Electronic health record tools to assist with children's insurance coverage: A mixed methods study

Jennifer Devoe, Megan Hoopes, Christine A. Nelson, Deborah Cohen, Aleksandra Sumic, Jennifer Hall, Heather Angier, Miguel Marino, Jean P. O'Malley, Rachel Gold

Research output: Contribution to journalArticle

1 Citation (Scopus)

Abstract

Background: Children with health insurance have increased access to healthcare and receive higher quality care. However, despite recent initiatives expanding children's coverage, many remain uninsured. New technologies present opportunities for helping clinics provide enrollment support for patients. We developed and tested electronic health record (EHR)-based tools to help clinics provide children's insurance assistance. Methods: We used mixed methods to understand tool adoption, and to assess impact of tool use on insurance coverage, healthcare utilization, and receipt of recommended care. We conducted intent-to-treat (ITT) analyses comparing pediatric patients in 4 intervention clinics (n = 15,024) to those at 4 matched control clinics (n = 12,227). We conducted effect-of-treatment-on-the-treated (ETOT) analyses comparing intervention clinic patients with tool use (n = 2240) to intervention clinic patients without tool use (n = 12,784). Results: Tools were used for only 15% of eligible patients. Qualitative data indicated that tool adoption was limited by: (1) concurrent initiatives that duplicated the work associated with the tools, and (2) inability to obtain accurate insurance coverage data and end dates. The ITT analyses showed that intervention clinic patients had higher odds of gaining insurance coverage (adjusted odds ratio [aOR] = 1.32, 95% confidence interval [95%CI] 1.14-1.51) and lower odds of losing coverage (aOR = 0.77, 95%CI 0.68-0.88), compared to control clinic patients. Similarly, ETOT findings showed that intervention clinic patients with tool use had higher odds of gaining insurance (aOR = 1.83, 95%CI 1.64-2.04) and lower odds of losing coverage (aOR = 0.70, 95%CI 0.53-0.91), compared to patients without tool use. The ETOT analyses also showed higher rates of receipt of return visits, well-child visits, and several immunizations among patients for whom the tools were used. Conclusions: This pragmatic trial, the first to evaluate EHR-based insurance assistance tools, suggests that it is feasible to create and implement tools that help clinics provide insurance enrollment support to pediatric patients. While ITT findings were limited by low rates of tool use, ITT and ETOT findings suggest tool use was associated with better odds of gaining and keeping coverage. Further, ETOT findings suggest that use of such tools may positively impact healthcare utilization and quality of pediatric care. Trial registration: ClinicalTrials.gov, NCT02298361; retrospectively registered on November 5, 2014.

Original languageEnglish (US)
Article number354
JournalBMC Health Services Research
Volume18
Issue number1
DOIs
StatePublished - May 10 2018

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Insurance Coverage
Electronic Health Records
Insurance
Odds Ratio
Confidence Intervals
Quality of Health Care
Pediatrics
Delivery of Health Care
Pragmatic Clinical Trials
Therapeutics
Health Insurance
Immunization
Technology

Keywords

  • Children
  • CHIP
  • Community health centers
  • Electronic health record
  • Health insurance
  • Medicaid

ASJC Scopus subject areas

  • Health Policy

Cite this

Electronic health record tools to assist with children's insurance coverage : A mixed methods study. / Devoe, Jennifer; Hoopes, Megan; Nelson, Christine A.; Cohen, Deborah; Sumic, Aleksandra; Hall, Jennifer; Angier, Heather; Marino, Miguel; O'Malley, Jean P.; Gold, Rachel.

In: BMC Health Services Research, Vol. 18, No. 1, 354, 10.05.2018.

Research output: Contribution to journalArticle

Devoe, Jennifer ; Hoopes, Megan ; Nelson, Christine A. ; Cohen, Deborah ; Sumic, Aleksandra ; Hall, Jennifer ; Angier, Heather ; Marino, Miguel ; O'Malley, Jean P. ; Gold, Rachel. / Electronic health record tools to assist with children's insurance coverage : A mixed methods study. In: BMC Health Services Research. 2018 ; Vol. 18, No. 1.
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abstract = "Background: Children with health insurance have increased access to healthcare and receive higher quality care. However, despite recent initiatives expanding children's coverage, many remain uninsured. New technologies present opportunities for helping clinics provide enrollment support for patients. We developed and tested electronic health record (EHR)-based tools to help clinics provide children's insurance assistance. Methods: We used mixed methods to understand tool adoption, and to assess impact of tool use on insurance coverage, healthcare utilization, and receipt of recommended care. We conducted intent-to-treat (ITT) analyses comparing pediatric patients in 4 intervention clinics (n = 15,024) to those at 4 matched control clinics (n = 12,227). We conducted effect-of-treatment-on-the-treated (ETOT) analyses comparing intervention clinic patients with tool use (n = 2240) to intervention clinic patients without tool use (n = 12,784). Results: Tools were used for only 15{\%} of eligible patients. Qualitative data indicated that tool adoption was limited by: (1) concurrent initiatives that duplicated the work associated with the tools, and (2) inability to obtain accurate insurance coverage data and end dates. The ITT analyses showed that intervention clinic patients had higher odds of gaining insurance coverage (adjusted odds ratio [aOR] = 1.32, 95{\%} confidence interval [95{\%}CI] 1.14-1.51) and lower odds of losing coverage (aOR = 0.77, 95{\%}CI 0.68-0.88), compared to control clinic patients. Similarly, ETOT findings showed that intervention clinic patients with tool use had higher odds of gaining insurance (aOR = 1.83, 95{\%}CI 1.64-2.04) and lower odds of losing coverage (aOR = 0.70, 95{\%}CI 0.53-0.91), compared to patients without tool use. The ETOT analyses also showed higher rates of receipt of return visits, well-child visits, and several immunizations among patients for whom the tools were used. Conclusions: This pragmatic trial, the first to evaluate EHR-based insurance assistance tools, suggests that it is feasible to create and implement tools that help clinics provide insurance enrollment support to pediatric patients. While ITT findings were limited by low rates of tool use, ITT and ETOT findings suggest tool use was associated with better odds of gaining and keeping coverage. Further, ETOT findings suggest that use of such tools may positively impact healthcare utilization and quality of pediatric care. Trial registration: ClinicalTrials.gov, NCT02298361; retrospectively registered on November 5, 2014.",
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T2 - A mixed methods study

AU - Devoe, Jennifer

AU - Hoopes, Megan

AU - Nelson, Christine A.

AU - Cohen, Deborah

AU - Sumic, Aleksandra

AU - Hall, Jennifer

AU - Angier, Heather

AU - Marino, Miguel

AU - O'Malley, Jean P.

AU - Gold, Rachel

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N2 - Background: Children with health insurance have increased access to healthcare and receive higher quality care. However, despite recent initiatives expanding children's coverage, many remain uninsured. New technologies present opportunities for helping clinics provide enrollment support for patients. We developed and tested electronic health record (EHR)-based tools to help clinics provide children's insurance assistance. Methods: We used mixed methods to understand tool adoption, and to assess impact of tool use on insurance coverage, healthcare utilization, and receipt of recommended care. We conducted intent-to-treat (ITT) analyses comparing pediatric patients in 4 intervention clinics (n = 15,024) to those at 4 matched control clinics (n = 12,227). We conducted effect-of-treatment-on-the-treated (ETOT) analyses comparing intervention clinic patients with tool use (n = 2240) to intervention clinic patients without tool use (n = 12,784). Results: Tools were used for only 15% of eligible patients. Qualitative data indicated that tool adoption was limited by: (1) concurrent initiatives that duplicated the work associated with the tools, and (2) inability to obtain accurate insurance coverage data and end dates. The ITT analyses showed that intervention clinic patients had higher odds of gaining insurance coverage (adjusted odds ratio [aOR] = 1.32, 95% confidence interval [95%CI] 1.14-1.51) and lower odds of losing coverage (aOR = 0.77, 95%CI 0.68-0.88), compared to control clinic patients. Similarly, ETOT findings showed that intervention clinic patients with tool use had higher odds of gaining insurance (aOR = 1.83, 95%CI 1.64-2.04) and lower odds of losing coverage (aOR = 0.70, 95%CI 0.53-0.91), compared to patients without tool use. The ETOT analyses also showed higher rates of receipt of return visits, well-child visits, and several immunizations among patients for whom the tools were used. Conclusions: This pragmatic trial, the first to evaluate EHR-based insurance assistance tools, suggests that it is feasible to create and implement tools that help clinics provide insurance enrollment support to pediatric patients. While ITT findings were limited by low rates of tool use, ITT and ETOT findings suggest tool use was associated with better odds of gaining and keeping coverage. Further, ETOT findings suggest that use of such tools may positively impact healthcare utilization and quality of pediatric care. Trial registration: ClinicalTrials.gov, NCT02298361; retrospectively registered on November 5, 2014.

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KW - Children

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KW - Community health centers

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KW - Health insurance

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