Enhancing Complex Care through an Integrated Care Coordination Information System

描述（由申请人提供）：在一个已经支离破碎的卫生保健系统中，由于缺乏协调和质量，慢性疾病患者面临并发症和不必要的疾病恶化的风险。许多护理管理模式，如护理管理Plus (CMP)，通过使用卫生信息技术（HIT）进行临床重新设计，成功地改善了健康结果。为了改善对具有复杂需求的患者的护理，这些模型使用了人口管理、以患者为中心的目标、质量措施和临床提醒。拟议的研究有三个目标。1)了解是否可以使用经过认证的电子病历和现有标准在不同的诊所中创建综合护理协调信息系统（ICCIS）。2)评估ICCIS系统的功能是否可以被诊所使用。3)评估这些系统变化是否会改善患者的预后。首先，研究小组将评估参与站点的现有HIT能力。在初步评估的基础上，将实施ICCIS，以确定是否有可能在具有复杂医疗保健需求的患者中使用HIT。接下来，将使用格拉斯哥REAIM模型评估实施过程及其感知效益。REAIM是为衡量个人、计划、组织和政策层面的成功而设计的。一项随机对照试验将检验6家参与试验的诊所是否可以使用HIT通过护理协调模型（第1组）或质量表现模型（第2组）来监测和提供高风险患者的护理。将审查两项结果措施。1)利用的变化-住院和急诊室就诊；2)临床层面的患者满意度。利用账单数据，通过比较实施前后的住院率和急诊科访问量来检查使用率。患者满意度将通过对干预前后1200名患者的随机抽样调查来评估。研究人员将管理ACAHPS调查，并提出关于护理过渡和护理协调的具体附加问题。

DESCRIPTION (provided by the applicant): Patients with chronic illness are at risk for complications and unnecessary disease exacerbations from a lack of coordination and quality in an already fragmented health care system. Many models of care management, like Care Management Plus (CMP), have been successful in improving health outcomes through clinical redesign using health information technology (HIT). To improve care for patients with complex needs these models use population management, patient-centered goals, quality measures, and clinical reminders. There are three objectives for proposed study. 1) To understand if an integrated care coordination information system (ICCIS) can be created in a diverse set of clinics using certified EHRs and existing standards. 2) To assess if the functions in the ICCIS system can be used by the clinics. 3) To evaluate if these system changes lead to improved patient outcomes. First, the research team will assess existing HIT capabilities of participating sites. Based on the initial assessment ICCIS will be implemented to see if HIT use in care of patients with complex healthcare needs is possible. Next, the implementation process and its perceived benefits will be assessed using the Glasgow REAIM model. REAIM is designed for measuring success at individual, programmatic, organizational, and policy levels. A randomized controlled trial will examine whether six participating clinics can use HIT to monitor and deliver care for high risk patients with a care coordination model (arm 1) or quality performance model (arm 2). Two outcome measures will be examined. 1) Change in utilization - hospitalizations and ED visits and 2) Patient satisfaction at the clinic level. Utilization will be examined by comparing hospitalization rates and ED visits before and after implementation using billing data. Patient satisfaction will be assessed by surveying a random sample of 1200 patients pre- and post-intervention. Research personnel will administer the ACAHPS survey with specific additional questions about transitions of care and care coordination.