Table 1 Summary of ICT-supported elements of the CCM
CCM element | Description | ICT-supported elements |
|---|---|---|
Community resources and policies | Providers connecting patients to community programs through partnerships that expand health system services beyond primary care. Providers promote patient self-help strategies, including connecting to real and virtual social networks. | Health-related social networks and eCommunities that support health and social care connections. |
Health system | Designing health systems to support organizations and providers in their interactions with patients around chronic disease care. Organizational and senior leadership support creating a culture of safety and improvement across all organizations that make up the health system. Including supporting data sharing across the system to improve chronic disease care. | EHRs, PHRs, mHealth and Telehealth, online resources/systems that support quality improvement and patient engagement. |
Delivery system design | Adopting a proactive patient management approach through care coordination and case management, especially for complex patients. Includes provider team members having clear roles and responsibilities, ensuring regular follow-up, and care that patients understand, find acceptable and fits with their cultural background. | EHRs, PHRs, mHealth and Telehealth that enable information sharing and span the system. |
Self-management support | Supporting patients with chronic illnesses to make decisions and engage in actions that improve their health (self-management). Providers collaborate with patients to define problems, set goals, and create treatment plans (self-management support strategies). | PHRs, online resources/systems, mHealth and Telehealth, and applications that support patient-provider interactions. |
Decision supports | Supporting the use of evidence-based guidelines into daily practice which can be shared with patients. Education and training for providers and integration of specialist expertise included in this element. New models of provider education in particular eHealth Education (added in the eHealth enhanced CCM): encourages the development of eHealth skills for patients and providers that can enhance all six elements of CCM. | Electronic access to evidence-based guidelines, protocols, standing orders, and reminders for providers and patients, through EMRs, EHRs, or online resources. Appropriate training for providers and patients on eHealth Education systems. |
Clinical information systems | Information systems providing ready access to key data on individual patients—reminders for services and data to track and plan care—and at the practice level, population data to monitor performance and improve quality, in particular for relevant subpopulations. | EMRs, EHRs, and PHRs that support coordinated care and monitoring performance at the individual level and practice level. |