Informatics Systems and Tools to Facilitate Patient-centered Care Coordination

References
1 Committee on Quality of Health Care in America, Insitute of Medicine.. Crossing the quality chasm: a new health system for the 21^st century. Washington, D.C: National Academy Press; 2001
2 Gerteis M, Edgeman-Levitan S, Daley J, Delbanco T. editors. Through the patient’s eyes: understanding and promoting patient-centered care. 1st ed. San Francisco, CA: Jossey-Bass; 2002
3 Osborn R, Moulds D, Squires D, Doty MM, Anderson C. International survey of older adults finds shortcomings in access, coordination, and patient-centered care. Health Aff (Millwood) 2014; Dec 33 (Suppl. 12) 2247-55.
4 Bates DW, Bitton A. The future of health information technology in the patient-centered medical home. Health Aff (Millwood) 2010; Apr 29 (Suppl. 04) 614-21.
5 Epstein RM, Street RL. The values and value of patient-centered care. Ann Fam Med 2011; 9 (Suppl. 02) 100-3.
6 National Committee for Quality Assurance.. NCQA patient-centered medical home: improving experiences for patients, providers, and practice staff. Washington, D.C: NCQA; 2014
7 O’Malley AS, Gourevitch R, Draper K, Bond A, Tirodkar MA. Overcoming challenges to teamwork in patient-centered medical homes: a qualitative study. J Gen Intern Med 2015; Feb 30 (Suppl. 02) 183-92.
8 Rodriguez HP, Meredith LS, Hamilton AB, Yano EM, Rubenstein LV. Huddle up!: The adoption and use of structured team communication for VA medical home implementation. Health Care Manage Rev 2014 July 15. [Epub ahead of print]
9 Gabrielová J, Veleminsky Sr. M. Interdisciplinary collaboration between medical and non-medical professions in health and social care. Neuro Endocrinol Lett 2014; 35 Supp 59-66.
10 Talliani CA, Bricker PL, Adelman AM, Cronholm PF, Gabbay RA. Implementing effective care management in the patient-centered medical home. Am J Manag Care 2013; Dec 19 (Suppl. 12) 957-64.
11 Legault F, Humbert J, Amos S, Hogg W, Ward N, Dahrouge S. et al. Difficulties encountered in collaborative care: logistics trumps desire. J Am Board Fam Med 2012; Mar-Apr 25 (Suppl. 02) 168-76.
12 Gurwitz J, Field T, Ogarek J, Tjia J, Cutrona S, Harrold L. et al. An electronic health record–based intervention to increase follow-up office visits and decrease rehospitalization in older adults. J Am Geriatr Soc 2014; May 65 (Suppl. 05) 865-71.
13 Saleh S, Freire C, Morris-Dickinson G, Shannon T. An effectiveness and cost-benefit analysis of a hospital-based discharge transition program for elderly Medicare recipients. J Am Geriatr Soc 2012; Jun 60 (Suppl. 06) 1051-6.
14 Wee S, Loke C, Liang C, Ganesan G, Wong L, Cheah J. Effectiveness of a national transitional care program in reducing acute care use. J Am Geriatr Soc 2014; Apr 62 (Suppl. 04) 747-53.
15 Tang N, Fujimoto J, Karliner L. Evaluation of a primary care-based post-discharge phone call program: keeping the primary care practice at the center of post-hospitalization care transition. J Gen Intern Med 2014; Nov 29 (Suppl. 11) 1513-8.
16 Marek K, Stetzer F, Ryan P, Bub L, Adams S, Schlidt A. et al. Nurse care coordination and technology effects on health status of frail older adults via enhanced self-management of medication: randomized clinical trial to test efficacy. Nurs Res 2013; Jul-Aug 62 (Suppl. 04) 269-78.
17 Jones K, Dunning T, Costa B, Fitzgerald K, Adaji A, Chapman C. et al. The CDM-Net Project: the development, implementation and evaluation of a broadband-based network for managing chronic disease. Int J Family Med 2012; 2012: 453450.
18 Adji A, Schattner O, Jones K, Beovich B, Piterman L. Care planning and adherence to diabetes process guidelines: medicare data analysis. Aust Health Rev 2013; Feb 37 (Suppl. 01) 83-7.
19 Rosenbloom ST, Harris P, Pulley J, Basford M, Grant J, DuBuisson A. et al. The Mid-South Clinical Data Research Network. J Am Med Inform Assoc 2014; Jul-Aug 21: 627-32.
20 Eslami S, Askari M, Medlock S, Arts DL, Wyatt JC, van Weert HC. et al. From assessment to improvement of elderly care in general practice using decision support to increase adherence to ACOVE quality indicators: study protocol for randomized control trial. Trials 2014 Mar 19 15(81)
21 Man C, Nguyen C, Stephen Lin M. Effectiveness of a smartphone app for guiding antidepressant drug selection. Fam Med 2014; Sept 46 (Suppl. 08) 626-30.
22 Obviagele B. Phone-based intervention under nurse guidance after stroke: concept for lowering blood pressure after stroke in sub-saharan Africa. J Stroke Cerebrovasc Dis 2015; Jan 24 (Suppl. 01) 1-9.
23 Børøsund E, Ruland CM, Moore S, Ekstedt M. Nurses’ experiences of using an interactive tailored patient assessment tool one year past implementation. Int J Med Inform 2014; Jul 83 (Suppl. 07) e23-e34.
24 Alden DL, Friend J, Schapira M, Stiggelbout A. Cultural targeting and tailoring of shared decision making technology: a theoretical framework for improving the effectiveness of patient decision aids in culturally diverse groups. Soc Sci Med 2014; Mar 105: 1-8.
25 Durand MA, Carpenter L, Dolan H, Bravo P, Mann M, Bunn F. et al. Do interventions designed to support shared decision-making reduce health inequalities? A systematic review and meta-analysis. PloS One 2014 Apr 15 9 (Suppl. 04) e94670.
26 Connecting for Health, Markle Foundation.. The personal health woring group: final report. New York, NY: Markle Foundation; 2003
27 Ronda MC, Dijkhorst-Oei LT, Rutten GE. Reasons and barriers for using a patient portal: survey among patients with diabetes mellitus. J Med Internet Res 2014 Nov 25 16 (Suppl. 11) e263.
28 Krist AH, Woolf SH, Bello GA, Sabo RT, Longo DR, Kashiri P. et al. Engaging primary care patients to use a patient-centered personal health record. Ann Fam Med 2014; Sept-Oct 12 (Suppl. 05) 418-26.
29 Van Gorp P, Comuzzi M, Jahnen A, Kaymak U, Middleton B. An open platform for personal health record apps with platform-level privacy protection. Comput Biol Med 2014; Aug 51: 14-23.
30 Greysen SR, Khanna RR, Jacolbia R, Lee HM, Auerbach AD. Tablet computers for hospitalized patients: a pilot study to improve inpatient engagement. J Hosp Med 2014; Jun 9 (Suppl. 06) 396-9.
31 Cabitza F, Simone C, Michelis GD. User-driven prioritization of features for a prospective InterPersonal Health Record: perceptions from the Italian context. Comput Biol Med 2015; Apr 59: 202-10.
32 Tom J, Mangione-Smith R, Solomon C, Grossman D. Integrated personal health record use: association with parent-reported care experiences. Pediatrics 2012; Jul 130 (Suppl. 01) e183-90.
33 Logue M, Effken J. An exploratory study of the personal health records adoption model in the older adult with chronic illness. Inform Prim Care 2012; 20 (Suppl. 03) 151-69.
34 Wagner P, Dias J, Howard S, Kintziger K, Hudson M, Seol Y. et al. Personal health records and hypertension control: a randomized trial. J Am Med Inform Assoc 2012; Jul-Aug 19 (Suppl. 04) 626-34.
35 Steventon A, Bardsley M, Billings J, Dixon J, Doll H, Hirani S. et al. Effect of telehealth on use of secondary care and mortality: findings from the Whole System Demonstrator cluster randomised trial. BMJ 2012 Jun 21 344: e3874.
36 Takahashi PY, Pecina JL, Upatising B, Chaudhry R, Shah ND, Van Houten H. et al. A randomized controlled trial of telemonitoring in older adults with multiple health issues to prevent hospitalizations and emergency department visits. Arch Intern Med 2012 May 28 172 (Suppl. 10) 773-9.
37 Looman W, Erickson M, Garwick A, Cady R, Kelly A, Pettey C. et al. Meaningful use of data in care coordination by the advanced practice RN: the TeleFamilies project. Comput Inform Nurs 2012; Dec 30 (Suppl. 12) 649-54.
38 Natsiavas P, Filos D, Maramis C, Chouvarda I, Schoneberg H, Pauws S. et al. A computational infrastructure for evaluating care-coordination and telehealth services in Europe. Stud Helath Technol Inform 2014; 205: 216-20.
39 Segal J, DuGoff E. Building blocks for measuring care coordination with claims data. Popul Health Manag 2014; Aug 17 (Suppl. 04) 247-52.
40 Darkins A, Kendall S, Edmonson E, Young M, Stressel P. Reduced cost and mortality using home telehealth to promote self-management of complex chronic conditions: a retrospective matched cohort study of 4,999 veteran patients. Telemed J E Health 2015; Jan; 21 (Suppl. 01) 70-6.
41 McFarland M, Davis K, Wallace J, Wan J, Cassidy R, Morgan T. et al. Use of home telehealth monitoring with active medication therapy management by clinical pharmacists in veterans with poorly controlled type 2 diabetes mellitus. Pharmacotherapy 2012; May 35 (Suppl. 05) 420-6.
42 Stenger RJ, Smith J, McMullan Jr. JB, Rodriguez GS, Dorr DA, Minniti M, Jaffe A, Pollack D. et al. Defining the medical home: the Oregon experience. J Am Board Fam Med 2012; NovDec 25 (Suppl. 06) 869-77.
43 Weeks DL, Polello JM, Hansen DT, Kenney BJ, Conrad DA. Measuring primary care organizational capacity for diabetes care coordination: the Diabetes Care Coordination Readiness Assessment. J Gen Intern Med 2014; Jan 29 (Suppl. 01) 98-103.
44 Alexander J, Paustian M, Wise C, Green L, Feters M, Mason M. et al. Assessment and measurement of patient-centered medical home implementation: the BCBSM experience. Ann Fam Med 2013; MayJun 11 Suppl 1: S74-81.
45 Borson S, Chodosh J. Developing dementia-capable health care systems: a 12-step program. Clin Geriatr Med 2014; Aug 30 (Suppl. 03) 395-420.
46 DuGoff E, Dy S, Giovannetti E, Leff B, Boyd C. Setting standards at the forefront of delivery system reform: aligning care coordination quality measures for multiple chronic conditions. J Healthc Qual 2013; Sept-Oct 35 (Suppl. 05) 58-69.
47 Vanderlip E, Cerimele J, Monroe-Devita M. A comparison of assertive community treatment fidelity measures and patient-centered medical home standards. Psychiatr Serv 2013 Nov 1 64 (Suppl. 11) 1127-33.
48 Wang J, Cha J, Sebek K, McCullough C, Parsons A, Singer J. et al. Factors related to clinical quality improvement for small practices using an EHR. Health Serv Res 2014; Dec 49 (Suppl. 06) 1729-46.
49 Kansagara D, Tuepker A, Joos S, Nicolaidis C, Skaperdas E, Hickam D. Getting performance metrics right: a qualitative study of staff experiences implementing and measuring practice transformation. J Gen Intern Med 2014; Jul;29 (Suppl. 02) S607-13
50 Casey M, Prasad S, Klingner J, Moscovice I. Are the CMS hospital outpatient quality measures relevant for rural hospitals?. J Rural Health 2012; Summer 28 (Suppl. 03) 248-59.
51 Eidus R, Pace W, Staton E. Managing patient populations in primary care: points of leverage. J Am Board Fam Med 2012; Mar-Apr 25 (Suppl. 02) 238-44.
52 Bottino CJ, Cox JE, Kahlon PS, Samuels RC. Improving immunization rates in a hospital-based primary care practice. Pediatrics 2014; Apr 133 (Suppl. 04) e1047-54.
53 Ohl M, Dillon D, Moeckli J, Ono S, Waterbury N, Sissel J. et al. Mixed-methods evaluation of a telehealth collaborative care program for persons with HIV infection in a rural setting. J Gen Intern Med 2013; Sep 28 (Suppl. 09) 1165-73.
54 Baus A, Wood G, Pollard C, Summerfield B, White E. Registry-based diabetes risk detection schema for the systematic identification of patients at risk for diabetes in West Virginia primary care centers. Perspect Health Inf Manag 2013 Oct 1:1f. eCollection 2013.
55 Brown C, Perkins J, Blust A, Kahn R. A neighborhood-based approach to population health in the pediatric medical home. J Community Health 2015; Feb 40 (Suppl. 01) 1-11.
56 Reuben D, Evertson L, Wenger N, Serrano K, Chodosh J, Ercoli L. et al. The University of California at Los Angeles Alzheimer’s and Dementia Care Program for comprehensive, coordinated, patient-centered care: preliminary data. J Am Geriatr Soc 2013; Dec 61 (Suppl. 12) 2214-8.
57 Commission to the European Parliament, the Council, the European Economic and Social Committee, and the Committee of the Regions, European Comission.. eHealth Action Plan 2012-2020- Innovation for the 21^st Century. Brussels, Belgium: 2012