Electronic health record tools to assist with children’s insurance coverage: a mixed methods study

We implemented the EHR-based tools in four intervention CHCs and selected four matched control CHCs for comparison. We used a retrospective cohort design to identify our pediatric study population (aged 0–19 at time of visit). We measured tool use; assessed facilitators and barriers to tool use; and assessed tool impact and effect on health insurance coverage, CHC utilization, and receipt of recommended care. We used intent-to-treat (ITT) analyses to measure tool impact at the population level. We used effect-of-treatment-on-the-treated (ETOT) analyses to measure what happened when the tools were used and to distinguish consideration of the tools’ effect on individuals from consideration of the tools’ effect on populations. Details of the study design and tool development processes were previously described [21, 23, 24].

The tools were implemented on 6/1/2014; we collected and analyzed data from 6 months pre-implementation through 18 months post-implementation.

Participating CHCs were members of OCHIN, Inc., a 501(c)(3) organization that provides health information technology to CHCs [25, 26]. The majority of these CHCs’ pediatric patients met income eligibility for Medicaid or CHIP, yet many were uninsured at the time of a visit, and thus could benefit from the tools. OCHIN members share an Epic© EHR, making it possible to build and implement the study tools on a single EHR platform, and centrally obtain EHR data.

Eight CHCs participated in this study: four Oregon CHCs volunteered to be ‘intervention’ sites, and four ‘control’ sites were selected from a pool of 38 non-intervention CHCs in Oregon using a propensity score technique [27] to match sites by patient population demographics (ratio of children to adults and percent Hispanic ethnicity) and date of EHR implementation (number of months of clinic EHR experience). The clinic with the closest propensity score was selected as the matched control for each intervention clinic. In addition to matching, we controlled for differences between intervention and control sites (i.e., residual confounding) through statistical regression adjustment.

We developed the EHR tools in OCHIN Epic© via a user-centered design process, described elsewhere [23, 24]. Detailed tool descriptions are provided in Additional file 1. The central tool was a health insurance assistance tracking form in a patient’s medical record; we used data from this tool to determine that patients had been exposed to the intervention. In addition to the tracking form, pop-up alerts were built into the EHR to notify staff when a patient’s insurance was soon to expire or when a patient appeared eligible but was not enrolled in public insurance. These were visible in the EHR at all relevant patient visits. A data roster tool was also available for CHC staff to create lists of patients for whom insurance assistance had been initiated and required follow-up, or who had an upcoming appointment and might need enrollment support. The tools were designed with low-income pediatric patients in mind but were available for use on any patients at the intervention clinics.

We used patient-level EHR data to assess whether or not the health insurance assistance tracking form was used, and to obtain demographic and visit data. We also used EHR data to assess coverage status at visits. To quantify longitudinal insurance coverage periods (coverage start and end dates), we created individual patient linkages between EHR data and Medicaid/CHIP enrollment data from the state of Oregon, per established methods using Medicaid/CHIP identification numbers [28‐30]. We used household case numbers in the Medicaid/CHIP enrollment data to measure how long each household was established at a clinic.

The primary predictor variable for ITT analyses was whether a pediatric patient received care at one of the four intervention clinics versus one of the four control clinics. The primary predictor variable for ETOT analyses was whether or not a pediatric patient in the intervention clinics had the tracking tool used to assist them or not. Other covariates are shown in the tables. Outcome variables were: health insurance coverage status, coverage gain, coverage loss, utilization of care, and receipt of recommended care (assessed using healthcare quality measures from the Children’s Health Insurance Program Reauthorization Act (CHIPRA)) [31].

We used mixed methods to measure rates of tool use and to understand facilitators and barriers to tool use [32]. We used ITT and ETOT analyses to assess the impact of the tools on health insurance coverage, CHC utilization, and receipt of recommended healthcare services. In ITT analyses, we compared pediatric patients with ≥1 clinical visit at an intervention clinic (n = 15,024) to those with ≥1 clinical visit at a matched control CHC (n = 12,227); see Fig. 1. In ETOT analyses, among all pediatric patients with ≥1 clinical visit at an intervention clinic, we compared those patients on whom the tracking tool was used (n = 2240) with those on whom the tool was not used (ETOT comparisons, n = 12,784); Fig. 1. To assess outcomes related to coverage and utilization, we conducted several of the analyses in subgroups of patients for whom we had Medicaid data (described below).

The tracking tool was used for approximately 15% of pediatric patients with ≥1 clinical visit at an intervention site (Fig. 1 and Table 1). Tool use changed over time: an initial spike in use, which then followed by decreasing use over several months. After additional site visits and trainings, tracking tool use increased gradually but steadily throughout follow-up. By the end of follow-up, the tracking tool was being used on about 17% of pediatric patients per month (Fig. 2).

The characteristics of children at intervention clinics differed from those seen in matched control clinics. Intervention clinic patients were older, more commonly Hispanic and Spanish-speaking, and had lower household incomes (p < .001 for all). Within the intervention clinics, patients with tool use differed from those for whom the tool was not used, notably by ethnicity: 95% of patients with tool use were Hispanic, compared to 65% of within-clinic comparison patients; and 88% used Spanish as their primary language, compared to 51% (p < .001 for both, Table 1). Qualitative findings concurred that patients’ ethnicity and language drove tool use in the intervention clinics. Children for whom the tool was used were also older, had lower household incomes, were more likely to be established clinic patients, and had more clinical encounters during the study period compared to within-clinic comparison patients (p < .001).

Although designed for use with established pediatric patients, we observed tool use in two additional groups: (1) children with no clinical visits in the assessment period (n = 969), and (2) adult patients (n = 3207); see Additional file 2. We also qualitatively observed eligibility specialists using the tracking tool in unanticipated ways. For example, family members often came in together for insurance assistance, and eligibility specialists initiated entries into the tracking tool for everyone in the family. Additionally, almost one-third of adults with a Medicaid ID for whom the tracking tool was used did not share a case number with other household members, which indicated that the tracking tool was used for ‘single’ adults, not just family members of children being assisted.

Qualitative data suggest that tool use was affected by two factors. First, several initiatives were occurring concurrent to the study period, including Oregon’s 2014 Medicaid expansions; the US Health Resources and Services Administration (HRSA) funding for CHCs to extend insurance assistance to all community members; [34] and an alternative payment program requiring staff to document every type of patient interaction, including insurance assistance, using specified reporting methods.

These concurrent initiatives created a frenzy of insurance-oriented change, increased eligibility specialists’ workloads, and distracted staff from using the tracking tool consistently. In addition, our tools could not be easily adapted to the new workflow and reporting requirements involved in the HRSA and alternate payment model initiatives. Consequently, to avoid duplicate data entry, CHC staff often tracked insurance-related interactions in spreadsheets, rather than the tracking and roster tools. Eligibility specialists’ increased workloads also limited the time they had to use the roster tool to identify patients whose insurance was nearing expiration:

It’s been really hard for me to get into that list. I know I should be working on it … even though I do the application online, it’s fairly time consuming ... So unless we block the schedule … there is not enough time to do the follow-up list. [Clinic 4, Eligibility Specialist]

Second, as the state was flooded with expanded Medicaid insurance applications, some enrollees had their insurance ‘end dates’ electronically extended, so the end dates shown in our tools did not always coincide with the end dates an enrollee received from the state. This discrepancy confused eligibility specialists about when they should help patients reapply:

We think that the insurance is supposed to be expired by January. Then we realize that it’s been extended three more months. When we check [in] three more months, the next day there’s another three more months. So my staff are like, “How can I do any follow up?” […] There is not a real and exactly accurate redetermination date for us to support our patients. [Clinic 4, Eligibility Specialist Supervisor]

We were excited because [the tools were] going to tell us when it’s time to renew. We’re going to be able to research all these patients and call them ... But then it didn’t really work. And then the front would schedule appointments because [the tool] would say it’s time to renew. But then when they would come [in] I would call and [the state] would say, no, it’s not time. So that was kind of a bummer. We thought it would work, and ... help not only the patient but, you know, us too. [Clinic 5, Eligibility Specialist]

As a result, staff who were initially excited about using the tools could not trust the pop-up alerts to accurately notify them when patients needed to re-enroll, so they ignored the pop-ups and did not initiate tracking tool entries for additional patients.

In ITT analyses, 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 (Table 2). Similarly, in ETOT analyses, patients with tool use had higher odds of gaining insurance (aOR = 1.83, 95%CI 1.64–2.04), and lower odds of losing it (aOR = 0.70, 95%CI 0.53–0.91), versus patients in the clinic without tool use; Table 2.

In ITT analyses, uninsured intervention clinic patients had higher odds of being uninsured at all return visits (aOR = 2.00, 95%CI 1.37–2.94) and lower odds of being insured by Medicaid at any return visit (aOR = 0.42, 95% CI 0.29–0.61), compared to control clinic patients (Table 3). These relationships were reversed in ETOT analyses: uninsured patients with tool use had lower odds of being uninsured at all return visits (aOR = 0.49, 95%CI 0.27–0.90), and a trend toward higher odds of being insured by Medicaid (aOR = 2.00, 95% CI 0.93–4.31, ns), compared to patients without tool use (Table 3). The ETOT analysis also found higher odds of a return visit after an uninsured visit among treated patients (aOR = 1.78, 95%CI 1.42–2.23), Table 3.

In ITT analyses, intervention clinic patients had lower odds of receipt of several services versus control clinic patients (well-child visits in first 15 months, chlamydia screening, and MMR), but higher rates and odds of immunizations for adolescents (Table 4). In ETOT comparisons, tool use was associated with higher rates of receipt of most assessed services (Table 4). For example: 63% of eligible patients with tool use received recommended well-child visits by 15 months of age, versus 39% of within-clinic comparison patients (p < .001; aOR = 1.54, 95% CI 1.06–2.25); females for whom the tool was used were more likely to complete human papillomavirus (HPV) vaccination by age 13 (54%), versus 36% of within-clinic comparisons (p < .001; aOR = 1.44, 95%CI 1.12–1.84).

To accommodate stakeholder requests, our intervention was not randomly allocated to the four CHCs we initially recruited – all four received the intervention. Instead, we used propensity score techniques to identify four comparable matched CHCs. Although this approach is not as closely controlled as a more traditional randomized trial, it was chosen to suit this pragmatic, real-world evaluation. This approach was also more ethically appropriate for research in this setting because it enabled us to avoid recruiting CHCs who were very reluctant to be randomized into a control arm. Even using these matching methods, there were still significant differences between intervention and control sites, due to the small number of non-intervention CHCs available for matching. We attempted to address this imbalance through additional statistical regression adjustment. As with any observational study, there may have been unobserved differences between study groups, which in turn may have affected the study results. Due to EHRs not being structurally designed to link records for families, we could not assess whether tool use was impacted by the number of individuals assisted in a given family. The length of our follow-up period was 18 months, which may not have been sufficiently long to assess tool adoption and impact, including changes to CHC utilization and recommended care receipt. In addition, it was only technically feasible to quantify use of the tracking tool at the individual level, so we selected use of this tool to indicate that individual patients had been exposed to the intervention. While we evaluated use of the pop-up alert and roster tools in qualitative data collection, we were not able to assess whether use of these other features impacted the outcomes of interest. It is possible that non-tool use patients (our ETOT comparison group) had some action taken from the pop-up or roster tools that was not quantitatively tracked, thus underestimating our measures of tool effect.

While many of the ETOT results are promising, we caution against drawing long term conclusions based on these results in light of the more equivocal ITT findings. For EHR tools such as these to show convincing population-level impacts, they must be broadly adopted. Nonetheless, we did observe significant benefit among patients for whom clinic staff thought the tools would be useful.

Despite barriers to tool adoption, our results suggest several future potential benefits of EHR-based insurance assistance tools. CHC staff saw benefit in using the tools, especially for Hispanic, Spanish-speaking patients, and for some individuals beyond the study population (e.g., adults). It was encouraging to observe that the tools were used to assist many adults (n = 3207) as well as children (2240) in the intervention clinics. Many of these adults had a child who was also assisted, and qualitative data concurred that eligibility specialists often aided entire families. This finding led our team to obtain funding to develop and test similar tools for adults [37]. We also learned that designing and implementing EHR-based insurance assistance tools requires close collaboration with payers (e.g., Medicaid/CHIP), an infrastructure that can generate accurate data on insurance end dates, [38] and one that can be easily adapted to a changing insurance landscape.