Introduction
Effective coordination of patient care by a multidisciplinary team is a key goal of the patient-centered medical home (PCMH).1 Care coordination is particularly important for complex patients, or those with multiple comorbidities and social support needs. However, care coordination is often hampered by disjointed communication and lack of a supportive documentation infrastructure. Care planning has been proposed as a solution for improving team-based care of complex patients. An effective ECP provides an overarching blueprint centered around a patient’s needs, improves coordination among the different team members (TMs) caring for a patient, establishes task accountability and supports selfmanagement goals.2,3
Despite recognition of care planning’s potential, information technology (IT) tools that effectively facilitate this process are not regularly available within current PC IT systems. Additionally, although small studies have demonstrated the benefit of EMR-based ECP tools,4 in practice, ECPs are not typically used in the ambulatory setting and significant ambiguity exists regarding what constitutes care planning.3 Where longitudinal ECPs exist, they are often not standardized or interdisciplinary in nature and are variably found in electronic format.5 And while care planning and coordination are of significant interest to commercial vendors, commercial tools are more commonly used for data aggregation and identification of high-risk populations and overdue interventions rather than for workflow coordination or communication enhancement capabilities.6
In order to be effective, IT tools should be designed to fit the needs of on-the-ground users. We thus conducted a qualitative study to identify the characteristics of a tool that would facilitate electronic, team-based care planning for medically and socially complex patients.