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digital.ahrq.gov/ahrq-funded-projects/implementation-electronic-care-plan-people-multiple-chronic-conditions
January 01, 2023 - Medical Condition
Cardiovascular Disease
Chronic Pain
Diabetes Mellitus
Renal (Kidney) Disease … Health Care Theme
Care Coordination
Care Planning
Clinical Decision Making
Care … Existing care plans are typically those focused on a single disease or care setting and do not meet the … for managing those with chronic kidney disease and at least one additional chronic condition, such as … Design and execute a plan for pilot-testing the e-care plan applications by using the IG in a mix of
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digital.ahrq.gov/sites/default/files/docs/survey/mainehealthcoalitionossurvey_comp.pdf
January 01, 2007 - Does your practice have an intervention program (written care
plan or tool kit, or referral source) … promote the best practice of care for a specific condition. … physicians and patients in discussing the care
plan for the patient. … referral to educators specializing in a specific disease or condition. … from a hospital, health plan, PHO, or other organization.
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digital.ahrq.gov/ahrq-funded-projects/community-shared-clinical-abstract-improve-care-mn
January 01, 2023 - A Community-Shared Clinical Abstract to Improve Care
Project Description … Setting
Ambulatory Setting
Emergency Department
Hospital
Medical Condition
Congestive … Acute Care
Health Care Theme
Medication Reconciliation
Transitions in Care … In this project, three partnering health care systems set out to develop an implementation plan for exchanging … Because the time for proposal preparation was unexpectedly halved, some planning steps were modified or
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digital.ahrq.gov/program-overview/research-stories/designing-digital-healthcare-technology-support-cognitive-team
January 01, 2023 - on the severity of the patient’s condition. … Each needs to know what has happened: the initial incident, the current clinical condition including … It is imperative that each role coordinates and communicates their patient assessment and plan across … what happened to the child, what the current clinical condition is, and what the plan is. … “The trauma surgeon may want to see some clinical data point or representation that is different from
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digital.ahrq.gov/health-it-tools-and-resources/pediatric-resources/pediatric-rules-and-reminders/asthma-overdue-action-plan-review
Asthma, Overdue for Action Plan Review
Clinician Summary
AAP practice guidelines recommend … Review
Primary Clinical Area
Pediatrics
Secondary Clinical Area
Risk Group … Details for Risk Group
Asthma problem
Asthma med codes
Triggering Condition
Last … in note subject/title
Condition
Displayed Message
Patient has asthma. … their interpretation by clinicians at Partners Healthcare System, may not represent the standard of care
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digital.ahrq.gov/ahrq-funded-projects/chronic-care-technology-planning-project
January 01, 2023 - No statement in this report should be construed as an official position of AHRQ or of the U.S. … System
Medical Condition
Chronic Conditions
Population
Rural Populations … The Clinical and Technology Teams met to address needed clinical information, the current status of technology … No statement in this report should be construed as an official position of AHRQ or of the U.S. … Staff/Clinician Care Setting: Across the Health Care System Technology: Clinical Decision Support
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digital.ahrq.gov/sites/default/files/docs/citation/09-10-0091-1-EF.pdf
October 01, 2009 - Patients may request for a variety of reasons that aspects of their medical care or
condition be protected … Chronic Care Use Case
A chronic condition is an affliction that lasts a year or longer, limits what … chronic conditions: monitoring the
condition(s) and adapting the treatment plan. … EHR System Boundary
Patient
Clinician
Staff
Monitor
Condition
Adapt
Treatment
Plan … the patient care plan
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digital.ahrq.gov/sites/default/files/docs/page/asthma-action-plan-overdue.pdf
July 31, 2017 - Pediatric Rules and Reminders - Asthma, Overdue for Action Plan Review
Pediatric Rules and … Review
Primary Clinical Area Pediatrics
Secondary Clinical Area
http://www.nhlbi.nih.gov/guidelines … Details for Risk Group
Asthma problem
Asthma med codes
Triggering Condition
Last documented visit … Condition
Displayed Message
Patient has asthma. … their
interpretation by clinicians at Partners Healthcare System, may not represent the
standard of care
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digital.ahrq.gov/ahrq-funded-projects/evaluation-scaled-scaling-acceptable-cds-approach-implementation-interoperable-cds-venous
January 01, 2024 - Medical Center
Hospital
Medical Condition
Thromboembolism
Trauma (Physical) … Acute Care
Health Care Theme
Patient-Reported Outcomes
There is a critical … Patients with traumatic brain injuries (TBI) are at high risk for venous thromboembolism (VTE), a serious condition … where a blood clot can develop in the leg or arm and either dislodge or block leg or arm blood flow, … To reduce VTE events, patients need preventive care, but guidelines for providing preventive VTE care
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digital.ahrq.gov/sites/default/files/docs/publication/r18hs020846-fricton-final-report-2016.pdf
January 01, 2016 - . 2) Action Plan –
this recommended actions assuming the most severe condition, and following severity … and implement a personalized action plan that outlined specific
steps recommended by clinical guidelines … Clinical care guidelines. … changes in care or in improved clinical outcomes, such as decreased complications and
improved periodontal … Clinical decision
support in electronic prescribing: recommendations and an action plan.
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digital.ahrq.gov/sites/default/files/docs/survey/tamc-provider-questionnaire.pdf
September 29, 2016 - Individual or group classes about a specific
chronic disease/ condition 0 1 1 … self-management needs and activities regularly assessed and recorded
in standardized form linked to a treatment plan … in peer support groups or mentoring
programs? … Any Chronic
Disease/Condition COPD Diabetes Hypertension Hypercholesterol
D2. … Have your consultations with clinical
specialists for the care of patients with chronic
disease increased
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digital.ahrq.gov/ahrq-funded-projects/cloud-care-feasibility-study-cloud-based-care-plans-children-medical-complexity
January 01, 2024 - Caregiver
Children
Clinical Staff/Clinician
Individuals with Special Health Care Needs … care plan. … plan for CMC called Cloud Care. … or patient portal, and the lack of data being able to flow between the EHR and Cloud Care. … system, and a match of structured data fields between the care plan and the EHR.
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digital.ahrq.gov/sites/default/files/docs/page/medicaid_health_it_initiatives_boot_camp__understanding_and_managing_multiple_medicaid_health_it_projects_5.pdf
December 31, 2015 - Industry Standards Condition
Leverage Condition
Business Results Condition
Reporting Condition … Care Act
40
4. … against or struck by
unspecified sports equipment
64
Range of Applications
• Improved care … MITA Condition
3. Industry Standards Condition
4. Leverage Condition
5. … Business Results Condition
6. Reporting Condition
7.
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digital.ahrq.gov/ahrq-funded-projects/integrating-contextual-factors-clinical-decision-support-reduce-contextual
January 01, 2023 - plan leads to the improvement of contextualized care plans that account for those factors. … of Care
Primary Care
Health Care Theme
Care Planning
Clinical Decision Making … Contextual errors occur when a care plan is inappropriate because of inattention to patient context. … For example, increasing the dosage of a patient’s medication to manage deterioration of a chronic condition … Passive and active interruptive alerts were used to direct clinicians toward a contextualized care plan
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digital.ahrq.gov/sites/default/files/docs/citation/appendix-e-cdspain-sample-clinical-practice-guidelines.docx
October 16, 2020 - Appendix E: Tapering Opioid Medication: Considerations for Clinical Practice
Rationale
Long-term use … The purpose of this guideline is to summarize the state of clinical guidelines on safe tapering of opioids … by a disease or condition, injury, medical treatment, inflammation, or an unknown reason.1,2
Acute Pain … *A Patient Aligned Care Team (PACT Team) provides care centered around the patient’s goals by a team … A veteran with high risk due to a medical condition may have decompensation during the taper and may
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digital.ahrq.gov/program-overview/research-stories/evaluation-scaling-acceptable-cds-scaled-approach-interoperable
January 01, 2023 - Shareable clinical decision support: patient-centered outcomes research can translate findings into clinical … Patients with traumatic brain injuries (TBI) are at high risk for venous thromboembolism (VTE), a serious condition … where a blood clot can develop in the leg or arm and either dislodge or block leg or arm blood flow, … To reduce VTE events, patients need preventive care, but guidelines for providing preventive VTE care … The researchers plan to widely disseminate this new VTE prophylaxis CDS tool for TBI patients to U.S.
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digital.ahrq.gov/ahrq-funded-projects/patient-centered-outcomes-research-clinical-decision-support-learning-network
January 01, 2023 - No statement in this report should be construed as an official position of AHRQ or of the U.S. … Decision Support System
Patient-Generated Health Data
Care Setting
Across the Health … Care System
Medical Condition
Substance Use Disorder
Population
Clinical … Decisionmaker
Implementer
IT Staff
Patient
Payer
Researcher
Stakeholder
Health Care … Clinical Decision Support Learning Network (PCCDS-LN or “the Learning Network”), was created as a multistakeholder
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digital.ahrq.gov/sites/default/files/docs/publication/r18hs017270-fricton-final-report-2011.pdf
January 01, 2011 - and a dental plan. … Clinical care guidelines. … changes in
care or in improved clinical outcomes, such as decreased complications and improved periodontal … This was measured by any urgent care, emergency, or inpatient care related to the
condition. … , or inpatient care related to the condition.* (Mean fu time in days, pre is 359 and post 245 days
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digital.ahrq.gov/sites/default/files/docs/citation/ecare-plan-final-report.pdf
November 01, 2022 - The search turned up no errors or exceptions and retrieved
hundreds of Condition resources across all … /kidney-clinical-research-epidemiology/health-information-
technology/development-electronic-ckd-care-plan … /research-programs/kidney-clinical-research-epidemiology/health-information-technology/development-electronic-ckd-care-plan … Are there any burdens for you and/or your staff associated with the provider-facing
e-care plan app … Review care team (look for dietician and/or counselor)
Im
plem
entation of an eC
are Plan
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digital.ahrq.gov/sites/default/files/docs/page/use_of_health_it_and_hie_in_section_2703_medicaid_health_homes_5.pdf
January 01, 2017 - ■ Health home is a new Medicaid State plan option that
provides a comprehensive system of care coordination … more chronic conditions,
□ one condition and the risk of developing another,
□ or at least one serious … ■ Care management/clinical support:
□ medical director,
□ clinical pharmacists,
□ targeted clinical … and pregnancy home coordinators. 27
Managing Clinical Care
(Spreading Best Practices)
28
Current … Network Has:
Managing Clinical Care�(Spreading Best Practices)
Current Statewide Disease and�Care Management