Communication Processes for Accountable Care Enhancement (C-PACE)

描述(由申请人提供)：C-PACE项目(加强负责任护理的通信流程)将开发一种新的创新形式的社会计算，为虚弱的老年患者的护理定制。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、第三方付款人、责任护理组织和其他医疗保健组织监控临床结果所需的数据。C-PACE非常适合它最初的目标人群--老龄化人口。这些复杂的患者经常在提供者和护理场所之间来回穿梭。但是，追踪和照顾这些人所需的信息并不一定跟随他们--甚至令人惊讶的是，在电子健康记录(EHR)时代也是如此。在数字时代，这样的事情怎么可能发生呢？答案看起来很简单。EHR坐在筒仓中，适合计费，并被设计为记录单个护理事件。它们包含可能描述护理事件和相关成本的信息，但很少包括某些批判性思维过程。这样的思维过程，包括患者的偏好，是“下游”提供者需要的，以便从字面上理解下一步需要发生什么。今天，关于护理过渡的沟通、信息的传递、临床医生相互提醒的沟通，或者相互请教的沟通，都是护理过程中没有记录的关键部分，结果就是迷失了方向。C-PACE是一种软件工具，可以在持久的数字记录中捕获这些关于患者的临床交流，这些交流共同形成护理协调。C-Pace背后的科学借鉴了医学和技术的不同学科，包括老年病学、人类因素、医学信息学、社交网络分析和用户界面设计。这一跨学科工作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来表明建立这样一个系统是否可行。C-Pace可以重写规则手册，方法是采用一直被人注意到的东西--关怀-协调--并使其可见、得到良好支持和负责任。

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.