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 8 CHCs in Oregon |
Interventions/
Comparators |
- EHRs equipped with a health insurance enrollment tracking form
- Nonautomated and nonstandardized tracking outside of EHRs
|
| Outcomes |
Primary: obtaining and maintaining insurance coverage
Secondary: odds of return visit after uninsured visit, odds of being uninsured at return visit, 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.
