What Are the Critical Components of an Electronic Care Plan Tool for Primary Care?

Abstract

Background: There is a critical need for electronic tools that facilitate multidisciplinary care for complex patients in the PCMH. Our goal was to identify the essential components of a PC-based ECP tool necessary for next-generation health information technology systems. Methods: We conducted 3 focus groups, 9 semi-structured interviews, and a 4-week pre-post pilot study of an ECP prototype at the Jen Center for Primary Care, an academic internal medicine practice that serves ~20,000 complex patients. Results: The critical components of an ECP identified were: 1) patient background information, including: patient demographics, care TM designation and key patient contacts, 2) user- and patient-centric task management functionalities, 3) a summary of a patient’s care needs linked to the responsible member of the care team, and 4) integration with the EMR. Use of an ECP tool supported by team-based huddles increased satisfaction with intra-team task assignment, intra-team appointment referrals, and accessing background information. It also resulted in staff members having a more unified understanding of shared patients’ goals and priorities. Conclusions: An ECP tool with key components incorporated can significantly enhance the practice of team-based PC. Our experience emphasizes the utility of ECP tools that are readily editable, facilitate intra-team information sharing, and support team-based workflows.