health insurance data. Maternal and Child Health Journal (November 2014).

DeVoe J, Angier H, Likumahuwa S, et al., Use of qualitative methods and user-centered design to develop customized health information technology tools within federally qualified health centers to keep children insured. The Journal of Ambulatory Care Management (April-June 2014).

Hatch B, Angier H, Marino M, et al., Using electronic health records to conduct children's health insurance surveillance. Pediatrics (December 2013).

Devoe, JE. Being uninsured is bad for your health: can medical homes play a role in treating the uninsurance ailment? Annals of Family Medicine (September-October 2013).

Journal of the American Board of Family Medicine

Lessons Learned from Developing a Patient Engagement Panel: An OCHIN Report

Journal of Comparative Effectiveness Research

IMPACCT Kids' Care: a real-world example of stakeholder involvement in comparative effectiveness research.

Journal of Women'S Health (2002)

Using geographic information systems (GIS) to identify communities in need of health insurance outreach: An OCHIN practice-based research network (PBRN) report.

Page Last Updated:

September 20, 2017