Table 2 Vulnerabilities Experienced by Each Clinic

 Have to track some patients in own mind or side system

5

X

X

X

X

X

 Creating list of patients requiring monitoring takes time

5

X

X

X

X

X

 Looking up each patient’s information takes time

4

X

X

X

X

 Maintaining list of patients requiring monitoring takes time

4

X

X

X

X

 Outside of visit-based care, don’t always know when patients need follow-up monitoring

4

X

X

X

X

 Manually monitoring patients is time intensive

4

X

X

X

X

 Don’t always know which patients need to be called back for monitoring

3

X

X

X

 Have to spend too much time scheduling

2

X

X

 Manually monitoring patients is error-prone

2

X

X

 Analyzing data in ad hoc manner is time intensive

4

X

X

X

X

 Inefficient system to create personal, siloed reminders for follow-up

4

X

X

X

X

 List of patients we use outdates quickly

3

X

X

X

 Can’t divert alerts to other providers

3

X

X

X

 Analyzing data in ad hoc manner is error-prone

3

X

X

X

 Don’t always know when patient data is missing

2

X

X

 Can’t find missing data from outside clinic

1

X

 Don’t always want alert when patient status changes

1

X

 Don’t have adequate real-time data

1

X

 Can’t edit patient’s care pathway as needed based on frontline data

1

X

 Can’t find missing data within clinic

1

X

 Systems don’t talk to each other

4

X

X

X

X

 Don’t have a system that puts patients into subgroups for more efficient monitoring

4

X

X

X

X

 Can’t share patient list with entire care team

3

X

X

X

 Don’t always have the time to perform the assigned role

2

X

X

 Hard to stratify patients into subgroups for monitoring due to many individual patient differences

2

X

X

 Care plan is poorly documented

2

X

X

 Don’t know what types of scheduling challenges occur most often

1

X

 Overlapping efforts

4

X

X

X

X

 Don’t always know when the loop closes

3

X

X

X

 Everyone inputs data differently

2

X

X

 Knowing who is managing at each stage is unclear

2

X

X

 Mapping patient to care plan requires clinical judgment

2

X

X

 Coordinating scheduling efforts across care teams is difficult

3

X

X

X

 Little or no performance data about monitoring so don’t know where to focus any improvement efforts

3

X

X

X

 Stretched for resources to reach out to all patients in need of follow-up

3

X

X

X

 Unaware of clinic’s performance in patient monitoring

2

X

X

 Don’t know when patient misses appointment

4

X

X

X

X

 Don’t always know when patient doesn’t have PCP

4

X

X

X

X

 Don’t always know patient’s vulnerabilities relevant to monitoring (e.g. patient’s work schedule, can’t get to clinic, substance abuse)

3

X

X

X

 Difficulty communicating patient needs with entire care team

2

X

X

 Don’t know when patient changes status

2

X

X

 Inconsistent process for informing PCP

3

X

X

X

 Can’t use patient data for operational improvement

2

X

X

 Involving PCP when not necessary

1

X

 PCP doesn’t have overview of all patient info/care pathway

3

X

X

X