The eHealth Initiative has released a new report exploring the role of  electronic health records in care coordination for patients with complex illnesses, such as type 2 diabetes and heart disease.

The eHealth Initiative conducted the study with Sanofi-Aventis and Health & Technology Vector (H&TV).

Researchers on the project said the study was needed because EHRs are considered an essential ingredient of care coordination by medical homes, but "detailed descriptions of how it actually happens in real life are rarely found."

[Read more on medical home models: Use your head when putting business intelligence to work.]

For the study, researchers said they began with an operational definition of, and measures for, care coordination. They also tried to identify existing gaps in care coordination between medical homes and specialists.

Many statistics gathered for background in the study pointed to the need for better care coordination in ambulatory care, specifically the rates of unnecessary hospitalizations, adverse drug events and re-admissions nationally, they said.

The study was based on a 12-month project that tracked 119 patients with type 2 diabetes and heart disease over a six-month period at two pilot sites: Community Health Center, Inc. in Connecticut and a small primary care practice that is part of Taconic Independent Practice Association in New York.

"We knew going into this project that interaction between caregivers and patients was important, but our observations at the two test sites drove home the fact that care coordination requires ongoing and explicit three-way communication between patient, primary care physician and specialist in order to be successful and sustainable, said Jennifer Covich Bordenick, CEO of the eHealth Initiative.

Victor Villagra, MD, president of Health & Technology Vector, worked directly with the clinics on the project.  "With use of a care plan enabled by the EHR, we were able to streamline the care process for these patients and more efficiently track their progress," Villagra said. "For example, at one site, six separate cardiology referral forms were used before the project began. Following the intervention a single form was developed and formatted within the EHR."

The full report can be found here.

[See also: Los Angeles health centers go for medical home model.]

Follow Diana Manos on Twitter @DManos_IT_News.