Communication Processes for Accountable Care Enhancement (C-PACE)

描述（由申请人提供）：C-PACE项目（负责护理增强的通信过程）将开发一种新的创新形式的社会计算，为体弱的老年患者提供定制的护理。一个成功的C-PACE系统将改善以患者为中心的医疗保健，减少医疗差错，并提供CMS、第三方支付者、责任医疗组织和其他医疗保健组织所需的数据，以监测临床结果。C-PACE非常适合最初针对的老龄化人群。这些复杂的病人不断地在提供者和护理场所之间来回穿梭。但追踪和护理这些人所需的信息并不一定会跟随他们--令人惊讶的是，即使在电子健康记录（EHR）时代也是如此。在数字时代，这种事情怎么可能发生？答案看似简单。EHR位于筒仓中，用于计费，旨在记录单个护理事件。它们包含的信息可能描述护理事件和相关费用，但很少包括某些批判性思维过程。这种思维过程，包括病人的偏好，是“下游”提供者所需要的，以理解，从字面上看，下一步需要发生什么。今天，关于护理过渡的通信、信息传递、临床医生之间的通信，以相互“提醒”，或相互征求意见，这些都是护理过程中的关键部分，没有记录在案，因此，只是迷失了方向。C-PACE是一种软件工具，可在持久的数字记录中捕获有关患者的临床通信，这些通信共同形成护理协调。C-PACE背后的科学来自不同的医学和技术学科，包括老年医学，人为因素，医学信息学，社会网络分析和用户界面设计。这一跨学科努力的第一阶段将通过开发和评估以用户为中心的C-PACE人机界面、基础数据模型和数据挖掘能力，显示建立这样一个系统是否可行。C-PACE可以通过采取一直“在雷达下”的护理协调来重写规则手册，并使其可见，得到良好的支持和负责。

DESCRIPTION (provided by applicant): The C-PACE Project (Communications Processes for Accountable Care Enhancement) will develop a new and innovative form of social computing that is customized for the care of frail, elderly patients. A successful C-PACE system will improve patient-centered health care, reduce medical errors, and provide the kind of data that CMS, third party payers, Accountable Care Organizations and other health care organizations need in order to monitor clinical outcomes. C-PACE is ideally suited to the aging population toward which it will be initially targeted. These complex patients are constantly shuttled back and forth between providers and venues of care. But the information needed to track and care for such individuals does not necessarily follow them - even, surprisingly, in the era of electroni health records (EHRs). How could such a thing possibly happen in the digital age? The answer is deceptively simple. EHRs sit in silos, geared for billing and designed to document single events of care. They embody information that may describe care episodes and associated costs, but rarely include certain critical thought processes. Such thought processes, including patient preferences, are needed by "down-stream" providers to understand, literally, what needs to happen next. Today, communications about transitions of care, information hand-offs, clinicians' communications to give one another "heads-ups," or to pick each other's brains are key pieces of the care process that are not documented and that, as a result, just get lost. C-PACE is a software tool that captures, in a lasting digital record, these clinical communications about patients that collectively form care coordination. The science behind C-PACE draws from different disciplines of medicine and technology including geriatrics, human factors, medical informatics, social network analysis, and user interface design. Phase I of this interdisciplinary effort will show whether the building of such a system is feasible, by developing and assessing a user-centered C-PACE human- computer interface, an underlying data model, and a data mining capability. C-PACE can rewrite the rule-book by taking what's always been "under the radar" -- care-coordination -- and making it visible, well-supported, and accountable.