Person:

Amir, Ofra

Teamwork and care coordination are of increasing importance to health care delivery and patient safety and health. This paper describes our initial work on developing agents that are able to make intelligent information sharing decisions to support a diverse, evolving team of care providers in constructing and maintaining a shared plan that operates in uncertain environments and over a long time horizon.

Children with complex health conditions require care from a large, diverse team of caregivers that includes multiple types of medical professionals, parents and community support organizations. Coordination of their outpatient care, essential for good outcomes, presents major challenges. Extensive healthcare research has shown that the use of integrated, team-based care plans improves care coordination, but such plans are rarely deployed in practice. This paper reports on a study of care teams treating children with complex conditions at a major university tertiary care center. This study investigated barriers to plan implementation and resultant care coordination problems. It revealed the complex nature of teamwork in complex care, which poses challenges to team coordination that extend beyond those identified in prior work and handled by existing coordination systems. The paper builds on a computational teamwork theory to identify opportunities for technology to support increased plan-based complex-care coordination and to propose design approaches for systems that enable and enhance such coordination.

Children with complex health conditions require care from a large, diverse set of caregivers that includes parents and community support organizations as well as multiple types of medical professionals. Coordination of their care is essential for good outcomes, and extensive research has shown that the use of integrated, team -based care plans improves care coordination. Care plans, however, are rarely deployed in practice. This paper describes barriers to effective implementation of care plans in complex care revealed by a study of care providers treating such children. It draws on teamwork theories, identifying ways AI capabilities could enhance care plan use; describes the design of GoalKeeper, a system to support providers use of care plans; and describes initial work toward information sharing algorithms for such systems.