American Academy of Nursing on Policy

The importance of health information technology in care

coordination and transitional care
Pamela F. Cipriano, PhD, RN, NEA-BC, FAANa,*, Kathryn Bowles, PhD, RN, FAANb,
Maureen Dailey, DNSc, RN, CWOCNb, Patricia Dykes, DNSc, MA, RN, FAANb,
Gerri Lamb, PhD, RN, FAANb, Mary Naylor, PhD, RN, FAANb
a
Galloway Consulting and University of Virginia School of Nursing, Charlottesville, VA
b
Care Coordination Members

Executive Summary
Care coordination and transitional care services are
strategically important for achieving the priorities of
better care, better health, and reduced costs embodied
in the National Strategy for Quality Improvement in
Health Care (National Quality Strategy [NQS]). Some of
the most vulnerable times in a persons care occur with
changes in condition as well as movement within and
between settings of care. The American Academy of
Nursing (AAN) believes it is essential to facilitate the
coordination of care and transitions by using health
information technology (HIT) to collect, share, and
analyze data that communicate patient-centered in-
formation among patients, families, and care providers
across communities.
HIT makes information accessible, actionable,
timely, customizable, and portable. Rapid access to
information also creates efficiencies in care by elimi-
nating redundancies and illuminating health history
and prior care. The adoption of electronic health re-
cords (EHRs) and information systems can enable care
coordination to be more effective but only when a
number of essential elements are addressed to reflect
the team-based nature of care coordination as well as a
focus on the individuals needs and preferences.
To that end, the AAN offers a set of recommendations
to guide the development of the infrastructure,
standards, content, and measures for electronically
enabled care coordination and transitions in care as
well as research needed to build the evidence base to
assess outcomes of the associated interventions.
Technology, and the Administrator for the Centers for
Medicare and Medicaid (CMS) should expedite
completion and dissemination of the format for a sin-
gle consensus-based, longitudinal patient-centered
plan of care (LPC) framework to enhance coordinated
care planning and implementation, communication,
and continuity. Furthermore, they should endorse the
use of this single framework and ensure the following:
1. The LPC framework must include data generated by
all clinicians.
2. The CMS must reconcile or harmonize the data re-
quirements for home care, long-term care, acute and
postacute care.
3. The LPC data must be interoperable and accessible to
all providers across settings.
4. Patients and their families must have access to their
own data and information.
Recommendation 2
To ensure an adequate diversity of perspectives, HHS,
the Office of the National Coordinator of HIT (ONC), the
National Quality Forum (NQF), CMS, and the Agency for
Healthcare Research and Quality (AHRQ) should appoint
a greater number of nurses and other health care pro-
fessionals who are carrying out or researching care co-
ordination and transitional care activities to decision-
making bodies that will determine the frameworks,
standards, and electronic measures (eMeasures) for care
coordination activities and effectiveness. Broader input
is needed to address the following:

1. Technical expert panels developing care coordina-

Recommendation 1 tion concepts and specifications for eMeasures
require the expertise of nurses and others delivering
The Secretary of Health and Human Services (HHS), these services directly to patients and families as
the National Coordinator for Health Information well as those with relevant research expertise.

Reviewers: Dana Alexander, MSN, MBA, RN, FHIMSS, FAAN, Norma Lang, PhD, RN, FRCN, FAAN.
* Corresponding author: Dr. Pamela F. Cipriano, 512 Rosemont Drive, Charlottesville, VA 22903.
E-mail address: pcipriano93@gmail.com (P.F. Cipriano).
0029-6554/$ - see front matter 2013 Elsevier Inc. All rights reserved.
http://dx.doi.org/10.1016/j.outlook.2013.10.005
476 Nurs Outlook 61 (2013) 475e489
2. Data elements required for effective care coordina-
tion that are built into HIT systems must capture
actions of all care providers;
3. Data elements for care coordination and transitional
care must articulate patient and caregiver preferences
and needs across patient settings and professional
groups;
Recommendation 3
The AAN together with the American Nurses Associa-
tion, other national nursing organizations, and nurse
leaders must do the following:
1. Articulate the data elements that describe
nurses actions and shared activities of care co-
ordination and transitional care to be captured in
EHRs that will build the evidence base for these
actions.
2. Stipulate that the inclusion of care coordination and
transitional care data elements be part of the con-
tent in electronic clinical information systems (CISs)
as a requirement for purchase.
3. Develop and advance a research agenda to the
Agency for Healthcare Research and Quality,
the National Institutes of Health (NIH), CMS, and the
National Library of Medicine (NLM) to secure funding
for the following:
a. Research studies and quality improvement ini-
tiatives that analyze care coordination data el-
ements and show the relationship between
structures, processes, and outcomes;
b. Research studies that identify standardized data
elements leading to the rapid identification of
individuals in subpopulations who will benefit
from care coordination and transitional care
interventions (e.g., those with multiple chronic
or comorbid conditions);
c. Coordination and transition intervention studies;
d. Usability testing of HIT across venues of care;
e. Development and testing of personal health re-
cords content, utilization, and impact;
f. Electronic clinical decision support (CDS) for
coordination and transitional care interven-
tions;
g. Development and testing of e-measures for care
coordination and transitions.
Recommendation 4
Measure developers must create a broader array of
performance eMeasures to evaluate effective care co-
ordination across teams and settings. Attention should
focus on measure topics that are most relevant to
public reporting of outcomes, quality improvement,
and value-based payments. The following are expected:
1. Data capture and reporting are automatic as a
byproduct of clinical documentation.
2. Data elements in the EHR and CDS must describe the
patient-centered LPC, transitional activities, and
outcomes relevant to nursing practice and coordi-
nation of care.
3. Structural measures are included to evaluate the HIT
infrastructure as well as the workforce capacity and
competence in care coordination and transitional
care that contribute to outcomes.
4. Process and outcomes measures are included to
illuminate best practices for at-risk populations that
will identify indications for transition to an appro-
priate care setting and prevent adverse events.
The AAN applauds the continuing efforts of the
Department of Health and Human Services to
encourage the adoption and use of EHRs and CISs to
improve care. Ongoing efforts to strengthen the coor-
dination of care, improve safety, and engage patients
in their own care can be greatly enabled by the strategic
use of HIT that provides sharing of health information
among health care providers, patients, families, and
other stakeholders across all settings of care.
Glide Path to Achieve Improved Care
Coordination with HIT
The coordination of care, especially at transitions,
strives to overcome the cracks in our fragmented
health care system. Coordination demands timely
communication and collaboration among providers
and organizations together with patients and their
caregivers. HIT is a necessary tool to accomplish the
rapid and systematic collection, use, and analysis of
data as well as the sharing of information, which is
critical for patient safety and effective care. The rec-
ommendations included in this article are intended to
accelerate the effective use of HIT for care coordination
as well as to provide specific directives to ensure the
representation and measurement of team-based
approaches to improving coordination and transitions
in care.
HIT can facilitate efficient and successful care co-
ordination by linking patients and providers with data
and information. HIT can ensure that actionable,
timely, patient-centered information is accessible to all
involved in care through interoperable electronic re-
cords. Included in those records must be a single LPC
that supports and guides care team decision making
(inclusive of the patient) across the life span and care
settings. HIT makes possible, in the most efficient
manner, the organization and sharing of information,
collection, clinical use, analysis, and reporting of data
for quality measurement and multidirectional com-
munication among patients and providers and the
greater health care community. The presence and
sharing of information is essential for keeping patients
safe in any setting and during transitions of care. HIT
 Nurs Outlook 61 (2013) 475e489
augments the human interactions that aim to deliver,
measure, and evaluate care.
HIT is a broad array of hardware and software
products that supports the secure collection, clinical
use, storage, and movement of large amounts of
health data about individuals. HIT is a critical foun-
dation of high-value care coordination and transi-
tional care serving patients and providers from
primary care through end-of-life care. Care coordina-
tion and transitional care require timely flow and
synthesis of information among providers within and
across any care experience.1 Closing gaps that have
prevented the availability of timely information en-
sures better integration of care and makes transitions
safer, seamless, efficient, and effective. When widely
adopted, HIT enables communication among pro-
viders, caregivers, patients, and families, which in
turn helps prevent threats to safety, thereby
improving quality and preventing avoidable costs. In
addition, individual data are aggregated and trans-
mitted for use in public health and public reporting
and by payers and policy makers.
This article describes the essential functions of HIT
in care coordination informing nurses and other
health care professionals, care partners, consumers,
payers, and policy makers about the imperative to
ensure the transmission of consistent, timely, patient-
centered2 information among providers, patients and
families, and other stakeholders in the health care
system. The article builds on the AANs policy brief
The Imperative for Patient, Family, and Population
Centered Interprofessional Approaches to Care Coor-
dination and Transitional Care, which offered a set of
recommendations designed to accelerate the delivery
of effective care coordination and transitional care to
ensure better care, better health, and lower costs.
Building on a review of the strengths and challenges
of current EHRs,3 key recommendations focus on
steps to achieve an effective LPC and an interoperable
architecture to support and improve care coordination
1
Transitional care is the range of time-limited services and
environments that complement primary care and are designed to
ensure health care continuity and avoid preventable poor out-
comes among at-risk populations as they move from one level of
care to another, among multiple providers and across settings
(Naylor & Keating, 2008). Care coordination incorporates transi-
tional care and includes a range of continuous activities and
services designed to organize and integrate patient information
and care within and across providers and settings to ensure that
patient needs and preferences for services are met over time.
Although transitional care is targeted at primarily at-risk pop-
ulations, care coordination is relevant to the health care of all
individuals and populations (adapted from McDonald et al., 2010
and NQF, 2006).
2
The terminology patient-centered is used throughout this
article; however, it should be noted that the reference is evolving
to terms such as person-centered and user of health care
services.
3
An EHR is an electronic repository of longitudinal health in-
formation gathered across care settings and care providers
(Caligtan and Dykes, 2011).
477
and transitional care. Also discussed are needed
functionalities, such as the electronic exchange of
information, to better support emerging models of
care believed to be essential for transforming health
care.
The AAN believes that the use of HIT is an essential
tool to meet the strategic imperative to improve care
coordination and transitional care outlined in the NQS
aimed at achieving better care, healthy people and
communities, and affordable care with lower costs
(Department of Health and Human Services, 2011).
Consistent with the Federal HIT Strategic Plan (ONC,
2011), nurses and other health care providers who
strive to deliver patient-centered, efficient, and coor-
dinated care support the use of a wide range of HIT
applications to achieve those goals.
Throughout this article, the AAN recommends
actions to ensure the timely availability of data to pa-
tients, their caregivers, health care providers, and
organizations to facilitate care coordination and
essential activities during transitions in care. The rec-
ommendations address electronic infrastructure,
standards, content, and quality measurement to assess
the effectiveness of care coordination represented in a
single unified plan of care and embodied in team-based
care delivery.
Background: Effective Care Coordination
The AAN recognizes that care coordination and tran-
sitional care are central components of all care de-
livery models to achieve better care, improved health,
and lower costs. The AANs March 2012 policy brief
offered specific recommendations to accelerate the
development and delivery of high-value care coordi-
nation and transitional care. The AANs recommen-
dations highlighted the need for (a) consistent
application of definitions of patient- and family-
centered care coordination and transitional care;
(b) implementation of payment models that support
evidence-based care coordination, including transi-
tional care, within communities by teams that include
nurses and other health professionals; and (c) support
for the infrastructure including workforce develop-
ment and relevant performance measures to promote
replicability and sustainability of such models. The
AAN brief also emphasized the importance of HIT in
supporting high-value care coordination and transi-
tional care by members of the interprofessional health
care team.
The American Nurses Association (2012) issued a
white paper in June 2012 titled The Value of Nursing
Care Coordination, highlighting the central role that
registered nurses play in care coordination and rein-
forcing the Institute of Medicines Future of Nursing
report that nurses and all members of the health care
team must practice at the top of their license to
ensure achievement of the national safety goals. The
478 Nurs Outlook 61 (2013) 475e489
ANAs paper highlights successful care coordination
activities by nurses leading to improved quality and
efficiency across a variety of patient groups and care
settings. The ANA recommends additional research to
advance quality measure development and to
broaden understanding of best practices for care co-
ordination; enhanced education about care coordina-
tion and team-based approaches to care; and support
for nurse-led models of care coordination that offer
greater patient, family, and other community care-
giver engagement. HIT is foundational to these
efforts.
HIT-Enabled Care
The general benefits of HIT-enabled care are amplified
when applied to care coordination. This underscores
the urgency for the greater adoption of EHR systems to
achieve safer, more effective, and more efficient team-
oriented, patient-centered care. If designed and used
appropriately, HIT enables the benefits detailed later
and helps drive accountability for care.
The benefits of HIT-enabled care are as follows:
1. Data availability 24/7
2. Informed decision making
3. Mutually agreed-on patient-centered plan of care
4. More timely actions
5. Automated capture of data for clinical decision
making, reporting of quality measures, and research
6. Opportunity to assess team member contributions
7. Creation of a learning health system
8. Uniform interoperable set of data among health care
organizations and health professionals
EHRs have been associated with significant im-
provements in the transfer of clinical information
among multiple clinicians as well as facilitating
agreement on treatment goals and plans (Graetz et al.,
2009). To ensure widespread benefits of HIT, stan-
dardized, integrated, and interoperable systems must
provide access to patient-related information
including care provided, treatment indications, results,
and ongoing plans across providers, settings, condi-
tions, and time.
New delivery models embodied in Accountable Care
Organizations and patient-centered medical (health)
homes rely on HIT to connect care team members,
patients, caregivers, health plans, and regulatory
agencies and to provide tools for care coordination.
Data analytics, still in their early development, can
provide intelligence to identify high-risk patients,
construct predictive models for risk analysis, avoid
errors and unnecessary care, help manage cost,
improve quality, and measure and report results. The
combination of improved efforts to coordinate care and
apply timely analytics offers the promise of acceler-
ating improvements in population health.
Importance for Patients and Families
The mission of the Federal HIT Strategic Plan 2011 to
2015 (ONC, 2011) is to improve health and health care
for all Americans through the use of information and
technology. The plans goals include the improved
design of HIT policies and programs that will better
meet individual needs and expectations, such as
increased access to personal health information and
the integration of communications between patients
and providers. With easier access to information from
their health care providers and health plans, it is
anticipated that consumers can better manage their
health and health care (Skipper, 2012).
The continuity of care and seamless transition ex-
periences, which is essential to improving health and
health care for patients and family caregivers, can best
be achieved with the aid of HIT. The use of HIT tools
such as EHRs and personal health records (PHRs)4
support comprehensive and efficient coordination of
care. If these records are functionally connected, care
coordination can increase the possibility that patient-
centered goals are met, and patient self-care actual-
ization is supported while avoiding duplicate, futile,
and unwanted care or unnecessary cost.
Joint decision making by stakeholders including
the patient and family can be enhanced through the
use of key EHR information, particularly during tran-
sitional care planning. The information can guide the
type of long-term post-acute care (LTPAC) services
that patients need, prefer, and are covered for on
hospital discharge. For example, access to necessary
insurance coverage information should include cur-
rent LTPAC coverage type (e.g., setting and services),
length of coverage, and so on. This information is very
useful to patients and caregivers during transition
phases.
Current State of EHRs
Over more than 30 years, EHRs have evolved from
simple data collection to aid in diagnosis to becoming
complex tools that support care delivery workflow
and decision making by capturing, aggregating,
analyzing, and moving data across the continuum of
care. However, current EHRs are inadequate to deliver
the patient-centric view needed to improve care
transitions because they are designed to capture data
in a linear and not dynamic fashion and to reflect
structures built to optimize documentation for billing
and not for describing the patient experience; they
also lack interoperability with other providers EHRs
(OMalley, Grossman, Cohen, Kemper, & Pham, 2010).
4
A PHR is a lifelong, universally available resource of health
information that is separate from the EHR (Caligtan and Dykes,
2011).
 Nurs Outlook 61 (2013) 475e489
The idealized vision for the EHR is that it contains a
single source of data that are entered once and reused
repeatedly by all team members, including patients
and family caregivers, to support decision making,
reporting, benchmarking, and research. Debate con-
tinues about the accuracy and redundancy of data
because there is not a mechanism to verify which
data are correct. Many EHR systems in use today
include a range of clinical applications such as pro-
vider order entry, e-prescribing, patient problem lists,
plan of care, flow sheets, note templates, and closed-
loop medication systems to facilitate safe medication
administration processes. The degree to which these
systems leverage existing standards to facilitate sec-
ondary use of data and benchmarking is variable.
Even if adopted and fully implemented, the recom-
mended data set for care transitions (S&I, 2012) is
medically focused, not patient centric, and may be
inadequate to describe patient goals and conditions. It
is unclear whether existing standards will relay the
complete set of information needed to understand
patient status and to identify issues relevant to
nursing practice. Moreover, functionality to synthe-
size data to provide context, identify the most salient
points, and to prevent cognitive overload is needed
(Caligtan, Carroll, Hurley, Gersh-Zaremski, & Dykes,
2012).
In addition, an existing plan of care functionality is
lacking. Individualized patient care is often not visible
(Keenan, Yakel, Tschannen, & Mandeville, 2008), and
discrepancies exist between information found in the
plan of care and verbal reports from providers and
patients about their perception of the plan (Ehrenberg
& Ehnfors, 2001). Poorly designed electronic systems
can exacerbate these problems. Although interdisci-
plinary plans of care are required by regulatory
agencies for accreditation and reimbursement (CMS,
2012a), the majority of research to date has focused
on the development of plan of care applications for use
by a single discipline, such as nursing or medicine
(Darmer, 2006; Dellefield, 2006; Elnahal, Joynt, Bristol, &
Jha, 2011). This siloed approach is unlikely to meet the
desired effects of a patient-centered plan of care. The
plan, if done correctly, should bridge communication
among care team members and should be available to
patients and their caregivers. It should also reflect an
interdisciplinary approach to problem identification,
goal setting, interventions, criteria for terminating in-
terventions, and documentation of progress toward
meeting the patients goals. In organizations in which a
patient-centered plan of care is developed, institution-
specific formats preclude routine sharing of key com-
ponents across care transitions. Even vendor systems
that enable intraoffice or intraorganizational commu-
nication and coordination do not routinely capture
information needed to understand the context of care
and to support coordination across organizations or
settings (OMalley et al., 2010). This problem is exac-
erbated by the widespread development of
479
organization- and setting-specific data collection
forms for multiple new programs aimed at reducing
hospitalization and other adverse outcomes. Most
notably, a comprehensive, longitudinal plan of care to
support continuity, quality, and safe patient-centric
care is often lacking. The proposed meaningful use
standards promulgated by the ONC such as the
Consolidated Clinical Document Architecture (CCDA)
address barriers related to standardizing the informa-
tion and terminology models needed to share patient
plans and summaries across settings. However, addi-
tional work is needed to ensure that the core data and
information captured and transmitted are adequate to
provide context into the patient story and to inform
nursing care that is consistent with best evidence and
patient preferences.
Recommendation 1
The secretary of the HHS, the national coordinator for
Health Information Technology, and the Administrator
for the Centers for Medicare and Medicaid (CMS)
should expedite completion and dissemination of the
format for a single consensus-based, longitudinal
patient-centered plan of care (LPC) framework to
enhance coordinated care planning and implementa-
tion, communication, and continuity. Furthermore,
they should endorse the use of this single framework
and ensure the following:
1. The LPC framework must include data generated by
all clinicians.
2. The CMS must reconcile or harmonize the data re-
quirements for home care, long-term care, and acute
and postacute care.
3. The LPC data must be interoperable and accessible to
all providers across settings.
4. Patients and their families must have access to their
own data and information.
A uniform, single electronic patient-centered LPC is
needed to enhance care planning and continuity in all
settings from primary care through end of life, during
patient transitions from one setting to another, or
during a health status change. The use of multiple care
plans with different data elements measured in
different ways creates unnecessary obstacles to con-
tinuity of care and achieving patient- and family-
centered goals. The LPC needs to be the focal point of
the patients care over time, across settings of care, and
inclusive of all providers. Patients and designated
caregivers can access electronic care plans efficiently,
empowering them by providing them with essential
information during critical discussions with other
members of the care team. These discussions include
goal setting and other key decisions, such as alignment
of treatment choices, re-evaluation of progress and
goals, and symptom management. Together patients,
480 Nurs Outlook 61 (2013) 475e489
caregivers, and providers share accountability to
address patient-centered goals.
An accurate, dynamic plan that links all episodes of
care into a portable personal health care story will
require capturing data in the correct format based on
its intended use. For example, detailed patient-level
elements are needed to drive secondary use of data,
such as decision support, reporting, and research.
These data must be represented as structured, coded
data elements using standard vocabularies. However,
narrative text may also be needed to support the un-
derstanding of context and transmission of the pa-
tients story. The increased development of natural
language processing may facilitate the use of narrative
findings. However, at this time, electronic information
systems require the use of electronic readable data
elements. Patient-friendly tools are needed to support
patient participation and updates to their plan of care.
A limitation of existing EHR systems is that they rarely
provide access or the tools to enable patients to
communicate their preferences, status, and other
health-related data that are needed to ensure that the
plan of care is optimized from the patients perspec-
tive. Additional work is needed to develop consumer
vocabularies to improve patient access to health in-
formation and to ensure that information is displayed
in a format that is consistent with their level of health
literacy (Cardillo, Tamilin, & Serafini, 2011).
Another concern is the underrepresentation of
robust EHRs or HIT capabilities in LTPAC5 settings.
Despite hospitals progress to address care transitions,
the coordination of care will only be effective with
integration and communication across the whole
spectrum of providers and settings. Transitions to and
from LTPAC settings are often the most sensitive to
information gaps and produce failures, resulting in
complications, delayed recovery, readmissions, and
mortality. Many of these organizations have been un-
able to make investments to obtain an EHR and rely on
antiquated means such as facsimile transmission for
much information. The Standards & Interoperability
Longitudinal Care Coordination Workgroup of the
ONCs HIT Policy Committee has engaged the LTPAC
community to develop the standards for interopera-
bility and exchange of patient assessments, transitions
of care documents, and LCPs among these settings.
Interoperable LPC Adds Value
To be used effectively, the LPC data must be interoperable
and used across settings. As well, longitudinal and cross-
continuum care coordination and plans of care must
5
LTPAC settings include home health, hospice, long-term care
facilities such as skilled nursing homes, inpatient rehabilitation,
long-term care hospitals, and community-based care services.
Patients may receive services for chronic illness or for short- or
long-term functional impairment. Care is shared by team mem-
bers who may have no common organizational affiliation and are
not in close physical proximity.
extend across EHRs and other information systems. A
data aggregation intelligence platform and a health in-
formation exchange (HIE) strategy are also essential
components to extend the capabilities of any EHR or HIT.
Shared care plans and patient-centered goals align
the most appropriate team members with the skills/
knowledge needed to best assist the patients/care-
givers to meet their needs. For example, a patient with
an advanced pressure ulcer may require access to a
certified wound care nurse to consult on pressure ulcer
prevention interventions and wound healing during
hospitalization and after discharge. The use of this
single source document by teams can promote ac-
cess to the right care at the right time with transitional
care continuity, which is consistent with patient/
caregiver goals and preferences. Moreover, the use of
this comprehensive plan will help to prevent duplicate
care as well as avoidable suffering and cost. This is
empowering to patients/caregivers, particularly during
vulnerable periods such as during disease progression,
coping with new loss of function, and at end of life.
The need for a uniform, single patient-centered LPC
is heightened during transitions to and from acute care
settings. Hospitalizations are a time of substantial
vulnerability and risk for patients and families and far
too often result in preventable readmissions. The vol-
ume of complex self-care education and other infor-
mation is often overwhelming for patients/caregivers
during hospital discharge. Personalization of the LPC,
informed by comprehensive team member assess-
ments, facilitates transition/discharge planning and
timely joint decision making with patients/caregivers.
For example, using the care plan to inform transitional
care requirements can cue necessary discussions
about needed but noncovered services. Integral to
transition/discharge planning, the LPC provides infor-
mation for timely decision making and linkages to
community-based transitional care services that can
prevent avoidable deterioration, complications, and
hospital readmissions or emergency department visits.
Patient and Family Access to Information
Patient and family access to health information is
central to achieving the goals of patient-centered care.
Although the provision of personal health data is in its
infancy, research findings reflect a growing trend in
which patients and families with access to key infor-
mation about their health and test results have become
engaged in their care (Schnipper et al., 2012). In one
trial, patients were more likely to improve the accuracy
of medications at home (Krist et al., 2012). Another
study showed improved preventive care by seeking
cancer and other disease screenings. Other studies are
not definitive, citing the low volume and infrequency
of patients accessing their personal health records
(Wagner et al., 2012; Tenforde, Nowacki, Jain, &
Hickner, 2012). The ONC is promoting the use of PHRs
 Nurs Outlook 61 (2013) 475e489
Figure 1 e The Blue Button logo.
in the Putting the I into HIT campaign (www.healthit.
gov). Nursing has pledged to engage more nurses and
patients in using PHRs given the advancement of
technology and standards. Further evidence of the
promotion of patient access to information is the
ONCs meaningful use incentive requirement that a
written clinical summary be provided to the patient at
the conclusion of any clinical office visit.
Consumers have the right to access their health in-
formation, and the process is being simplified with the
use of technology, signified by an electronic Blue But-
ton, which provides secure online access and download
of personal health data (ONC, 2013) (Figure 1). The
project was initiated by the Department of Veterans
Affairs. Data were initially available only to veterans
and military personnel and then extended to Medicare
beneficiaries. Today, a growing number of insurance
companies and health care organizations are providing
easy access through this technology. To further spread
the application of the Blue Button, the Department of
Health and Human Services, the White House, and the
Department of Veterans Affairs have forged the Blue
Button for the American collaborative with the goal of
having any consumer, regardless of setting, be able to
view, download, and share personal health data from
any data holder. Many organizations are signing a
voluntary Blue Button pledge to make health informa-
tion available on demand to their members and patients
and to help them manage their health.
Timely provider/patient/caregiver team decisions
enhance patient/caregiver engagement, safety, and
other key outcomes over time. Team interactions that
include the patients and caregivers rely on efficient
access to additional health information such as test
results and medication lists. Patients and caregivers
are eager for efficient access to health information that
they can use to stay well, manage chronic illnesses or
symptoms, and prevent complications. For example,
patients using warfarin at home need to be aware of
avoidable complications, such as stroke or bleeding
related to laboratory values that are out of therapeutic
range. These preventable complications can occur if
tests are not completed and results are not reviewed in
a timely manner and if appropriate dosage changes are
not made through effective communication with pa-
tients and/or their caregivers. Patient and caregiver use
of PHRs and access to key health information (e.g.,
medication list and laboratory work data) as part of
PHRs can help to reduce avoidable errors during verbal
481
dosage change instructions. Thus, PHRs are likely to be
a useful tool to prevent avoidable medication-related
emergency department visits and hospitalizations.
Patient and caregiver reported information will likely
increase with greater adoption of PHRs.
Standards and Interoperability for Data
Capture and Movement
There is general consensus on the need for standards
and interoperability of EHRs as proposed by the ONC.
The achievement of these goals is foundational to
advancing care coordination and transitional care.
Therefore, it is essential to accelerate the adoption of
national standards for data structures, messaging,
terminologies, and EHR content that address the need
to capture and improve care coordination and transi-
tional care activities. To achieve the coordination of
care, interoperable data elements must include all
health professionals plans along with patient goals
and preferences.
Capturing Essential Data
Capturing care coordination activities of diverse pro-
viders, although challenging, is important to identi-
fying and improving those activities related to
improved outcomes and lower costs. Using standard-
ized terminologies that are mapped to reference
terminologies, such as Systematized Nomenclature of
MedicinedClinical Terms6 or Unified Medical Lan-
guage System, across settings enables a common un-
derstanding of what is meant, easy comparison and
measurement, and the ability to quantify the numbers
and types of problems and interventions. Standardized
terminologies are necessary for the interoperability of
data, and using standardized languages to code
nursing actions provides a way to evaluate the value
and importance of nursing care.
One way to capture nursing assessment and inter-
vention data in a standardized electronic format is
through the routine use of recognized standardized
terminologies. Nursing-specific terminologies such as
the Omaha System, the Clinical Care Classification,
North American Nursing Diagnosis Association,
Nursing Interventions Classification, and Nursing Out-
comes Classification used individually or in
combination describe patient problems, nursing in-
terventions, and outcomes essential for communica-
tion, quality measurement, decision support, research,
and reimbursement. Although there has been some
6
Systematized Nomenclature of MedicinedClinical Terms is a
reference terminology with mappings to all of the nursing clas-
sification systems accepted by the American Nurses Association.
It is also one of the standards for meaningful use. It will be ad-
vantageous to use the Systematized Nomenclature of
MedicinedClinical Terms mappings when structuring nursing
data in any electronic format.
482 Nurs Outlook 61 (2013) 475e489
progress in the past 2 decades to describe and link
nursing actions to reference terminologies, we are
reminded of the gravity of this work proffered by Dr.
Norma Lang that if we cannot name it, we cannot
control it, finance it, teach it, research it, or put it into
public policy (Clark and Lang, 1992). Over time, research
that links particular types of patient problems with in-
terventions that are associated with quality outcomes
will yield evidence to build decision support and show
the nurses contribution to high-quality, high-value
care. There is a growing need for and interest of nurse
scientists to use and contribute to standardized termi-
nologies in their respective areas of research.
HIE
The electronic exchange of information is a founda-
tional element to the communication of data beyond
boundaries of a single provider, institution, or health
system. Automated data exchange needs to address
semantic differences among health care providers. The
use of standardized data sets allows data to be
exchanged electronically and communicate in
commonly understood terms. Electronic exchange also
relieves administrative burdens traditionally associ-
ated with communication among other providers,
payers, and patients. Fully executing effective care
coordination includes closing many communication
feedback loops well suited for the use of HIT.
HIE providers are offering services that facilitate
communication with referring providers (e.g.,
requesting services or results delivery); share relevant
information for retrieval by any other provider at any
time; provide clinical care summaries for referrals and
at care transitions; provide two-way connectivity for
providers with patients, families, and caregivers;
automate review and updating of complex files such as
medication records; generate provider and patient
alerts; offer tools for chronic care management and
immunization reporting; and ensure information is
accessible in the event of the need for emergency care.
Achieving HIE can broaden the reach of the hospital-
centric system of EHRs. Without interoperability be-
tween a primary care providers EHR and associated
hospital systems EHRs, the patient and provider may
have incomplete and/or conflicting information. As
patients and their caregivers seek access to a common
EHR or one that is extensive, some mechanism to
navigate the contents will be necessary. Most organi-
zations provide patients with only limited access to a
small amount of data, without patients having been
involved in determining the portions to which they
have access. As the public demands more transparency
in the future, critical personal health information such
as that related to care transitions must be accessible.
Eventually, the availability of data about large pop-
ulations of patients will enable review and analysis of
trends that can inform ways to improve population
health. Extensive efforts to build trust and ensure pri-
vacy of HIE promise to enhance consumer and provider
adoption of HIE at all levels.
Long-term post-acute care, growing faster than
acute care, serves persons with complex conditions.
The need for improved efficiency, effective transitions,
and the ability to prevent the duplication of care can be
achieved, in part, through longitudinal coordination of
care. The exchange of data at transitions can mitigate
the risks posed by the lack of support of electronic re-
cords; it can also improve efficiency by focusing the
essential clinical data from various sources to provide
safe and appropriate care. The ONCs Standards &
Interoperability Longitudinal Coordination of Care
Workgroup and its subgroups aim to overcome the
challenges restraining the clinical data standards for
transitions of care (S&I Framework, 2013).
The LTPAC Health IT Collaborative has created a
road map that includes prioritizing technologies to
promote care coordination and the continuity of
care (2012). Home care providers as well as nursing
homes and inpatient rehabilitation facilities are
already required to electronically transmit patient
assessment information using standardized in-
struments. However, a significant limitation is that
these instruments do not yet conform to the same
standards for data exchange, thus preventing the
efficient reuse of data across providers and settings.
The adoption of the CCDA across settings could
improve the communication of assessment infor-
mation; however, standardized content (e.g., the
same evidence-based assessment scales and
response sets) mapped to standardized terminol-
ogies is also needed to ensure semantic interopera-
bility and data reuse. The CMS is supporting a
Continuity Assessment Record and Evaluation that
aims to move this goal forward.
Transformational new technology used by con-
sumers, such as smart phones and PHRs, also may
enhance the coordination of care. With the increase in
near-patient testing and telehealth devices in the
home, patients and caregivers can communicate
health data via their PHR, their cell phone, or other
mobile devices to their primary care providers and
other team members to facilitate care management
and self-care. Additional potential features of PHRs
that patients and caregivers value include direct e-mail
with providers, appointment requests, prescription
management, and access to educational tools (e.g.,
self-care including symptom management). However,
it is important to consider how these data are inte-
grated into the EHR, PHR, and LPC.
Involving Expert Clinicians in Designing HIT
to Support Care Coordination
Nurses and other professionals who carry out care
coordination and transitional care activities have a
critical role in defining the content and designing the
 Nurs Outlook 61 (2013) 475e489
functionality of HIT systems that support care coordi-
nation. The volume and depth of nurse-collected pa-
tient-centered data and information are significant,
affording an opportunity to maximize the use of data
for communications, quality measurement, decision
support, research, and reimbursement. For example,
upon admission to any health care settingdbe it acute,
home, or long-term carednurses are often the first
point of contact for patients and their families. The
admission assessment information, collected pre-
dominantly by nurses and augmented by the other
disciplines, forms the foundation for developing the
single patient-centered LPC.
Recommendation 2
To ensure an adequate diversity of perspectives, HHS,
the ONC, the NQF, CMS, and the Agency for Healthcare
Research and Quality should appoint a greater number
of nurses and other health care professionals who are
carrying out or researching care coordination and
transitional care activities to decision-making bodies
that will determine the frameworks, standards, and
electronic measures (eMeasures) for care coordination
activities and effectiveness. Broader input is needed to
address the following:
1. Technical expert panels developing care coordina-
tion concepts and specifications for eMeasures
require the expertise of nurses and others delivering
these services directly to patients sand families as
well as those with relevant research expertise.
2. Data elements required for effective care coordina-
tion that are built into HIT systems must capture
actions of all care providers;
3. Data elements for care coordination and transitional
care must articulate patient and caregiver prefer-
ences and needs across patient settings and profes-
sional groups;
HIT systems should contain the range of physical,
functional, emotional, cognitive, and social data ele-
ments required for comprehensive care planning and
care coordination. These systems should incorporate
evidence-based assessment tools to measure cogni-
tion, functional status, social support, and psycholog-
ical status such as depression. By using evidence-based
tools across care settings, providers and patients can
more easily recognize improvement or decline over
time, and providers can activate best practices as well
as correlate patient behavior or therapeutic in-
terventions to the response. For example, functional
status is commonly assessed upon admission, but
when there is no requirement for reassessment, subtle
changes can be overlooked. A high-value HIT system
could prompt providers to assess critical aspects such
as functional status at specified intervals and provide
summaries in text or graphic form for use in research,
quality improvement, referral decision making, or
483
patient teaching. An excellent, successful working
example of such a system is the work led by the
Canadian Nurses Association and Canada Health
Infoway (2009) called the Health Outcomes for Better
Information and Care. The Health Outcomes for Better
Information and Care introduces standardized ques-
tions into assessments about the following: functional
status, therapeutic self-care, pain, nausea, fatigue,
dyspnea, pressure ulcers, and falls. These assessments
are repeated over time, giving a longitudinal record of
progress or decline in important functional areas.
Nurse-collected information about the human
response to illness enriches our understanding from
the patients perspective and assists in setting collab-
orative patient-centered goals. The Canadian project
uses the International Classification for Nursing Prac-
tice and is working toward inclusion in electronic
systems.
Quality Measurement and Reporting
The implementation of the provisions of the American
Recovery and Reinvestment Act of 2009 is expected to
improve the quality of care by promoting adoption and
supporting meaningful use of EHRs (CMS, 2012b). The
American Recovery and Reinvestment Act requires
that hospitals and health care providers show mean-
ingful use of EHRs through the following mechanisms:
(a) use of a certified EHR; (b) facilitation of care coor-
dination and quality by participating in the exchange
of electronic health information; and (c) submission of
data for quality reporting. On the national level, a
number of initiatives aim to provide the informatics
platform needed for automated quality reporting.
These initiatives seek to drive improved processes and
outcomes in general and specifically processes related
to care transitions. For example, the NQF appointed the
HIT Expert Panel to establish a set of building blocks to
move the U.S. health care system away from manual
data abstraction and performance measurement ap-
proaches toward automation. The set of tools devel-
oped by the HIT Expert Panel, including the Quality
Data Model (NQF, 2012b) and the Measure Authoring
Tool (NQF, 2012a), provide a standard and consistent
way to describe concepts across all quality measures.
Several Quality Data Model categories proposed for
2013 are relevant for care coordination and transitions,
including a focus on developing formal definitions for
the concepts of care goal, communication, and trans-
fer. Consistent electronic representation of quality
measure data will provide a means to automate mea-
surement and to deliver real-time decision support to
improve transition processes, leading to improved
quality and cost outcomes. In addition, the CCDA is
specified by Meaningful Use Stage 2 as the standard
archetype to be exchanged electronically with pro-
viders upon transition of care. The CCDA includes the
484 Nurs Outlook 61 (2013) 475e489

Figure 2 e The building blocks of interoperable informatics infrastructure.

 Nurs Outlook 61 (2013) 475e489
core set of data and information needed by both pro-
viders and patients to support quality transitions (HL7,
2012), including closing the referral loop. The com-
posite of building blocks for an interoperable infor-
matics infrastructure outlined in Figure 2 will
transform the use of EHRs and health information.
The urge to customize clinical information systems
to meet local norms should be restrained. Custom-
ization removes the standardization of data between
systems and can lead to interoperability and semantic
operability challenges even when working within the
same vendor system. For example, if a measure con-
tains the pick list choices of excellent, good, fair, and
poor, to customize the system to excellent, very
good, good, average, and poor creates a different scale
and incongruence for the exchange of information for
research and clinical care.
A variety of private and public groups are advancing
the use of HIT to improve care coordination. Their ef-
forts range from regulatory initiatives to improve the
infrastructure for exchange of information vital to care
transitions, initiation of quality measures that
encourage widespread standardization, and use of care
coordination approaches and tools. Appendix 1 in-
cludes examples of these national efforts.
Building the Evidence Base
HIT has produced a flood of available information with
vast potential for its use in the research needed to
advance the science of health, including diagnosis and
treatment of symptoms and diseases, service planning,
delivery and evaluation, and public health. However,
there has been less data and information useful to nurses
about nursing care. Although the emphasis for HIT has
been on reaping the benefits in better patient care and
health outcomes through improvements in patient safety
and the use of decision support, significant opportunities
also exist for research that will produce the evidence base
needed to develop effective treatment approaches and
efficient health services that are both discipline specific
and across team-based care. Emphasis has also been on
data required for payment and public reporting.
Recommendation 3
The AAN together with the American Nurses Associa-
tion, other national nursing organizations, and nurse
leaders must do the following:
1. Articulate the data elements that describe nurses
actions and shared activities of care coordination
and transitional care to be captured in EHRs that will
build the evidence base for these actions.
2. Stipulate the inclusion of care coordination and
transitional care data elements be part of the content
in electronic CISs as a requirement for purchase.
485
3. Develop and advance a research agenda to the
AHRQ, the NIH, the CMS, and the National Library of
Medicine to secure funding for:
a. Research studies and quality improvement ini-
tiatives that analyze care coordination data el-
ements and show the relationship between
structures, processes, and outcomes;
b. Research studies that identify standardized data
elements leading to the rapid identification of
individuals in subpopulations who will benefit
from care coordination and transitional care
interventions (e.g. those with multiple chronic
or comorbid conditions);
c. Coordination and transition intervention stu-
dies;
d. Usability testing of HIT across venues of care;
e. Development and testing of personal health re-
cords content, utilization, and impact;
f. Electronic CDS for coordination and transitional
care interventions;
g. Development and testing of e-measures for care
coordination and transitions.
To use this rich data resource to answer clinical and
translational research questions central to nursing will
require attention to data and their meaning at the
conceptual, implementation, organization, and policy
levels. If data are to be valid and reliable, a continued
and concerted effort must be given to the selection of
data to be included in the EHR, particularly the concepts
most relevant to clinical nursing. Nomenclature, ter-
minology, vocabulary, and data representation used to
record data (Lobach & Detmer, 2007) related to nursing
(Thede, 2008) and nurse-led care coordination activities
will be critical. In many instances, the evidence base for
current measures of these important concepts is
limited, resulting in challenges in EHR utilization for
research. Likewise, future endorsed electronic mea-
sures of care coordination and transitional care must be
structured to include data elements reflecting nursing
and other disciplines care contributions.
The results of secondary analyses of data acquired
through the use of HIT are already affecting health care
decisions and priorities selection at the agency, regional,
national, and international levels. If used as proposed,
these decisions and priorities will significantly affect the
practices and resources of nurses. Much of the emphasis
in the use of HIT as it relates to nursing care to date has
been on determining compliance with prescribed treat-
ments and safety protocols. Limited attention has been
given to the use of HIT in creating the evidence base
needed to develop and evaluate clinical care provided by
nurses and other disciplines. For example, there has not
been systematic attention to the use of the EHR data to
understand nursing questions/problems or the clinical
decisions that nurses make and the impact of those de-
cisions on patient outcomes. By not leveraging the
research potential of the EHR, nursing is denied oppor-
tunities for scientific advances and inhibited from
486 Nurs Outlook 61 (2013) 475e489
making visible nursing contributions to individual pa-
tient care, health care, and health policy.
With the shift to team-based care, HIT enables the
sharing of information among caregivers within an
organization and across practice settings. As interpro-
fessional team practice becomes mainstream, as
characterized by team-based principles and values
(Mitchell et al., 2012), research about team perfor-
mance is necessary to evaluate the knowledge, abili-
ties, approaches, and impact of disciplines
contributing to care. One of the significant areas ripe
for investigation is the effectiveness of team actions on
care coordination, individually and collectively. Data
entry, capture, and analytics of elements describing
team actions will be essential to perform such evalu-
ation research.
The Need for Improved Measures of Care
Coordination
HIT capacity is an essential component of performance
measurement for both internal performance im-
provement and external public reporting. Numerous
U.S. government agencies and organizations engaged
in activities related to performance measurement and
HIT have work groups that are exploring the features
and readiness of HIT needed to support care coordi-
nation and transitional care performance measures.
Many of the issues under discussion by these groups
are significant to the capture and reporting of care co-
ordination measures relevant to nurses showing their
contribution to coordination and transitional care
outcomes across service delivery models and settings.
Recommendation 4
Measure developers must create a broader array of
performance e-measures to evaluate effective care
coordination across teams and settings. Attention
should focus on measure topics that are most relevant
to public reporting of outcomes, quality improvement,
and value-based payments. It is further expected that
(a) data capture and reporting are automatic as a
byproduct of clinical documentation; (b) data elements
in the EHR and CDS must describe the patient-centered
LPC, transitional activities, and outcomes relevant to
nursing practice and coordination of care; (c) structural
measures are included to evaluate the HIT infrastruc-
ture as well as the workforce capacity and competence
in care coordination and transitional care that
contribute to outcomes; and (d) process and outcomes
measures are included to illuminate best practices for
at-risk populations that will identify indications for
transition to an appropriate care setting and prevent
adverse events.
At present, the set of endorsed performance mea-
sures for care coordination and transitional care is
limited in scope and size. Priorities for new measures
to fill critical gaps have been identified by the AAN
(2012), the NQF (2012), and the Measure Application
Partnership (2012). Clinical information systems and
EHRs must accommodate current measures and
anticipate the inclusion of new ones. The design and
capacity of HIT must support central features of care
coordination and transitional care. Such data capture,
interpretation, and reporting are extremely chal-
lenging activities.
Approaches to improve care coordination and
traditional care performance measurement should
include the following features:
1. Patient and family centered: HIT must support pa-
tient and family participation in a single, integrated,
evolving plan of care that is accurate, complete, and
available to relevant providers as well as a patients or
families in real time. In addition, HIT must allow for
discipline-specific components of the plan of care for
dissemination and synthesis by all interprofessional
team members.
2. Outcomes focused: the development of HIT will need
to anticipate and address new domains for outcome
measures, such as quality of life and functional
status, with potential requirements for risk adjust-
ment and other reporting features.
3. Team-based care: HIT must reflect team-based care
processes that cross multiple settings and providers,
including those within the traditional health care
system, community, and alternative systems. Capture
of team-based care and mechanisms for transfer of
data and protections for confidentiality are essential.
4. Workforce concerns: HIT should address prepara-
tion of the workforce and staffing for care coordi-
nation or transitional care delivery. The potential
addition of new structural measures of care coordi-
nation and transitional care must be considered.
Although a number of emerging care coordination
and transitional care models document these re-
quirements for HIT systems, the capacity and readi-
ness of current systems to support them has not been
evaluated in detail. This work is under way by a num-
ber of groups, including the Care Coordination HIT
Critical Paths Technical Expert Panel convened by the
NQF (2012c) in 2012. There are significant opportunities
to influence the design and implementation of HIT
systems to support capture, synthesis, and reporting of
care coordination and transitional care performance
measures. Technical models are emerging whereby
data from multiple systems are aggregated to an in-
telligence platform and then parsed to reporting ap-
plications for cross continuum care coordination, thus
enhancing quality measure reporting.
Attribution and Shared Accountability across the
Team
Data captured in the EHR during care coordination for
quality measurement also informs the best evidence-
 Nurs Outlook 61 (2013) 475e489
based practice and health care team characteristics.
The data captured at the point of care should include the
actions of each individual on the care team. These data
will inform the best mix of clinicians, roles, and the right
staffing for specific stratified populations. Thus, the EHR
becomes a learning system7 to inform health care
teams, organizations, and systems of care on the best
evidence-based practice and team characteristics to
yield the best outcomes for patients. High-performing
teams are central to meeting high-performance stan-
dards for patient safety and other quality-care targets as
well as the reduction of excessive cost. Nurses hold a
critical role, along with other team members and orga-
nizations, to best harness meaningful use by le-
veraging the important data and information contained
in EHRs.
Both attribution and shared accountability are
important to quality care. Attribution accounts for who
does what on a team (e.g., direct care, risk assessment,
screening). It does not mean that quality measurement
is occurring at the individual team member level, which
is not a feasible level of analysis in quality measure-
ment. Accountability is responsibility for the care out-
comes, including tracking of patient panels for
purposes of quality incentives. Team-based shared
accountability for care coordination is essential to meet
the NQS aims for health care transformation. Care co-
ordination has been recognized as a team sport by the
Measure Application Partnership. Accordingly, it is
essential to close the team-based shared accountability
measure gaps in the National Quality Forum (NQF)
portfolio and overcome methodologic barriers in order
to measure shared accountability.
Conclusion
Care coordination and transitional care services are
strategically important for achieving better health, bet-
ter care, and lower costs. A unified patient-centered LPC
enhances care planning, communication, and continu-
ity of care. This plan is best achieved with information
technology to collect and analyze data rapidly and to
share information with providers, patients, and other
caregivers regardless of location. The AAN urges swift
action by ONC, HHS, and CMS to promulgate the format
for the LPC followed by the development and approval of
a broad array of quality measures that evaluate the
effectiveness of care coordination and transitional care
interventions across settings and providers. The AAN,
together with the American Nurses Association and
other nursing organizations and nurse leaders, en-
deavors to be engaged in achieving the glide path to
7
The learning health system is embraced by the Institute of
Medicine as one that engages in continuous assessment, gener-
ates knowledge as a byproduct of the care experience, and im-
plements improvements/best practices for greater effectiveness
and efficiency.
487
better care coordination including transitions through
the effective and efficient use of HIT.
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 Nurs Outlook 61 (2013) 475e489
Appendix 1. Groups Working on HIT-Enabling Care Coordination and Related Regulations
National Quality Forum
ONC Standards and Interoperability wiki workgroups
ONC Policy Committee-Sponsored Work Patient
Engagement
ONC Policy Committee, Meaningful Use Care
Coordination
ONC Policy Committee, Quality Measures Workgroup
CMS
American Nurses Association Tipping Point Project
HL7 International
489
1. Care Coordination Steering Committee: Focus has been to
(1) conduct an environmental scan of current care coordi-
nation measures; (2) review commissioned paper on care
coordination and HIT capabilities; (3) issue call for and re-
view new care coordination measures; and (4) establish
priorities for future care coordination measurement.
Web link: http://www.qualityforum.org/Projects/c-d/Care_
Coordination_Endorsement_Maintenance/Care_
Coordination_Endorsement_Maintenance.aspx
2. Care Coordination HIT Critical Paths Technical Expert Panel
(TEP): Assesses the ability of the existing HIT infrastructure
to support quality measurement related to transitions of
care and communication of the patient plan of care.
Web link: http://www.qualityforum.org/HIT/Critical_Paths/
Care_Coordination.aspx
LTPAC:
http://ltpachitcollaborative.wikispaces.com/
http://wiki.siframework.org/
LTPACCareTransitionsSWG20120319
LCC LTPAC Transition: http://wiki.siframework.org/
LCCLTPACCareTransitionSWG
LTPAC LCC Longitudinal Care Planning: http://wiki.
siframework.org/LCCLongitudinalCarePlanSWG
LTPAC Longitudinal Care CoordinationdCMS OCSQ CARE
Tool: http://wiki.siframework.org/
LongitudinalCoordinationofCareWG
Consumer/Patient Engagement Power Team:
http://www.healthit.gov/policy-researchers-implementers/
consumerpatient-engagement-power-team
Quality Measures Workgroups Care Coordination Tiger
Team (no current meetings scheduled)dSubworkgroup#2
Patient Engagement (PFE):
http://healthit.hhs.gov/portal/server.pt?
open512&objID1472&mode2 (see Past and Future
Meetings for Workgroup#2 PFE presentations)
Subworkgroup#3 Care Coordination (Click on Past and Future
Meetings for Workgroup#3 presentations):
http://healthit.hhs.gov/portal/server.pt?
open512&objID1472&mode2
Quality Measures Workgroup evaluates quality measures in
the National Quality Strategy Priority Areas including care
coordination:
http://healthit.hhs.gov/portal/server.pt?
open512&mode2&objID3079 (Click on Past and Future
Meetings for Documents Including Recommended Care
Coordination Measures)
EHR Incentive Program, Stage 2 Final Rules
http://www.cms.gov/Regulations-and-Guidance/
Legislation/EHRIncentivePrograms/Stage_2.html
The Tipping Point (TP) initiative began in 2009 to promote the
development and endorsement of patient-sensitive quality
measures for incorporation into Meaningful Use (MU)
projects promulgated through the Office of the National
Coordinator of Health Information Technology (ONC) and
the Centers for Medicare & Medicaid Services (CMS).
HL7 Consolidated Clinical Document Architecture:
http://www.hl7.org/implement/standards/product_brief.
cfm?product_id258